The West Virginia Opioid Crisis

/in /by

The West Virginia opioid crisis has reached a dangerous level of seriousness within our communities in recent years. To understand this level of danger in an attempt to prevent and eradicate this epidemic an understanding of what opioids are, how they affect a person, how addiction begins, and how to recover from such addiction is crucial knowledge. This essay aims to define the West Virginia opioid crisis and its surrounding concerns such as overdose rates, strategies of recovery, treatment methods offered, and the effects of this epidemic on families and communities surrounding victims of addiction in an attempt to prevent and combat this crisis in the years to come.

Opioids include several prescribed and illicit drugs such as hydrocodone, oxycodone, and methadone, heroin, morphine, and fentanyl. Hydrocodone includes medications such as Lorcet, Lortab, and Vicodin that are commonly abused. Oxycodone features painkillers such as OxyContin, Percocet, and Percodan that are also commonly abused (Byrne, Lander, & Ferris, 2009). Opioids are highly addictive substances that are often prescribed for post-surgical pain and chronic pain, but many patients who begin taking these prescriptions are not thoroughly warned of their highly addictive nature.  Opioid addiction can be characterized by the inability to discontinue opiate use and a combination of physiological, behavioral and cognitive behavior with severe intensity in attempts to continue opiate use (Sharma, G., & Kaur, G. 2017). Addiction has a broad spectrum of substances such as alcohol, sex, shopping, and other drugs.

In 2017, research was conducted to reveal that health care providers in West Virginia wrote 81.3 opioid prescriptions for every 100 persons standing among the top ten rates for that year in the United States (National Institute on Drug Abuse, 2019). With more people being prescribed opioids in recent years, it should not be a surprise to our communities that the rate of addiction is rising each year as well. The increasing rates of persons being prescribed opioids have consequently caused these drugs to become increasingly popular in recent years because of their accessibility. Statistics have shown that illegal drugs, tobacco, alcohol, and steroid use in students in grades eight to twelve have decreased over recent years, while the misuse of prescription pain medications such as opioids has increasingly risen (Byrne et al., 2009). The rise of prescription pain killers has had a slow yet dangerous journey into the communities in the United States. Only 15 years ago people initiated the use of opioids over marijuana or cocaine, shedding a light on the steady growth of opioid use until now when an epidemic has swept the country.

As research continues to apprehend a cause of the large number of opioid abusers in the country, many have concluded that other disorders such as mental illness can be correlated to addiction. A number of disorders such as depression, anxiety, post-traumatic stress disorder, and externalizing conditions can be found within patients who are also suffering from substance abuse (Nadai, Little, Mccabe, & Schepis, 2019). With this knowledge, we can begin to understand the trail that leads to addiction in an attempt to prevent a person from consequently becoming an addict due to these circumstances. Many times, a person suffering from chronic mental or physical illness can turn to destructive coping mechanisms. Medical professionals are also a culprit in the cause of these characteristics within persons, as many patients suffering from these illnesses are prescribed addictive substances such as opioids in the name of treatment. The idea that medical professionals are over-prescribing patients has been addressed by multiple researchers.

When examining opioid prescribing data over the last 20 years, there is more than enough evidence to show that medical care providers, specifically surgeons, regularly overprescribe opioids to patients. From 1999 to 2008, the sales of prescription opioids were four times higher than in prior years, which was directly correlated with an increase in opioid-related deaths during the same period. A study done by the Center of Disease Control and Prevention in 2015 showed that there were enough opioids prescribed within that year to medicate every US adult with five milligrams of hydrocodone every four hours for three weeks. (Theisen, Jacobs, Macleod, & Davies, 2018). This study alone identifies the lack of understanding within the medical field of how to appropriately treat patients with acute or severe pain. Medical professionals have a bad habit of overprescribing pain medications “just in case,” due to the difficulty of filling another prescription for opioids and other Schedule II substances. Overprescribing within the medical field can be attributed to at least some, if not many, of the consequent addictions formed within the United States.

The Center for Disease Control and Prevention (2019) found that in 2017 over 70,000 people died from a drug overdose, with 68% of those overdoses involving a prescription or illicit opioid. As more illicit opioids are flooded into the street market, overdoses increase. Opioids such as heroin and fentanyl that are not tested or regulated can have varying potencies that stage a higher risk of overdosing from a smaller amount of the drug. The rate of overdoses in the United States has increased by 27.9% from 2015 to 2016 (Seth et al., 2018). The West Virginia opioid crisis attributes to a large number of these overdoses. West Virginia had a drug overdose death rate of 52 per 100,000 in 2015, which can be characterized as 250% more than the national rate of deaths attributed to drug overdoses, and West Virginia has stood as the highest opioid overdose death rate in the US since 2010. (Warfield, Pollini, Stokes, & Bossarte, 2019). An estimated 2.5 million people are addicted to opioids in the United States (Nguyen & Salinger, 2018). Examining the rates of overdoses within the state is an effective way to fully grasp the large number of West Virginia residents that are currently addicts. Although not every addict has overdosed, therefore we can assume that these numbers are even less than the actual number of victims suffering from addiction.

Recovery is an important stage that addicts hopefully reach within their addiction before an overdose occurs. Many steps within the recovery process are important in becoming sober and staying sober including detox, treatment, and abstinence. Facilities and programs designed for recovery are few and far between in West Virginia, which is a serious problem in our attempt to combat the epidemic. With the number of addicts in our state, there should be a facility for recovery on every corner, but there are only six inpatient facilities located throughout the state of West Virginia (Warfield et al., 2019). Primarily due to insufficient funding, only seventeen counties in West Virginia offer a harm-reduction program, leaving thirty-eight counties without access to services associated with addiction (Pollini, 2019). There are many different treatment methods associated with opioid drug abuse. Medication-assisted treatment includes methadone, buprenorphine and naltrexone, while other treatment plans include 12-step programs, psychosocial interventions, and residential rehabilitation treatment facilities (Nadia et al., 2019). Each of these methods are used to promote opioid abstinence, improve coping mechanisms within addicts, and treat lasting trauma associated with addiction. Treatment facilities and programs can highly impact the rate of recovery. Unfortunately, there is a large deficit in these services and a refusal by policymakers to support these treatment programs due to insufficient funding and stigma associated with lack of empathy and understanding (Pollini, 2019).

Social support is also a large factor in the effectiveness of these treatment options.  Self-help groups such as Alcoholics Anonymous (AA) meetings are a very beneficial tool in the recovery process (Levine, Perkins, & Perkins, 2005, p.333). Many addicts may feel alone in their struggle to become sober, and without a support system such as a family or close group of friends, it can become even harder to begin to recover from addiction. Self-help groups offer a group of people who are struggling with the same problems that an addict may be facing. These meetings can include sharing stories in exchange for support and encouragement, knowledge of coping mechanisms, and the promotion of positive mental health during stressful times. Rewards and celebrations also may be offered for a consecutive amount of time being sober, such as the tokens AA gives out after each month of sobriety. Positive reinforcers such as these are important due to the long process of opioid recovery that often involves increased physical, emotional, legal, financial, and social stress (Borsari & Read, 2019). Social support offered by family, friends, or self-help groups offer a positive alliance with an addict and their recovery process to encourage higher chances of lasting sobriety.

The stigma attached to addicted persons also take a role in the lack of support from surrounding persons. Many debate that drug addiction is a choice, therefore sympathy for a victim of addiction is not granted. This stigma lowers public support for programs focused toward drug-abuse, decreases access to helpful services, and negatively affects the recovery of addicts. (Nguyen et al., 2018) It only takes trying an illicit drug such as opioids one time to become addicted, and a majority of addicts never intended for their drug abuse to escalate so quickly and to impact their lives so heavily. The treatment of addiction as a chronic disease rather than a crime can positively impact the epidemic by promoting awareness and support. Stigmatizing these victims only increases the complexity of these epidemic-related obstacles.

The prevention of opioid abuse is very important in combatting the epidemic now and in the years to come. Prescription drug monitoring programs and other medication-assisted programs have made a positive impact on the opioid crisis, but there is much more to be done in attempts to end the massive opioid epidemic (Strand & Eukel, 2019). There has been struggles in applying effective prevention methods within the medical system due to the lack of information on how to identify the predisposed conditions and behaviors of an individual at risk of addiction. The Opioid Risk Tool (ORT) is a tool used by medical professionals to measure patients prescribed an opioid prescription for opioid misuse, and by using this tool in a population of those on chronic pain medication and individuals who have been exposed to opioid medications, pharmacists have identified a large group of patients who are at an elevated risk of opioid abuse (Webster & Webster, 2005). Tools such as the ORT are an effective way of identifying individuals at risk and warning them of the addictive nature of opioids so that prevention can take place.

Identifying addictive tendencies within the family of an individual is also an effective way of applying prevention before an addiction occurs due to the common occurrence of addiction running from generation to generation. Additive personalities can be identified from an early age by behavior such obsessive and compulsive tendencies, and individuals who present such behavior are at a much higher risk of becoming addicts. The appearance of mental health issues early in life may also point to an individual increased risk of addiction later in life. Studies that were previously discussed show the prevalence of mental disorders in correlation to drug addiction, therefore the identification of these individuals at an early stage of life may save them from resorting to destructive tendencies such as drug abuse when they are presented with stressful life events.

Drug addiction has multiple lasting effects on the family and friends surrounding a victim of substance abuse including feelings of guilt, shame, constant fear and worrying, resentment, mental-health issues, and the repercussions of witnessing traumatic experiences. It can be very destructive to a household when one or more persons within it become deviant in this manner. Often times, the adequate help needed for a victim of drug addiction cannot be provided by the family, therefore the household may blame themselves for the downfall of the victim. Many families experience the tragic loss of a family member due to overdose. An estimated 13.7 million people are living in a household with someone who received or is receiving treatment for drug abuse (Levine, Perkins, & Perkins, 2005, p. 23). Often times, treatment is needed for the people surrounding an addict due to the trauma that can occur when dealing with addiction. Families of addicts can attend self-help groups specifically for persons surrounding victims of drug abuse for comfort and encouragement during these stressful times.

The West Virginia opioid epidemic has also affected many communities negatively. West Virginia’s reputation as a beautiful mountain state has been heavily tainted by the sweeping epidemic. Parks, rivers, and other areas of community growth are littered by hypodermic needles and other drug paraphernalia. Physical environment has a large effect on the well-being of persons within that environment. Many factors can negatively affect an environment, such as the stressors and health of the individuals present (Levine, Perkins, & Perkins, 2005, p. 177-178). The streets of West Virginia are filled with persons who are blatantly under the influence, and this often poses a danger to the surrounding community. The stigma surrounding the opioid crisis in West Virginia has had a lasting effect on the tourism and economy of this state and is negatively impacting the expansion of services that will combat the opioid crisis (Pollini, 2019). An end to this epidemic is crucial in the near future, and the lack of effort by legislature and medical professionals within the state is highly concerning in this attempt. The victims of addiction in West Virginia are in need of our legislators, policy makers, and medical professionals to initiate a singular focus on the eradication of this opioid crisis in the name of our community. Without a sudden change in the approach to this epidemic, West Virginia may not survive the detrimental effects it will continue to make.

References

Evaluating How To Ensure Patient Safety Nursing Essay

/in /by

PATIENT SAFETY

According to World Health Organisation (2010) Patient safety is the prevention and avoidance of adverse circumstances or injuries coming from health care process. Accidents, errors are common events that can occur in the clinical area. Safety arises from the interaction from different parts of the system: it does not live in a person, department or device. Patient safety is a branch of health care quality.

Patient safety could be defined as the prevention of errors and adverse effect associated with patients in health care. Health care has become more complex and more effective with greater use of medicines, treatment and more use of technologies; also, patient safety is the prevention of adverse effects to patients and prevention of errors associated with health care. In every care given there is a certain degree of unsafe practice, wrong procedure, side effects of drugs, hazards done by a faulty or substandard medical device used in the health system, human errors or system errors (latent) failures (World Health Organization, 2002).

Patient safety is a global issue whereby about 2.3% -16.6% adverse event rates have been documented from acute care hospitals. 1.4 million people worldwide have also been reported by the World Alliance for patient safety are suffering from acquired infections from hospitals and in the developed world 10% of patients admitted to modern medical hospitals acquire one or more infections.

In Africa and Asia pacific region, patient safety is a very big issue of concern. In the developing countries the risk of health care associated infection is 2-20times higher than in developed countries, sometimes the percentage of health care acquired infection can exceed 25%. The countries rise of unsafe care is alarming (WHO, 2007, pp. 15).

Nursing literature and standards of professional conduct elevating patient safety and standard care all presuppose the importance of excellence in nursing practice. About what excellence is and how it may be operationalised as a moral essential in patient safety discourse is not well interpreted. It may not be possible to effect to any one specific definition of the idea what excellence in health and nursing care area is, but only to give examples of distinct excellences of professional practice and professional lives for example case of exceptional caring, exceeding honesty, outstanding understanding and skill, laudable wisdom, uncommon patience and eminent integrity.

RISK ASSESSMENT

It is the identification of attendant uncertainties in order to estimate the risk in an organization IPCS (2004). Risk assessment is the first constituent in risk analysis process which also includes management of risk and communication of risk. Risk assessment refers to techniques and methods that apply to the judgment of hazards. Risk assessment starts with problem formulation which includes four additional steps as elaborated below:

(1)Identification of hazards;

(2)Characterization of hazards;

(3)Assessment exposure;

(4)Characterization of risk (IPCS, 2004).

Identification of hazards entails recognizing the hazard and acting fast to prevent an incident from occurring. Characterization of hazards has to do with the drug, object or procedure that might cause the adverse effect. Assessment exposure involves how are patient expose to this hazards, how much danger is likely to occur, how long is the danger likely to occur, what measure of danger is appropriate for typifying health risk? Characterization of risk involves how does the assess exposure compare guidance value for the drug?

The nurses on duty in this case scenario did not act as harm absorbers by ensuring the safety of the young girl in the ward by combining expertise, experience and training which is required from experienced nurses. They needed mental alertness or foresight to identify on time that the patient tourniquet was not unfastened.

National Patient Safety Agency (2008) has developed a mental preparedness training program which aims at enabling nurses to increase knowledge of determinant that raises the chance of patient safety incidents, boost their confidence to keep patient safety incident from happening and understanding risk-prone situations better. Reason (2004) cultivated a method for analysing risks which was structured around the three-bucket model. According to the model, most patient safety incidents can be prevented if clinical staffs foresee error before any task, procedure or action is attempted. The assessment is divided into three parts, which are: the self-bucket, context-bucket and the task-bucket. Relating these three-bucket prediction approaches to the case scenario examined in this essay is detailed below.

In the self-bucket, the registered nurse that collected the blood sample from the little girl had a low level of competence and experience because it is the duty of a medical laboratory scientist which she is not. She was not aware of the policies that governs the procedure and never took her time to cross-check what she was doing.

In the context-buck the registered nurse on duty lacked team support from her colleagues. The four registered nurses on duty would have shared the patients in the ward to themselves in a ratio of 10:1 and the unfastened tourniquet would have been noticed by the staff nurse in charge of this young girl.

In the Task-bucket the registered nurse that collected the blood sample was unfamiliar with the task so did not remember to unfasten the tourniquet. She would have asked for a medical laboratory scientist who has more experience in this procedure and it would have help reduced the work load for this staff nurse because the ward was busy and full.

Reason (2004) noted that using foresight is a fundamental skill of an experienced registered nurse and for it to be more effective it must be practised. He goes on to say that healthcare professionals who needs to develop error wisdom, alertness and quick reactions needs to apply it, should use the simple three-bucket model of error which might help them the foresight factors that raises the chance of patient safety incidents. Training on risk assessment does not have to take place in classroom but can be cultivated in forming part of clinical handovers, or of daily training programmes involving for example, manual handling and lifting which was not done by the nurses on duty in this scenario.

The training programme designed created to equip staff with prospective risk assessment abilities and a simple model needed for use in their everyday work. It aim is to help nurses to do something to prevent incidents, improve nurses knowledge of the factors that can be added to make patient safety incident occur, educating nurses by encouraging them to share their experiences of patient safety incidents, improving their knowledge of risky situations.

The program also help prepare staff nurses to undertake urgent risk assessments of risky situations by encouraging them to accept that errors can and will always occur and to be more at alert of safety gaps where they work, know how to check situations before starting a task and so increases chances to minimise and avoid errors and to note and anticipate problems and to prepare in advance to deal with them. Ask for more qualified help when necessary and to know what stops them from asking for help.

THE SCENERIO

My patient case scenario happened in south — south Nigeria, West Africa where a student nurse did her clinical practice. An eight year old girl who was admitted for the treatment for malaria had her arm amputated before discharge from the hospital. This young baby as I will call her was admitted into a 40 bedded busy ward with just three trained registered nurses on duty on each shift. She came in with severe pyrexia which was later brought down, but on the third day of her stay in the ward as a stable patient, the medical doctor on duty ordered for a malaria parasite blood investigation to see if there are more parasites before discharge.

Fortunately the hospital management board had enacted a law which governs the hospital and the laboratory in this hospital whereby blood samples are collected by the nurse on duty to the medical laboratory scientist because the hospital had only one medical laboratory scientist that runs the laboratory. The hospital management board tells the Federal Government that they have employed ten medical laboratory scientists (Ghost workers) but apparently employed just one.

On that faithful morning one of the registered nurses on duty collected this patient blood for investigations but forgot to unfasten the tied tourniquet from the patient’s arm. The incident took place with the morning nurses on duty while handing over to the afternoon nurses the unfasten tourniquet was still on the patient arm so the tourniquet was there for two days without any of the nurses on duty noticing, the patient mum thought the on the girls arm was part of the treatment. 48 hours later a registered nurse on duty who went to give the patient bed bath saw it and by then blood supply to that arm has been cut off.

An incident report was filled and submitted to investigated the incidence but information collected could not be worked on appropriately because the structure of the management board is pathologic because they have this attitude already that they needed not to waste their time on patient safety issue (Parker, 2001)

SYSTEM FACTORS

Throughout management of care, registered nurses are used extensively. Most health management officers prefers using advanced practice nurses in their primary care duties in changing patients positions and in community settings. Another important role for the registered nurse is that of case management while on duty. As a case manager you will have to manage care for a patient during the whole of the health care system to minimize breakdowns, contain cost and improve the quality of life.

Nurses also help in a triage role, deciding the most suitable course of intervention and are often employed to render the most appropriate and cost-efficient care. This duty often involves moving a patient out of the hospital, a nursing home or with health service. The patients who are the consumers have different views towards managed care and their experiences. Some patients have good access, care givers they trust, various range of services and fair costs. Others have experienced access problem, refusal of treatment and limited coverage as seen in this case scenario. As patients become more informed, they began to fight for their rights to better health care services through legal system and reforms.

Reducing workforce as seen in this essay, without proper reconstruction simply leaves fewer people to realize already inefficient and ineffective work.Unluckly this short sighted approach is taken by various companies, both in and outside health sector. The outcome is poor morale, patient discontent, low-quality outcome and loss of able staff. Kuokkanen et al., (2003) in their studies noted that job satisfaction, empowerment and organizational obligations are closely linked.

Health care workers today are facing a very different work environment. They mostly have seven to ten different jobs during a typical work career moderately than the three jobs or lesser held by former generation.

Keys to successful reconstruction of the health system include strong leadership, support from the leaders from the top (resources, cultural, financial and time) positive thinkers, steadfastness and our being able to answer these few questions:

-What is our mission?

-What standard do we want?

-How do we need to go about our work?

-What people do we want to work with?

The history, political and socioeconomic factors of a country determines the characteristics of the health system, for example the hospital where this incidence occurred ,the organizational models are visionary and do not actually exist in a realistic pure state. Giving the Federal government a false figure of staff in each ward and having few staff is organisational failures that lead to the patient safety incidence. Due to the poor system normal daily nursing procedures were not carried out like taking of vital signs four hourly because if the normal routine procedure of taking vital signs was done the nurse that carried out the procedure would have seen the unfasten tourniquet that was tied on the little girls arm.

During handing and taking over of the morning nurses to the afternoon nurses, the blood specimen collection which was a latest development would have been reported to the head nurse on afternoon duty. The nurses on night duty also failed in their duties. If a proper night report was written and read out loudly by a night nurses in the presence of all the day duty nurses the next day the error would have still be noted.

Healthcare managers, strategy-makers and governors at the blunt-end-they decide on how care is delivered through strategies, financial control and directing the work of the healthcare professionals.

At the blunt-end, latent conditions occur. A working environment is made that increases the chances that there will be an active failure at the sharp end. There are a whole lot of latent failures-all with the possibility to cause an adverse event like what we have now in this patient case scenario. The healthcare system in this scenario is overloaded such as overbooking admissions into the ward with less staff. Normally there is a combination of many small factors, each appearing not to be important when viewed alone.

When latent failures occur in addition to only one active failure, such as forgetting to unfasten a used tourniquet by a registered nurse who is overtired because she has been working in an overcrowded and busy ward, the outcome is a recipe for an adverse event to occur.

HUMAN FACTORS

Human factor is the application of human knowledge, ability and limitations to the design of common systems of people, work tools and their environment to guarantee their influence, safety and ease of use. The above definition explains it further that the chores nurses perfrom,the equipment they are called to use, their work environment and the organizational procedures that moulds their activities may or may not be a good fit for their advantage and disadvantage. Poor outcome usually occurs when the sensory, behavioural and cognitive traits of providers are put together.

Most nursing work processes have evolved as a result of personal or practice first choice rather than through a systematic method of constructing a system that gives rise to small errors and greater effectiveness. Far too often, care givers and administrators have fallen into a current situation trap carrying out procedures simply because they always had been done that way. Experts in human factor on the other hand, look at human abilities and weakness in the construction of systems, stressing the importance of avoiding believe in memory, carefulness and follow up intentions-areas where human acts of avoiding confidence. Processes can be made easy and standardized, leading to less confusion, gains more effectiveness and fewer errors.

The area of human factors does not point solely on devices and technology. Human factor research came up during World War II as a result of showcasing equipment and controls that were not fitted to the visual and motor abilities of human users, decade after decade of human factors work has seen a broadening of the human accomplishment issues seen worthy of investigation. Lately a number of human factor experts with interest in improving health care standard and safety spoke addressing a more inclusive range of sociotechnical system factors, including only patient, care givers, the duty performed, and group work, but also work environments or Microsystems. One of the lessons coming from a systems method is that meaningful improvements in safety and quality are likely to be reached by seeing to and correcting the mistakes among these organizational and management matters, and socioeconomic factors outside of the institution. Managing the systems confidence of care, as seen by confidence of care, is a big challenge faced by providers and their human factor partners.

Human factor relevant to this case scenario is that there was an inadequate flow of information from the nurses during their handing over process. The nurses on each shift did not have the information they needed to appropriately care for the young girl. The (Joint Commission) 2006 advices on the improvement of effective communication which is include a requirement for a standardized handing-off of communications. Other human factors that lead to the incident were fatigue, stress and interruptions.

Although the nurse that carried out the procedure was not a medical laboratory scientist but she should have explained the procedure to the young girl or get an interpreter to interpret the procedure to the patients mother because she does not understand English. This effective communication before the procedure would have helped in great deal in preventing this accident because the mother caring for her daughter would have noticed the tourniquet still fastened on her daughters arm after the procedure was an error and would have drawn the attention of the nurse or any other nurse to unfasten it.

CONCLUSION AND RECOMMENDATIONS FOR PRACTICE

Increasing the number of medical staffing in order to achieve compliance will help in minimizing patient safety incidence rather than lying. Although increasing the number of medical staff is not a criterion that error will be prevented completely in the practical world.

Setting up assessment team amongst the nurses who will be dedicatedly positioned to centralised areas in the ward to assess acutely ill patients and strict monitoring while still on admission.

No matter how bad the case in a hospital is, there must be a patient safety champion in each department or division which should be recommended or nominated by the staff in the hospital.

The hospital should use the information generated by its incident reporting system and organization-wide risk assessments to proactively improve patient care.

An Overview Of Chemotherapy Induced Alopecia Nursing Essay

/in /by

Chemotherapy-induced alopecia has proven to be a substantial burden on an already overwhelmed and emotionally-burdened cancer patient population. Hair loss can cause detrimental effects on a patient’s confidence level, happiness, and self-esteem; all of which can be important factors in determining treatment outcomes <1>. Patients can become very self-conscious to the point where they isolate themselves from friends and family at a time when moral support is needed most. Hair loss is frequently listed high among some of the most feared and worrisome aspects of receiving chemotherapy. Among breast cancer patients, Browall found that many women undergoing a mastectomy followed by chemotherapy, rated baldness as a worse result than losing their breast <2>. In order to help patients prepare for, and potentially minimize this emotionally arduous aspect of cancer therapy, all health care practitioners within a patient’s circle of care need to properly address this sensitive subject.

Although recognized as a serious and concerning side-effect for many patients, alopecia is often inadequately addressed during cancer patient consultation <1>.

Biology of Chemotherapy-Induced Alopecia

Many of the prevalent side effects of chemotherapy are due to its cytotoxic effects on rapidly dividing cells. Along with bone marrow cells, skin cells, and cells lining the gastrointestinal lumen, hair follicle cells are also rapidly dividing. These can all therefore easily succumb to the cytotoxic effects of chemotherapy resulting in myleosuppression, hand-and-foot syndrome, nausea, vomiting, and alopecia <3>. Although a possible side effect to almost all types of chemotherapy, there remain certain agents which almost always result in significant hair loss to the patient (see Box 1).

BOX 1 Most Prominent Alopecia-Inducing Chemotherapies: <7>

adriamycin

cyclophosphamide

daunorubicin

docetaxel

epirubicin

etoposide

irinotecan

ifosfamide

paclitaxel

topotecan

vindesine

vinorelbineAlopecia is divided into two main types: telogen effluvium and anagen effluvium <3>. Telogen effluvium results from the majority of hair follicles on the scalp shifting to the telogen phase of the hair growth cycle. The resulting appearance is more hair-thinning than complete hair loss <3>. Anagen effluvium on the other hand results from hair follicles in the anagen phase becoming weakened due to the cytotoxic effects of chemo and subsequently falling out. Since the majority of scalp hair is in the anagen phase, this generally results in complete baldness <3>.

Treatment & Preventative Therapies

Aesthetics

Although not all chemotherapy patients experience obvious hair loss and in some cases preventative measure can be taken, it is always best to plan for the worst and invest time in consulting a wig-fitting specialist. Synthetic and natural hair wigs are available, sometimes at the expensive of private insurance payers, and are best selected and fitted prior to complete hair loss <3>. Alternative cover-up methods can involve scarves or turbans depending on patient preferences. What may seem like an unimportant cosemetic cover-up, studies are proving can be an immense healing tool to rid people of their “sick stigma” within society and substantially improve their coping strategies with such a crippling disease <4>.

Support

It is very important for healthcare providers to acknowledge the emotional and psychological impact of alopecia. To illustrate such an effect, McGarvey found that alopecia was cited as the most disturbing effect of undergoing chemotherapy treatment by 58% of breast cancer patients <5>. Among them, 8% reported being at risk of avoiding treatment altogether because of the risk of alopecia <5>. Although limited studies exist which examine the impact of social worker counselling and psychologist referrals for patients dealing with the effects of chemotherapy induced alopecia, the vast range of resources utilized throughout the internet and cancer treatment facilities can attest to the need for these interventions. One intervention study found that positive re-enforcement and hair loss counselling videotapes showed to ovarian cancer patients prior to starting chemotherapy improved their body image and confidence levels <6>.

Cold Caps

Aside from coping strategies, one of the best studied and potentially beneficial prevention strategies against chemotherapy induced alopecia remains the use of “cold-caps”. Numerous “cold caps” have been introduced and studied in oncology since the early 1970s. Despite the under-utilization of these devices in general oncology wards today, there remain 6 out of 7 randomized trials that have shown significant benefits in these patient populations with regards to minimizing alopecia <7>. The downfall in this area of research is the lack of standardization regarding type of cooling caps used, temperatures reached, and duration of treatments.

Throughout cold cap experimentation, there has remained concern regarding metastases to the scalp. Due to the fact that cooling the scalp constricts blood vessels and thereby reduces exposure of hair follicles to chemotherapeutic agents, it’s believed this mechanism of action provides a “safe-haven” for migrating malignant cells. Although studies regarding increased incidence of scalp metastases are limited, so far this hypothesize has not been proven to be true, specifically in the case of a median 15 month follow up of 74 patients post cold cap therapy by Ridderheim <8>. Despite a lack of evidence regarding increased risk of metastases to the scalp during cooling cap therapy, this type of treatment method remains contraindicated in patients with lymphomas and other hematological malignancies <7>.

AS101

Although limited, fairly new research is currently being done on several pharmacological agents for prevention of chemotherapy-induced alopecia. The novel immunomodulator AS101 is one such agent which has shown promise in phase II clinical trials. Prior to carboplatin & etoposide treatment regimens, 58 patients were injected with AS101 and demonstrated significantly less hair loss compared to controls.*SR In the same study, similar analyses were done on rat populations and in addition, showed alopecia protecting effects using both topical and injectable formulations of AS101 <9>. It was hypothesized that these effects were due to endogenous stimulation of IL-1 production by AS101 which plays a role in proliferation of epidermal keratinocytes <9>.

BOX 2 Non-Pharmacological Therapies to Combat Chemotherapy-Induced Alopecia: <12,13>

Wash hair less frequently

Use gentle, mild shampoo

Do not use blow dryers of curling irons

Protect hair from sun and cold temperatures

Avoid colouring agents or other chemical products

Use a soft hairbrush

Minoxidil

With regards to speeding up hair re-growth, there are very few pharmacological options. However the most commonly studied and utilized agents is 2% topical minoxidil. Hair re-growth tends to occur around 6 weeks post-treatment in the majority of patients. Minoxidil has been proven to reduce the period of baldness by an average of 50 days in breast cancer patients receiving chemotherapeutic regimens of cyclophosphamide, doxorubicin as well as cisplatin <10>. In earlier trials involving gynaecological cancer patients however, it failed to prove any benefit in preventing alopecia <11>.

Care Providers Responsibility

The historical method of dealing with chemotherapy-induced alopecia has been to simply refer the patient to a wig-fitting service and cease further consultation about the subject. Although still readily used, and for good reason, wig-fitting services remain only one avenue of alopecia treatment that should be discussed with patients about to undergo chemotherapy.

Pharmacists remain one of the most accessible healthcare professionals and are well placed to provide such

appropriate consultation and referrals. Along with providing patients counselling on their chemotherapy and supportive medication regimens, pharmacists can utilize time to make recommendations regarding pharmacological & non-pharmacological recommendations (see Box 2) regarding alopecia prevention strategies and treatment. Pharmacists also remain ideally positioned to screen and refer cancer patients to other supportive resources regarding alopecia and its effects on patient quality of life.

Select one article from a nursing journal focused on a cultural group. In the introduction, state your reason for selecting the cultural group and Summarize the key points of the article.

/in /by

Select one article from a nursing journal focused on a cultural group. In the introduction, state your reason for selecting the cultural group and Summarize the key points of the article.

 

 

Write a paper of 1,000-1,250 words on a specific cultural group. Use the following guidelines:

1. Select one article from a nursing journal focused on a cultural group.

2. In the introduction, state your reason for selecting the cultural group.

3. Summarize the key points of the article.

4. Apply the new information to a practice situation that demonstrates cultural sensitivity in communication, reflecting the reading in chapter 25.

5. Write a conclusion.

Prepare this assignment according to the APA guidelines found in the APA Style Guide

Breast Cancer Awareness And Assessment Health Essay

/in /by

Programme evaluation is one of the key skills required of public health professionals. Evaluating healthcare interventions is important in order to allocate resources efficiently, assist decision-making and inform policy[1].It is also important in order for programme managers to monitor progress in achieving set objectives, improving programme activities, justify need for continuity and accountability to project funders.

The proposed evaluation would be carried out using the CDC framework of programme evaluation which has six steps[2].This evaluation would be somewhat pluralistic in nature as there would be an interplay of the perspectives of different groups[3].However, the dominant perspective would however be that of the policy makers-a managerial perspective[1].This evaluation would be carried out three years after the start of the programme. It would take a long time to achieve the overall programme aim, hence the need for reliance on short or intermediate indicators (Parry)cited in[4]. An evaluation working team would be set up for the proposed evaluation and a leader would be appointed.

In this evaluation, the author would be the lead evaluator and would be responsible forselecting members of the evaluation team, scheduling meetingswith stakeholders, planning, and budgeting funds for the evaluation, addressing data collection needs, reporting evaluation findings, and working with consultants whose services may be required. Prioragreement would be on the reasons for carrying out the evaluation, the primary user of the evaluation findings, funding arrangements, time-line for completion of the evaluation and reporting of its findings.

Engaging stakeholders

The programme mainly targets postmenopausal women between 48 and 63 years as breast cancer commonly affects this population. However, the 40-47 age group would be included as early presentation occurs commonly in this population. The key stakeholders involved in the programme are the clients, the Federal Government of Nigeria, the Federal Ministry of Health, Oyo State Ministry of Health, the Ministry of Women Affairs, University College Hospital, Ibadan, programme managers, and staff. Professional associations-Nigerian Medical Association (NMA), Association of Radiologists of West Africa and the Medical Women Association ofNigeria (MWAN) -advocate for the implementation of a national breast cancer screening programme and policy which is currently non-existent[5, 6]. Other stakeholders are advocacy groups-the Genevieve Pink Ball Foundation , Breast Cancer Association of Nigeria (BRECAN),Medicines Plus; media groups-Silverbird Entertainment, Inspirational FM, City People, Genevieve magazine, Globacom Limited-a leading telecommunications firm.

The primary users of this proposed evaluation are the policy makers and the programme management.The findings would determine if the programme is worth its ‘value for money’ and would help inform decision on the whether the programme should be continued and if a screening policy would be implemented. The purpose of the evaluation would be made clear and agreed upon by all key stakeholders from the outset[4].

It would have been possible to develop the logic model for this evaluation using the theory of change approach with the stakeholders. Defining a theory of change which is agreed by all stakeholders can mitigate the effects of causal attribution[4].One representative would be selected from each key stakeholders group to form an evaluation working group. The stakeholders in the team would be asked about their vested interests in the programme, their expectations, and what resources they would put in during the actual implementation of the evaluation.

The Ibadan-Ibarapa Breast Cancer Screening Initiative

The programme was commissioned in December, 2006 in response to the growing concern for the need for early detection of breast cancer. The programme aims is to reduce incidence and mortality from breast cancer in women. Breast cancer screening is a secondary prevention programme that takes the form of physical examination using in combination with radiographic techniques-mammography. Health needs assessment using the epidemiological approach conducted prior to the implementation of the programme revealed that breast cancer is the most common cause of female cancer deaths in Nigeria.

Breast cancer is the most common cancer affecting women globally[7] and in Nigeria [5, 8-11].It accounts for the greatest proportion of cancer deaths in women in Nigeria. Previous surveys showed a rising prevalence in breast cancer in Nigeria from 33.6 per 100,000 in 1992[12] to 116 per 100,000 in 2001[5].A retrospective review of hospital-diagnosed cases of cancer revealed 1,216 cases over a four-year period with breast cancer accounting for 13.9% of the cases[11] .Differences exist between the aggressiveness and survival rates in Nigerian women when compared to other populations[13, 14]. The mean age at presentation is 48 years[5]. The average age at menopause of Nigerian women is 48 years[15, 16]. The intervention targeted at women between 40 and 64 years as early presentation-before menopause-has been observed to be the dominant pattern in this population.

There is generally a low level of awareness and knowledge of early detection breast cancer among Nigerian women [8, 10, 17-19].Despite the burden, there is currently no national policy or programme for early breast cancer detection[5, 18]. There is a high mortality from breast cancer in Nigeria. This is because most present for treatment late[18, 20-22] and tumours are more aggressive, responding poorly to medical treatment[23].Cultural factors and religious influences also affect health seeking behaviours with some detected cases seeking healing from lay or traditional practitioners.

Risk factors for developing breast cancer include age at menopause, at age at first live birth and parity, history of  first-degree relative with breast cancer[24]and smoking. Research evidence supports that early detection of breast cancer leads to improved outcomes. Surveys investigating the knowledge, attitudes and practice of female health care workers showed that with the exception of physicians, there are gaps in knowledge of the risks of breast cancer and low practice of early detection methods [6, 25].

The activities being carried out in this programme are:

  • Breast cancer seminars and workshops for nurses, physicians, community health workers, public health nurses and health promotion specialists in order to increase their knowledge of breast cancer risks and change their attitudes towards screening practices
  • Clinical Breast Examination (CBE) trainings using breast models -donated by the University of Chicago Medical Centre-in order to enhance clinical skills in breast lump detection.
  • Breast cancer education workshops and lectures for postmenopausal women and teaching skills in Breast Self Examination (BSE) to increase their knowledge of the benefits of early detection of breast cancer and to change their attitudes and beliefs on breast cancer
  • Counselling sessions by breast cancer survivors who are volunteers trained to help motivate women in utilising the screening service and reassurance that the benefit of screening outweighs any discomfort felt during the mammography procedure
  • Distribution of IEC (Information, education and communication) materials breast cancer facts leaflets and posters to increase knowledge of breast cancer risks and the benefits of early detection
  • Media campaigns through paid and unpaid advertisements in newspapers and magazines widely read by women; radio jingles in English and the local dialect; role plays on television by volunteers; health promotion messages on television aired in English and Yoruba languages
  • Provision of free Clinical Breast Examination (CBE) and free mammography screening to postmenopausal women between ages 40 to 63 years

Funding is mainly from the Federal Government with equal support from the Breast Cancer Research Foundation and the Genevieve Pink Ball Foundation. Shortage of health care staff and inadequately trained staff contribute to mortality from breast cancer. Cultural and religious beliefs also influence cancer health-seeking behaviours. There is increasing interest in cancer issues and many agencies are getting involved in breast cancer awareness activities.

Focusing the evaluation design

Evaluation design and perspective taken by an evaluation depends on who the primary user of the evaluation is[1].The proposed evaluation takes the managerial perspective[1]. The primary users of this evaluation are the programme managers and the policy makers (health systems). At this stage of the programme, three years after its implementation, it is inappropriate to make judgement based on the achievement of long-term outcomes. It will thus assess the changes in the knowledge, attitudes, and beliefs of the clients concerning breast cancer and the utilisation of the screening service.

Purpose of the evaluation

In future, evaluating the programme would determine if the breast cancer awareness programme and screening leads to a reduction in incidence and mortality from breast cancer in women aged 40-63 years .The proposed evaluation would carried out in order for policy makers to decide the effectiveness of the programme in promoting health i.e. to evaluate the effectiveness of breast cancer screening as a public health policy; to make decisions about continuity of the service in light of its cost-effectiveness in the face of other healthcare needs competing for funds and to assist in policy making and implementation [4]of a national breast cancer screening programme. It would also assist the programme manager in judging fidelity of implementing the programme activities.

The main evaluation questions to be dealt with can be thus can be summarised as follows:

  • Effectiveness-‘Is the programme working as intended?’ i.e.is it achieving the objectives it set out in its mandate?
  • Efficiency- ‘Are the programme activities being produced with minimal use of resources?’

The proposed evaluation would use the Before-After (Type 3) evaluation approach[1] in assessing the effectiveness of the programme in producing the change in knowledge, attitudes and behaviour that would ultimately lead to achievement of the programme’s goal of reducing the incidence and mortality from breast cancer. This evaluation needs to be carried out in a relatively short period and funding for the evaluation is limited. While true randomised controlled trials are said to be the gold standard for evaluation[26], they would be unethical; expensive to conduct and take a really long time to complete. The main problem with this before-after design is the issue of causal attribution- that the results may not be conclusive in proving that the outcomes are as a result of the programme activities[1].The opinions and inputs of the key stakeholders would also be taken into account at this stage[27].Stakeholders opinion would be sought on how the evaluation would be funded ,how long it would be carried out for and what the reasonable level of achievement should be. The number of years the programme has been in existence would help set the standard against which progress is monitored.

Gathering credible evidence-Data collection

The mixture of quantitative and qualitative methods would be used in data collection.Observational methods would be used in collecting some primary data for the evaluation as there are few existing databases from which the relevant information for the evaluation can be obtained. Green and South stress that selecting methods for measuring outcomes of health promotion programmes should be based on concern for “reliability, validity, suitability for purpose, feasibility, consistency with the values and methods of working of the project and appropriateness for use with various groups”[4].Although validity is recognised as being very important in selecting the indicators for evaluation, practical feasibility should also be put into consideration[4]. McNamara fallacy-‘making the measurable important rather than the important measurable’.

Change in the knowledge, attitudes and practice of healthcare workers would be assessed using a structured self-administered questionnaire placed in the staff pigeon holes at the teaching hospital where the programme activities are carried out. The questionnaire would be pre-tested prior to its use for the evaluation. Pertinent questions would reflect social and demographic characteristics of the respondents, level of knowledge about breast cancer, risk factors for its development, symptoms, screening methods known as well as their individual practice of breast self examination (BSE) and screening using mammography as appropriate. The questions would be closed and pre-coded responses would be included in the questionnaire as these are quick to analyse[28].Careful attention would be paid to the wording of the questionnaire and how the information is coded during its design in order to ensure its reliability and validity. The healthcare workers would be sampled using the stratified random sampling technique based on age and gender. Responses would be anonymised to reduce the chances of reporting bias. The number of healthcare workers would be determined from the training register kept by the programme monitoring and evaluation staff and it can be estimated from the survey in the absence of fidelity in the recording of programme activities.

In order to assess if the healthcare workers have developed the appropriate clinical competence in Clinical Breast Examination (CBE).Participants would be observed carrying out the examinations. A hospital researcher skilled in ethnographic methods would be called upon to engage in this aspect of the evaluation. The limitation of this method of investigation is that observer bias is an issue to contend with and the method is not objective[28].To limit observer bias, a different observer would also assess the trained participants-inter-observer comparison[28].The contribution of the Hawthorne effect-a reactive effect which produces bias- is also a limitation worth noting [28].If healthcare staff are aware that they are being studied, they strive to demonstrate that they have the required level of competence in carrying out the breast examination.

Changes in the knowledge, attitudes, and practice of screening in the clients would also follow the before-after method of investigation. Study participants would be randomly selected from the community. Informed consent would be ensured before data collection. Data would be obtained using structured pre-coded questionnaires with allowance for open-ended questions delivered via face-to-face interviews trained interviewers. The interviewers would trained on the social skills of establishing good rapport with people in order to reduce potential bias[28].Information obtained would include socio-demographic variables- age, marital status, level of education, religion, occupation-potential risk factors for developing breast cancer-family history of breast cancer, parity, duration of breast-feeding age at onset of menstruation, age at menopause-knowledge of screening methods-Breast Self Examination(BSE),Clinical Breast Examination(CBE) and mammography and on utilisation of screening services[29].Barriers to accessing service can also be explored. Mailed questionnaires would have taken less time and would be cheaper to administer but consideration is given to the fact that most people in this community do not have mailing addresses and the literacy level is generally low.

Justifying conclusions

Data collected from the surveys would be analysed using appropriate tests with statistical software. The main exposure variables of interest the educational component of the programme and the physician skills training in Clinical Breast Examination(CBE) while the main outcome of interest is the utilisation of mammography as a screening service. Secondary variables of interest are the media campaigns, healthcare workers training, Clinical Breast Examination Other factors that would be explored would be the effect of some key demographic characteristics like age, ethnicity, and level of education on the utilisation of the mammography service. In conducting the analysis, adjustment would be made for potential confounding by other influences.

The before-after status of the women receiving the educational programme would be compared. For the uptake of mammography as a screening method comparison before and after status would also be compared as though a few other mammography centres exist, none is currently running a similar awareness programme that may qualify its use as a non-random control.

The overall results obtained would be compared with the set standards as outlined in the programme objectives or in the absence of this, what was agreed upon at the stakeholders meeting as a measure of success

Ensuring use of the evaluation findings

The findings would be put together as a draft after representing the data in well-presented graphs and tables as appropriate and circulate among the stakeholders. After reviewing the draft with the stakeholders, the results would be disseminated widely in the hospital journals, as a government publication, in women magazines and other publications as defined by the stakeholders.

The results obtained are expected to help inform the development and implementation of a national breast screening policy and programme.

Quality assessment

There are a number of frameworks that have been developed for investigating the quality of healthcare services[30]. The Maxwell’s framework would be used for assessing the quality of the screening service.

Maxwell’s conceptualisation of health care quality is organised around the following six dimensions[31]:

  • Access to services-accessibility in terms of time ,distance and location of services, language and other cultural barriers
  • Relevance to need (for the whole community)
  • Effectiveness (for individual patients)
  • Equity (fairness)
  • Social acceptability(cultural competence)
  • Efficiency and economy.

Effectiveness

The effectiveness of mammography as a screening method has been proven to be beneficial by some studies. A case-control study reported a 50% reduction in mortality from breast cancer using mammography hence supporting its efficacy[32].A recent case control study also demonstrated similar results[33]. Collette et alevaluated a breast cancer screening programme using different methodologies and found that early detection using mammography reduced mortality in the 50-64 age groups[34]. Though a previous meta-analysis demonstrated no benefit to women in the 40-49 age group[35],the well cited Swedish trials have however suggested the need for screening in this age group.

Efficiency and economic evaluation

This would answer the evaluation question: ‘are we making the best use of limited resources?’ The economic evaluation of this programme would take the managerial standpoint to answer the policy makers question on if it is the best ‘value for money’. It is important in making resource allocation decisions[4]. The overall summary of the programme can be succinctly stated as:

Activities- breast cancer education workshops, lectures, and seminars, Clinical Breast Examinations (CBE) for healthcare workers distribution of information leaflets and posters, media campaigns, mammography.

Outputs-Number of educational sessions held, number of healthcare workers trained, no of women reached by educational programme, number of women counselled, number of women screened, and number of IEC materials distributed

Outcomes -increased awareness and knowledge of breast cancer risks and screening methods (short-term outcome)

-increased awareness of early detection (intermediate outcome)

-increase in uptake of breast cancer screening (behaviour change)

Goal-reduction in incidence and mortality from breast cancer (long term impact)

Accessibility, equity, relevance, and acceptability

The issue of accessibility and social acceptability would be addressed in the questionnaire survey of clients after the intervention.Relevance to need was initially addressed in the epidemiological needs assessment prior to programme implementation. In further evaluating the need for the programme with respect to the community, focus group discussions with carefully selected members of the community would be held. Members of women groups who are opinion leaders in the community would be involved in these interviews. This technique enables the evaluator explore in-depth views on how social, cultural, religious, and other barriers that affect the uptake of screening service. However, they are time-consuming; data is difficult to analyse; confidentiality is compromised and interviewer bias is a key issue[28].

References

  • Ovretveit, J., Evaluating health interventions : an introduction to evaluation of health treatments, services, policies and organizational interventions. 1998, Buckingham: Open University Press.
  • Centers for Disease Control and Prevention. Framework for Program Evaluation in Public Health.  1999  [cited 2010 7 February]; Available from: http://www.cdc.gov/eval/framework.htm.
  • Naidoo, J. and J. Wills, Evaluation in health promotion, in Foundations for health promotion. 2005, Baillière Tindall Edinburgh.
  • Green, J. and J. South, Key Concepts for Public Health Practice: Evaluation. 2006, Maidenhead: Open University Press.
  • Adesunkanmi, A.R.K., et al., The severity, outcome and challenges of breast cancer in Nigeria. The Breast, 2006. 15(3): p. 399-409.
  • Akhigbe, A. and V. Omuemu, Knowledge, attitudes and practice of breast cancer screening among female health workers in a Nigerian urban city. BMC Cancer, 2009. 9(1): p. 203.
  • Ferlay, J., et al., Global Burden of Breast Cancer. Li C et al. Breast Cancer Epidemiology, Springer Science, 2008.
  • Okobia, M., et al., Knowledge, attitude and practice of Nigerian women towards breast cancer: A cross-sectional study. World journal of surgical oncology, 2006. 4(1): p. 11.
  • Okobia, M.N. and U. Osime, Clinicopathological Study of Carcinoma of the Breast in Benin City. African Journal of Reproductive Health / La Revue Africaine de la Santé Reproductive, 2001. 5(2): p. 56-62.
  • Adebamowo, C.A. and O.O. Ajayi, Breast cancer in Nigeria. West African Journal of Medicine, 2000. 19(3): p. 179-91.
  • Nggada, H.A., et al., Breast Cancer Burden in Maiduguri, North Eastern Nigeria. The Breast Journal, 2008. 14(3): p. 284-286.
  • Ihekwaba, F.N., Breast cancer in Nigerian women. British Journal of Surgery, 1992. 79(8): p. 771-775.
  • Ikpatt, O.F., et al., Breast cancer in Nigeria and Finland: epidemiological, clinical and histological comparison. Anticancer Research, 2002. 22(5): p. 3005-12.
  • Huo, D., et al., Population Differences in Breast Cancer: Survey in Indigenous African Women Reveals Over-Representation of Triple-Negative Breast Cancer. Journal of Clinical Oncology, 2009. 27(27): p. 4515-4521.
  • Okonofua, F.E., A. Lawal, and J.K. Bamgbose, Features of menopause and menopausal age in Nigerian women. International Journal of Gynecology & Obstetrics, 1990. 31(4): p. 341-345.
  • OlaOlorun, F. and T. Lawoyin, Age at menopause and factors associated with attainment of menopause in an urban community in Ibadan, Nigeria. Climacteric, 2009. 12(4): p. 352 – 363.
  • Okobia, M., et al., Knowledge, attitude and practice of Nigerian women towards breast cancer: A cross-sectional study. World journal of surgical oncology, 2006. 4: p. 1 – 9.
  • Oluwatosin, O.A. and O. Oladepo, Knowledge of breast cancer and its early detection measures among rural women in Akinyele Local Government Area, Ibadan, Nigeria. BMC Cancer, 2006. 6(1): p. 271.
  • Odusanya, O.O., Breast cancer: knowledge, attitudes, and practices of female schoolteachers in Lagos, Nigeria. Breast J, 2001. 7(3): p. 171-5.
  • Ezeome, R.E., Delays in presentation and treatment of breast cancer in Nigeria. J Clin Oncol (Meeting Abstracts), 2009. 27(15S): p. 1527-.
  • Ekanem, V.J. and J.U. Aligbe, Histopathological types of breast cancer in Nigerian women: a 12-year review (1993-2004). African Journal of Reproductive Health, 2006. 10(1): p. 71-5.
  • Ukwenya, A., et al., Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. South African Journal of Surgery, 2008. 46(4): p. 106.
  • Gukas, I.D., et al., Clinicopathological features and molecular markers of breast cancer in Jos, Nigeria. West African Journal of Medicine, 2005. 24(3): p. 209-13.
  • Negri, E., et al., Risk factors for breast cancer: pooled results from three Italian case studies. American Journal of Epidemiology, 1988. 128(6): p. 1207-1215.
  • O. Odusanya, O.O.T., Olumuyiwa, Breast Cancer Knowledge, Attitudes and Practice among Nurses in Lagos, Nigeria. Acta Oncologica, 2001. 40(7): p. 844-848.
  • Black, N., Why we need observational studies to evaluate the effectiveness of health care. BMJ, 1996. 312(7040): p. 1215-1218.
  • U.S. Department of Health and Human Services. Centers for Disease Control and revention. Office of the Director, O.o.S.a.I., Introduction to program evaluation for public health programs: A self-study guide 2005: Atlanta, GA.
  • Bowling, A.,

    Research methods in health:investigating health and health services

    . 2002, Buckingham: Open University Press
  • Akhigbe, A.O. and V.O. Omuemu, Knowledge, attitudes and practice of breast cancer screening among female health workers in a Nigerian urban city. BMC Cancer, 2009. 9: p. 203.
  • Gray, S., The contribution of health services to public health, in Public Health for the 21st Century:new perpectives on policy,practice and participation, J. Orme, et al., Editors. 2007, Open University Press: Maidenhead.
  • Maxwell, R., Quality assessment in health. British Medical Journal, 1984. 288(6428): p. 1470-1.
  • Walter, S.D., Mammographic screening: case-control studies. Annals of Oncology, 2003. 14(8): p. 1190-1192.
  • Puliti, D., et al., Effectiveness of service screening: a case-control study to assess breast cancer mortality reduction. British Journal of Cancer, 2008. 99(3): p. 423-427.
  • Collette, H.J., et al., Further evidence of benefits of a (non-randomised) breast cancer screening programme: the DOM project. Journal of Epidemiology and Community Health, 1992. 46(4): p. 382-386.
  • Kerlikowske, K., et al., Efficacy of Screening Mammography: A Meta-analysis. JAMA, 1995. 273(2): p. 149-154.

An argument in favor of what the U.S. Supreme Court did in Kelo is that although some individuals are displaced they are paid well for their land and the majority of the community benefits. The philosophy of Utilitarianism supports this result. It says a moral act is one which provides the greatest good for the greatest number.

/in /by

An argument in favor of what the U.S. Supreme Court did in Kelo is that although some individuals are displaced they are paid well for their land and the majority of the community benefits. The philosophy of Utilitarianism supports this result. It says a moral act is one which provides the greatest good for the greatest number.

1. What are the pros and cons of this philosophy?

It makes somewhat sense as to why under certain circumstances there is a need for the U.S. Supreme Court to side with what the beneficial factors are to society when it comes to certain developments. I feel that it would need to be a moral act that makes sense just as stated that it should provide the greatest good for the greatest number. It makes a lot of sense in certain case scenarios where if in certain areas that would need to have a hospital built in order for public to use in case of emergencies or certain health needs.

I personally would be willing to settle and find somewhere else to move for this cause. The cons of following the philosophy of Utilitarianism would be as if instead of building a hospital and goes right on ahead and builds a large x-rated adult shop would be a terrible thing to do. This would look bad through all aspects of the idea or build and would not be morally beneficial or good for the greatest number of people in the area.

2. Do you agree with this philosophy as applied to the situation in Kelo?

In reference to the Kelo case, it was a very sad story and the outcome did not result in any good in the end. It was not morally or ethically right to take over the land that Kelo and others lived on.

The story has not ever fulfilled its purpose or reasoning. It was unjust and did not seem to have precedence. It was nice to hear that the public stood up to say the least and leaving a historical imprint so that it doesn’t happen again, at least hopefully.

Compare ways in which the concepts of “God,” “Person,” “Environment,” “Health,” and “Nursing” would be defined according to Colossians 1.

/in /by

Compare ways in which the concepts of “God,” “Person,” “Environment,” “Health,” and “Nursing” would be defined according to Colossians 1.

 

Read Colossians 1 in the Bible. Compare ways in which the concepts of “God,” “Person,” “Environment,” “Health,” and “Nursing” would be defined according to Colossians 1.
Please write 6 substantial post based this discussion. Each indiviual post with minimum 4 sentences with proper citations.
Answer

Business management homework help
This is property of essayprince.org. Welcome for all your Research paper needs and our professional tutors will help you from start to finish. Sign up NOW and fulfill your Research paper help needs

Explain how sexual attitudes and behaviors are perceived and displayed within each culture.

/in /by

Explain how sexual attitudes and behaviors are perceived and displayed within each culture.

 

Cultural Sexual Behaviors

For this Assignment, choose one sexual attitude (e.g., abstinence, monogamy, etc.) and one sexual behavior (e.g., chastity, infidelity, etc.).

The Assignment (4 pages)

Use the African culture and select another culture of interest to you.
Compare the similarities and differences of sexual attitudes and behaviors in each culture.
Describe the cultural factors that influence sexual attitudes and behaviors.
Explain how sexual attitudes and behaviors are perceived and displayed within each culture.
Be specific and provide examples.

Please use these as reference:
Course Text: The Handbook of Culture and Psychology
Chapter 9, “Culture and Moral Development”

Article: Bedford, O., & Hwang, K. (2003). Guilt and shame in Chinese culture: A cross-cultural framework from the perspective of morality and identity. Journal for the Theory of Social Behaviour, 33(2), 127–144.
Retrieved from the Walden Library using the Academic Search Complete database.

Article: Commons, M., Galaz-Fontes, J., & Morse, S. (2006). Leadership, cross-cultural contact, socio-economic status, and formal operational reasoning about moral dilemmas among Mexican non-literate adults and high school students. Journal of Moral Education, 35(2), 247–267.
Retrieved from the Walden Library using the Academic Search Complete database.

Article: Humphries, M. L., & Jagers, R. J. (2009). Culture: A possible predictor of morality for African American adolescents. Journal of Research on Adolescence, 19(2), 205–215.
Retrieved from the Walden Library using the Academic Search Complete database.

Article: Jensen, L. (2008). Through two lenses: A cultural–developmental approach to moral psychology. Developmental Review, 28(3), 289–315.
Retrieved from the Walden Library using the ERIC database.

Article: Sunar, D. (2002). The psychology of morality. In W. J. Lonner, D. L. Dinnel, S. A. Hayes, & D. N. Sattler (Eds.), Online Readings in Psychology and Culture (Unit 2, Chapter 11). Retrieved from https://www.wwu.edu/culture/Sunar.htm

Gardiner, H., & Kosmitzki, C. (2011). Lives across cultures: Cross-cultural human development (5th ed.). Boston, MA: Prentice Hall.

Effects of Red Bull on Young Adults

/in /by

Research Proposal

Aims

The aim of this study is to investigate the acute effects of drinking a can of Red Bull, which includes taurine and caffeine, on heart rate and blood pressure in healthy young adults. It is hoped that this study will lead to the mandatory regulation of the amount of caffeine contained in all energy drinks and the mandatory inclusion of a warning label on every can to hopefully eliminate adverse effects due to the overconsumption of energy drinks.

Introduction

Energy drinks such as Red Bull®, V®, Rockstar® and Mother® are caffeinated beverages promoted for improving physical performance, concentration, endurance and also being beneficial in increasing stamina. Young adults, especially students and athletes, are the target of advertising campaigns by companies that manufacture these beverages. Energy drinks account for approximately 20 per cent of beverages sold in Australian convenience stores. The Food Regulation Standing Committee found that energy drinks sales in Australia and New Zealand have increased from 34.5 million litres in 2001 to 155.6 million litres in 2010.

Energy drinks contain varying quantities of caffeine (80–500 mg), taurine (1000–2000 mg), guarana, amino acids, sugar and vitamins. Caffeine is the most commonly consumed stimulant drug worldwide, with approximately 90% of adults regularly consuming it, but unlike many other stimulant drugs, it is legal and unregulated worldwide. At the cellular level, caffeine increases intracellular calcium and releases noradrenaline and intensifies dopamine receptors with stimulation of the cardiovascular system as well as the brain’s respiratory and vasomotor centers. In healthy adults, a caffeine intake of ≤400 mg/day is considered safe and not likely to result in any adverse effects. Additional amounts of caffeine are often found in energy drinks through additives, including guarana, cocoa, yerba mate, and kola nut. Guarana is a plant that contains caffeine. 40 to 80 mg of caffeine can be contained in each gram of guarana and it may also have a longer half-life due to interactions with other plant compounds. However, these ingredients are not required to be listed under the caffeine content by manufacturers thus the actual caffeine dose in a single serving may exceed that listed on the can.

Taurine is one of the most abundant amino acids in the human body. It is also naturally present in our diet as it is contained in meat and seafood. Taurine is also synthesized in the liver from the amino acid cysteine, as well as from other sulphur compounds. It is present in relatively high amounts in skeletal and cardiac muscle and it is involved in the formation of bile salt, neuronal excitability, cell membrane stability and the modulation of calcium flow. There is no evidence of adverse effects in humans in short term studies with large daily doses (6000 mg per day for 42 days) of Taurine.

Both caffeine and taurine have been shown to have direct effects on cardiac function and hemodynamic status. A pilot study on healthy volunteers in the United States found that one can of Red Bull containing 80 mg of caffeine increased BP compared to 80 mg of caffeine alone. Another study investigated the effects of energy drink consumption on hemodynamic and electrocardiogram (ECG) parameters in healthy young adults and reported a significantly increased heart rate and blood pressure within 4 hours (Steinke and Lanfear). In another study, the influence of a multi constituent energy drink and its individual ingredients on the heart was compared and found that stroke volume and diastolic intake velocity were significantly increased in the red bull group compared to a similar drink that contained caffeine but not taurine.

A poisons information line in NSW reported almost 300 cases of toxicity due to energy drink consumption, with the average age being 17 years old and the average number of drinks consumed in one session being 5. The most common physical effects reported included peripheral vasodilation, palpitations, agitation, tremor, insomnia and gastrointestinal upset. 128 people were hospitalized and 21 people had symptoms of serious neurological or cardiac toxicity. Most worrying is the growing trend of young people combining these energy drinks with alcohol. Research from the United States has shown that individuals who combine alcohol and caffeinated energy drinks consume more alcohol more often compared to individuals who don’t consume alcohol and caffeinated energy drinks. It has also shown that that there is a significantly higher prevalence of alcohol related consequences, including alcohol poisoning, impaired driving, physical injury, and sexual victimisation.

Energy drinks have previously been classified and marketed as dietary supplements, which have minimal regulation. Canada has recently changed their classification to foods which have tighter regulations. It is time that energy drinks are subjected to greater regulation worldwide, this includes regulating the amount of caffeine in a single serving. Only a few energy drinks have a fine-print warning label, which state that they may not be safe for children, caffeine sensitive individuals, or for pregnant or nursing women however this is not mandatory it is up to the company to add this.

It should be noted that, although energy drinks have been sold worldwide for more than a decade, only a few published studies have examined their effects on health and well-being. However, studies have not been conducted on an isolated island population with a defined population such as this.

Research Plan/ Methods

Participants

The participants for this study are healthy young adult Islanders from a virtual environment called The Island. The Island provides a unique sample population. 30 Islanders either gender, aged 18–30 years will be selected at random using a random number generator and asked if they would like to participate in the study. A minimum and a maximum will be entered into the random number generator for the number of towns on the island, the number of houses in the town were and also for the number of residents in the house if more than one resident aged 18-35 years old lives in that particular house. The study will be unblinded. Each resident will be assigned a number from 1-30 with numbers 1-10 receiving the placebo, which contained no caffeine or other stimulant, and thus the control group, numbers 10-20 receiving the 1 Red Bull (80 mg of caffeine) and numbers 20-30 receiving 5 Red Bulls (400 mg of caffeine). Subjects have to meet a set of inclusion criteria obtained by a medical history/ task history examination blood pressure < 120/80 mmHg, non-smoking, absence of systemic diseases (including hypertension, diabetes, or vascular disease), evidence of abstinence from caffeine or caffeine beverages, and abstinence from use of any systemic drugs and/or alcohol. Subjects will be excluded if they have blood pressure outside the specified range, are smokers, if they have a systemic disease, if they have recently ingested caffeine, drugs or alcohol.

Instruments

Brachial artery systemic blood pressure will be assessed by automated sphygmomanometry and pulse rate will be measured using a heart rate monitor.

Procedure

Three solutions were administered: Placebo and Energy drinks with 80 mg and 400 mg of caffeine. As a control, 10 of the subjects were required to consume 250 mL of water. Of the two groups consuming the energy drinks one group will be required to drink 1 red bull which contains 80mg caffeine and 1000mg Taurine per 250ml and other group will be required to drink 5 Red Bulls which contains 400 mg caffeine and 5000mg Taurine per 1250ml. The reason we chose the two different doses of Red Bull are due to claims by Red Bull that 1 can of Red Bull contains the same amount of caffeine as a regular cup of coffee, which is 80mg. An

extensive review

of the scientific literature on caffeine was conducted by Health Canada. They concluded from the review that if the general population of healthy adults limit their consumption of caffeine to 400 mg per day they will not be at risk of any potential adverse effects thus we decided to use a maximum dose of 5 Red Bulls even though there is a warning to not have more than two 250ml cans per day. Measurements of BP and pulse rate were performed before (resting baseline) and after (30, 60, 90 min) ingestion of each of these solutions.

Statistical Analysis

The results for all subjects for each group, at each time point, will be combined and presented as the means ±standard deviation, to allow for statistical comparison. A one way analysis of Variance (ANOVA) will be used to see if there is any difference between all the measured variables. Statistical analysis of the data was performed with SPSS 16.0 software (SPSS Inc., Chicago, IL, USA).

P

-values less than 0.05 were considered as statistically significant.

Significance

It is expected that both doses of red bull will increase heart rate and systolic and diastolic blood pressure when compared to the control group however a larger response is expected in the group who consumed 5 cans of red bull. . It is hoped that this study will lead to the mandatory regulation of the amount of caffeine contained in all energy drinks and the mandatory inclusion of a warning label on every can to hopefully eliminate adverse effects due to the overconsumption of energy drinks.

References

  1. Franks AM, Schmidt JM, McCain KR, et al. Comparison of the effects of energy drink versus caffeine supplementation on indices of 24-hour ambulatory blood pressure.

    Ann Pharmacother

    2012; 46:192-199.
  2. Gunja N and Brown JA. Energy drinks: Health risks and toxicity.

    Med J Aust

    2012; 196:46-49.
  3. Koczwara K. Moms talk: Are energy drinks safe for teens?

    Fountain Valley Patch

    , April 26, 2012.
  4. Knowler W. Energy drinks must now carry warnings.

    Independent Online

    , May 3, 2012.
  5. Szotowska M, Bartmanska M, Wyskida K, et al. Influence of “energy drinks” on the blood pressure and the pulse rate in healthy young adults.

    J Hypertension

    2012; 30: e369.
  6. Wolk BJ, Ganetsky M, Babu KM. Toxicity of energy drinks.

    Curr Opin Pediatr

    2012; 24:243-251.

FINER

Feasible

This study is feasible as it has an adequate number of subjects and as the sample size is small, the cost of the trial is reduced. This study also has adequate expertise in the field as all staff members have been instructed by experts in the field on how to use the instruments used to measure heart rate and blood pressure. A nurse will also be present during all experimental procedures to ensure the health and safety of all the subjects. James Baglin who is a statistician at RMIT will be assisting with the statistical analysis of the results. The scope of the study is manageable as the experimental procedure only goes for 90 minutes therefore subjects do not have to do repeat testing after this time. Islanders are also easy to contact and find on the Island. This study will be funded by the National Health and Medical Research Council thus lack of funding will not be an issue.

Interesting

The study will be hopefully be able to shine a light on the dangers of caffeine in energy drinks in a sample population which is of great benefit to researchers and experts alike and also to the community.

Novel

Only a few published studies have examined the effects of energy drinks on health and well-being. However, studies have not been conducted on an isolated island population with a defined population such as this.

Ethical

All of the studies participants are healthy young adults aged between 20-35 years who have consented to be in our study. No children, disabled, senior, mentally or physically ill Islanders have been included in the study. There also aren’t any vulnerable islanders or islanders in dependant relationships in this study. This study is categorised as risk 2 –non invasive project as the subjects will be receiving either red bull or placebo and heart rate and blood pressure will be measured over a period of 90 mins. Participants are also not payed in this study.

Relevant

It is hoped that this study will lead to the mandatory regulation of the amount of caffeine contained in all energy drinks and the mandatory inclusion of a warning label on every can to hopefully eliminate adverse effects due to the overconsumption of energy drinks.

This research proposal was written by a student and is published as an example. See

How to Write a Dissertation Proposal

on our sister site UKDiss.com for guidance on writing your own proposal.

What will one require and expect in your own health care settings/services to believe that a facility/provider and their services are of high quality?

/in /by

What will one require and expect in your own health care settings/services to believe that a facility/provider and their services are of high quality?

1. How does quality in health care setting differ from quality and expectations of consumers in non-health care settings such as restaurants, clothing stores, automobile purchases, etc.

2. How is the long term care setting unique from other health care settings (such as acute care or physician practices) when it comes to the populations it serves and when measuring, evaluating and continuously improving quality?

3. What will you require and expect in your own health care settings/services to believe that a facility/provider and their services are of high quality? What are your expectations?