A Summary of fewer than 150 words should state the purpose of the study or investigation, basic procedures, main findings (giving actual results not just a broad description) and their statistical significance (using actual p values), and principal conclusions. The Summary should not be structured nor in note or abbreviated form. It should not state that ‘the results are discussed’ or that ‘work is presented’. Abbreviations should not be used except for units of measurement. Use the same order when discussing the methods and results as in the main body of the text, and always mention the groups in the same order.

Introduction:

Perioperative hypothermia, defined as a core temperature below 36°C, is still one of the most common side effects of general anaesthesia (21, 12) and results from low preoperative core temperatures (19), anaesthetic-induced inhibition of thermoregulatory defenses with redistribution of heat after induction of anaesthesia combined with a cold surgical environment, administration of unwarmed intravenous fluids, and evaporation from surgical incisions (25).

Several prospective, randomized trials and retrospective studies have shown that perioperative hypothermia is associated with numerous adverse effects and outcomes (24). Following head and neck surgery perioperative hypothermia can cause delayed extubation, the development of early perioperative wound complications e.g. neck seromas, and flap dehiscence (21, 26). Although the authors of these studies recommend active warming for patients at risk for intraoperative hypothermia (21, 26) most patients are not actively warmed during head and neck surgery.

The purpose of this prospective, randomized, controlled study was to test the hypothesis that the use of a new conductive warming system (PerfecTempâ„¢, The Laryngeal Mask Company Limited, St. Helier, Jersey) in combination with insulation is superior to reduce the incidence of intraoperative and postoperative hypothermia during head and neck surgery compared to insulation only.

Methods:

After approval of the protocol by our local hospital ethics committee, 40 patients were recruited. Written, informed consent was obtained from all patients on the day prior to anaesthesia and surgery. All patients in the study were required to be adults between 18 and 75 yrs, to have American Society of Anesthesiology physical status I-III and to undergo elective, head or neck surgery that was scheduled to last between 90 min and 180 min.

The exclusion criteria were: age > 75 yr; body mass index < 20 or > 30 kg/m²; preoperative temperature > 38°C or < 35°C; pregnancy or a history of thyroid disease, operating time < 60 min or > 180 min.

All patients were premedicated with 7.5 mg oral midazolam. General anaesthesia was induced with propofol (2 to 2.5 mg per kg of body weight) and remifentanil (0.2-0.5µg/kg) followed by rocuronium (0.4-0.6 mg/kg) to facilitate tracheal intubation. Anaesthesia was maintained with infusions of remifentanil and propofol titrated to maintain adequate anaesthetic depth and hemodynamic stability.

The ambient temperature of the O.R. was 19°C. Sublingual temperatures were measured preoperatively with an electronic thermometer (Geratherm rapid, Geratherm Medical AG, Geschwenda, Germany). During all measurements, sublingual placement and mouth closure was carried out by member of the study team (A.R.) experienced in the use of this device. Following induction, until the end of surgery, oesophageal temperatures were measured every 15 minutes using a temperature probe (TEMPRECISE #4-1512-A, Arizant International Corp. Eden Prairie, MN, USA) inserted 30 to 35 cm into the distal oesophageus.

All patients were identified through the daily surgical schedule. A computer generated randomisation list with four blocks of ten patients was used to allocate patients to either the treatment group (conductive warming and insulation) or control group (insulation only).

In the treatment group the patients were positioned supine on the conductive warming mattress (190.5 cm x 50.8 cm) (LMA PerfecTempâ„¢, The Laryngeal Mask Company Limited, St. Helier, Jersey) placed on the operating table, as suggested by the manufacturer. Then the patients were immediately insulated with a standard hospital duvet (188 cm x 122 cm), filled with Trevira (100% polyester) (Brinkhaus GmbH & Co. KG, Warendorf, Germany) with an insulation value of 1.29 clo (6). The conductive patient warming system was set to a temperature of 40.5°C throughout the study and warming was stopped when the oesophageal temperature was > 37.5°C.

Patients of the control group were positioned supine on the operating table and were immediately insulated with the standard hospital duvet.

All intravenous fluids were infused at room temperature. The duration of anaesthesia and surgery (time from skin incision to last suture) were recorded.

Power analysis, assuming a clinically important reduction in the incidence of intraoperative and postoperative hypothermia from 50 % to 90% suggested that eleven patients were required in each group (α = 0.05; β = 0.2). To compensate for unexpected dropout of patients with a shorter or longer duration of surgery than planned the initial total number of recruited patients was increased to 20 patients in each group.

Comparisons of nominal data were made using the Fisher’s exact test. A Kolmogorov-Smirnov test was used prior to parametric testing to ascertain that values came from a Gaussian distribution. Comparisons of normally distributed data were made using the Student’s t-test. Comparisons of not normally distributed data were made using the Mann-Whitney-U test. Time-dependent changes of core temperature were evaluated using repeated-measures analysis of variance (ANOVA) and post hoc Scheffé’s test. Results are expressed as means ± SD or as median and interquantil range as appropriate. A value for p < 0.05 was considered statistically significant. STATISTICA for Windows 9.0 (StatSoft Inc., Tulsa, OK, USA) was used for all analyses.

Results

A total of 86 patients were assessed for eligibility. 25 patients could not be asked to participate, because they came to the hospital on the day of the operation. 21 patients refused to participate. Of the 40 patients recruited, 10 patients had to be excluded because of an operating time below 60 minutes (five patients in the treatment and four in the control group) or above 180 minutes (one patient).

Figure 1: Flow diagram of the study

In three patients the conductive warming mattress did not fully heat up to 40.5°C for unknown technical reasons. These patients were still included in the data analyses. Data were therefore complete for 15 patients in each group. Patient characteristics, ambient temperature of the O.R., core temperatures before induction of anaesthesia and duration of surgery were not different (table 1).

Table 1 Patient characteristics and perioperative variables. Values are presented as mean values ± SD, median and interquantil range [IQR] or numbers of patients.

Variable

Treatment group (n = 15)

Control group (n = 15)

P-value

Age [yr]

51±18

51±15

0.99

Sex [m/f]

7/8

10/5

0.46

Height [cm]

173±11

175±10

0.64

Weight [kg]

74±16

80±9

0.21

Temperature of the O.R [°C]

19±1

19±1

0.3

Core temperature before induction of anaesthesia [°C]

36.1±0.4

35.9±0.5

0.33

Duration from positioning on the conductive warming mattress to induction of anaesthesia [min]

7 [IQR: 5-9]

–

–

Duration of anaesthesia [min]

118±28

122±38

0.74

Duration of surgery [min]

97±25

103±37

0.61

The ANOVA identified a significantly higher core temperature in the treatment group at 45, 60, 75, 90, 105 and 120 min (Figure 2). Further testing was futile as there were only three patients with a longer duration of surgery included.

Figure 2 Mean pre- and intraoperative temperatures of the treatment group and control group. Error bars represent SD. In each group data were complete for at least sixty minutes.

Furthermore, Fishers’s exact test confirmed a lower incidence of intraoperative (3 vs. 9 patients; p = 0.03) and postoperative hypothermia (0 vs. 6 patients; p = 0.008) in the treatment group. However, the mean duration of hypothermia was not significantly shorter in the treatment group (55±17 min vs. 80±51 min; p = 0.42). No adverse effects could be observed.

Discussion:

This prospective, randomized, controlled study demonstrates that, during head and neck surgery under general anaesthesia, a conductive warming mattress combined with insulation significantly reduces the incidence of intraoperative and postoperative hypothermia compared to insulation only. With this approach the incidence of intraoperative and postoperative hypothermia could be reduced significantly. However, the mean intraoperative duration of mild hypothermia could not be reduced significantly.

Redistribution of body heat from the core to the periphery was unusually small in this study and similar in both groups as core temperature decreased only 0.1°C in the control group and 0.2°C in the study group. In most clinical studies redistribution of heat after induction of anaesthesia leads to a reduction in core temperature of about 0.3°C to 0.8 °C (3, 4, 8, 28) in the first hour whereas under experimental conditions it can reach up to 1.7°C (17). This small decrease in core temperature may be explained by the fact that patients were kept comfortably warm during the whole preoperative period (ward, transport to the O.R. and induction of anaesthesia) with the same good insulating hospital blanket as used intraoperatively. This approach refers to the recent NICE guideline “Inadvertent perioperative hypothermia. The management of inadvertent perioperative hypothermia in adults” (22).

Patients during head and neck surgery are often thought to have a relatively low risk for perioperative hypothermia because in most cases no body cavity is opened, the surgical incisions as well as blood losses are small. This is probably why there are almost no studies about perioperative hypothermia and its prevention during head and neck surgery. However, many patients undergoing head and neck surgery are prone to hypothermia by advanced age (21, 14, 27) and cancer with associated malnutrition and low body weight (21, 16). According to their preoperative risk profile (e.g. ischemic heart disease, diabetes mellitus, chronic obstructive pulmonary disease, preoperative radiotherapy, preoperative chemotherapy) (20, 26) they are often vulnerable to hypothermia associated complications. These complications include an increasing incidence of myocardial ischemia (10, 11, 11) which is also a relevant complication after reconstructive head and neck surgery (7), augmenting blood loss (23), decreasing resistance to surgical wound infections or increasing local wound complications (21, 15, 18, 26), thus prolonging hospitalization.

The few existing studies were particularly focused on longer operations like parotidectomies, neck dissections (2) and reconstructive surgery with free tissue or regional flaps (13, 26). In the study of Agrawal et al. (2) the incidence of perioperative hypothermia was 65% in the unwarmed group showing clearly the high risk of perioperative hypothermia in patients during head and neck surgery. In our study with relatively short operations we observed an incidence of perioperative hypothermia of 40% in the control group. In contrast to the study of Agrawal et al. (2) we used a high insulation of 1.29 clo for these patients which is much more than the insulation value of most commercially available materials designed for use in the operating room. With this insulation heat losses from the covered skin can be reduced about 70%. (6). In most of our patients this insulation was able to maintain a stable thermal steady state with a relative constant core temperature. However, this thermal steady state was at a core temperature of about 36.0°C with many patients being hypothermic.

In general the efficacy of posterior patient-warming systems is limited (5, 9, 13, 21). These devices have the disadvantage that warming the back of the patient in the supine position is suboptimal. During surgery, little heat is lost from the back (9) and heat gain via the back is also limited, resulting in a small change in heat balance. However, in this special setting the additional heat generated by the conductive warming system leads to a positive thermal balance and an increasing core temperature after 30 minutes. In contrast to conventional circulating water mattresses the new conductive system is made of thick viscoelastic foam. This material enhances contact between the mattress and the back, thereby reducing thermal contact resistance and increasing the efficacy of heat exchange.

In contrast to forced-air warming the combination of good insulation and conductive warming has several advantages. There are no expensive disposables elements, low costs for maintenance, low power consumption and no relevant noise emission (28). Another advantage is that is very easy to use the system for prewarming as soon as the patient can be placed on the operating table when the controller unit is mounted at the operating table.

Our study has several limitations. First, two different anatomic locations were used to measure core temperature (oral temperature before induction of anaesthesia and oesophageal during general anaesthesia). However, both methods are reasonable methods for core temperature measurements and we could record the first reliable oesophageal temperature 5 minutes after induction of anaesthesia so that this temperature can serve as a reliable starting temperature.

Second, five patients per group had to be excluded from data analyses because the operation time was shorter or longer than planned. Nevertheless, we had to exclude these patients because it is not advisable to compare operations with durations of 30 minutes with operations of more than 3 hours.

Finally we did not fully take advantage of the possibility to prewarm our patients with the conductive system. On average time from the beginning of warming to induction of anaesthesia was only seven minutes. It seems to be likely that longer prewarming periods would enhance the efficacy of the conductive warming mattress.

Conclusion

The combination of good thermal insulation and conductive warming is effective to prevent perioperative hypothermia during head and neck surgery. In contrast to other warming methods there are no expensive disposables, low costs for maintenance, low power consumption and no relevant noise emssion.

HIV stands for Human Immunodeficiency Virus that attacks the immune system. This virus causes AIDS and interferes with the body’s ability to fight off infections. Majority people develop flu-like symptoms within a week or two after the virus has entered the body. These symptoms contain fever, headache, muscle aches, rash, and a sore throat. HIV spreads through fluids such as blood, semen, vaginal and rectal fluids. This virus also spreads through needles. HIV is diagnosed mostly by the testing of saliva and blood for antibodies to the virus. One primarily used treatment is medications that are prescribed by the doctor. Resources are available for individuals that are dealing with this virus such as counseling, joining a support group, and stress-free activities. African American women are one of the highest targeted ethnicity groups for HIV/AIDS. These women suffer from this virus for the rest of their lives, or some do not know that they are infected with HIV/AIDS.

The HIV/AIDS African American women population will impact health services administration and management in many ways. There will be a lot of planning, organizing, directing, and controlling in the health services. Health care administrators and management will educate populations at risk or living with HIV about effective tools, encourage people to learn their HIV standing and remain a believer to HIV treatment or prevention that is the most effective for these individuals. Organizations will support local and state health sectors and community-based facilities and clinics that offer HIV prevention and care services that include re-enforcing care for people who do not attend these services. They also want healthcare workers to improve efforts to decrease the chances that people miss for HIV prevention counseling, testing or association to HIV care. These organizations also want to embrace policies to help find and re-involve those people who are no longer under care anymore.

Today, most African American women do not have any insurance. These women are uninsured based off their income or just because they do not know how to get insured. Women that are affected with this chronic virus (HIV/AIDS) tend to suffer because they lack insurance. This has no certain impact on insurance rates because most of these women are not covered anyway. Some insurance companies do not pay for the cost of HIV/AIDS prescription meds. Women with no or little insurance have to deal with this virus for the rest of their lives. The insurance rates improve based off the amount you pat monthly, income of the owner, and the number of people on the policy. African American women tend to be treated or looked at differently based off the past or having a chronic virus such as HIV. Employees or Employers cannot be affected by this physically, but they can be emotionally. HIV/AIDS is one of the worst viruses that someone has to deal with. This virus can affect you mentally, emotionally, and physically. Employees can be affected by it by having to deal with the patient’s and the way they cope with it. Employees also can be affected when they have to tell a patient that they are positive for this virus. Employers can be affected by this by the reputation they hold for HIV/AIDS patients. These employers need to try to be the best to help and comfort these patients with this virus. The patients tend to look for the best employer when they are suffering for something so horrific. Both the employee and employers are affected and need to focus on the best thing to help patients to get over this horrible time.

HIV/AIDS burden estimate rates are obtained from the Global burden of disease. The Global Burden of Disease is a comprehensive assessment estimated 291 diseases and injuries from 1990 to 2010. In the last few decades, HIV has been one of the significant health challenges around the world. HIV is the leading cause of burden and mortality. Burden and Mortality have increased massively since 2004. The difficulty for HIV/AIDS differs across each demographic area and regions. The CDC provides a cost-effective analysis of the cost of HIV. The cost-effectiveness analysis is a program that is designed to evaluate the value and outcome of the intervention. A vast part of the financial weight of HIV/AIDS is the medicinal expenses of treating people with HIV. Medicinal cost gauges are regularly founded on human services usage by people with HIV illness. The costs related to social insurance usage in every illness organize summed over all sickness stages from contamination to death. The average yearly expense of HIV care in the ART period was assessed to be $19,912 (in 2006 dollars; $23,000 in 2010 dollars). The latest distributed gauge of lifetime HIV treatment costs was $367,134 (in 2009 dollars; $379,668 in 2010 dollars).

According to HIV.GOV, people living with HIV/AIDS can live a healthy normal life if they are receiving adequate treatment. Many people living with this illness can continue with their careers. As an employee living with HIV and AIDS, people have a right to continue their employment to remain in that workforce and receive many benefits and everything that job has to offer to any other employee and equal right employee opportunities. There are several locals, state, and federal laws that determine how employers design workplace programs for employees with HIV/AIDS; however, many are African American women. Individuals with this disease can request for accommodations at their place of employment.  An accommodation could be something simple as a different type of chair so that the employee can be comfortable at the workplace. An additional modification could be changing of a job schedule. People with HIV are constantly being seen by healthcare providers to check on their health status. So, the employees may have to miss certain days and be scheduled a bit different than other employees. Supervisors may not be trained to give additional to support to those who have HIV. It is up to management to create positive and supportive environments when they find out that a person lives with this illness.

Leadership however, is very important among management to protect that person who lives with HIV to have a productive and safe work zone. It is best that employees consult with the Human Resources department at their job. Individuals need to be employed to have financial stability. Working a lot will affect many different aspects in a person’s life who deals with this disease. Many people with this disease are often encouraged by HIV counselors, The Social Security Administrations Work Incentives Planning and Assistance Program, and employers at jobs to seek out information that would accommodate their needs status. According to the CDC disclosing status could create supportive relationships with co-workers. It also could create a negative environment disclosing to colleagues and coworkers for the time being. It is that person’s decision to determine which outcome is more realistic in terms of disclosing status. Employees with HIV/AIDS are protected by law under the Americans with Disabilities Act (ADA) of 1990 from discrimination in employment. This law protects all individuals with HIV to be protected from any discrimination. Many African American women faces discrimination in the workplace already. So, this event of them having HIV makes matters worse. Provisions under this law include hiring, work procedures, job training, and compensation all fall under this act. Many places of employment refuse to hire a HIV positive person also refuse to promote and advance those who are affected by this disease. There are many emotional obstacles that are faced by women who have HIV. Many African American are single mothers. HIV/AIDS affects staffing because those who carry this disease are often very ill and sometimes can’t come in to work because their health is declining. People with HIV have many doctors’ appointments they must attend too. Also, being terminally ill affects your work ethics. There will be many times where the management staff needs to be fully staff just in case that person cannot come in today because of their illness. It is always an idea to be fully staffed and have dependable staff when you have an HIV positive employee working at your businesses.

Furthermore, Ethics play a vital role in this HIV/AIDS because the privacy of women with this illness needs to be protected. Ethics is universal ethics applies to either employee or employer. It would be very unethical if a woman at a place of employment discloses her being positive for HIV/AIDS and her coworker discloses that information with other co-workers. If this scenario was to play out the employee can face penalties or could be written up for confidentiality reasons or maybe even terminated. Same way with a person of management that employee’s right should be protected. They need to be able to live in peace and not be judged because of a disease. Many people have negative connotations behind people with HIV/AIDS. People seem to treat them differently. However, fear can also lead people into fearing people who are living with HIV/AIDS. When people do not have accurate information about a certain topic, they place stigmas against those infected. Ethics should be used in handling persons who have this illness such as hiring and treating them fairly.

As far as professionalism goes, professionalism must be inside every workplace for things to run smoothly. People living with this virus should be responsible enough to disclose their status with their employers. Many employers need to be aware of all their employee’s status. People are afraid of what others may feel about them and they might feel like they might get fired because of their status. Also, employers should be professional as far as being discreet about keeping that employees issue confidential. As a supervisor or a manager, it might be a great idea to educate yourself on how to deal with issues related to HIV. It could also might be a great idea to educate employees also about ethics such as medical confidentiality and reasonable accommodation. Everyone should be trained on the workplace HIV/AIDS policies, and about awareness programs that are offered. Displaying cultural competence in dealing with HIV/AIDS will let people know that the work setting has rules and policies that each employee should follow dealing with HIV/AIDS. The key components for developing the components of cultural competence is awareness, attitude, knowledge, and training. Promoting a safe environment with produce positive worker productivity. Additionally, ethics, professionalism, and cultural competence all tie in together and are related because these will always be used to create a better work environment. If employees are adequately trained and consistently reminded of policies everything should be great. As a professional, it should be essential to maintain healthy habits in the workplace in the workplace environment. It is important to meet the needs of each employee with disabilities.

Moreover, the social determinants of health have a lot to do with African American women who have HIV/AIDS. According to Monica Melton, the social determinants of health describe the interrelationship between cultural, economic, and political elements that facilitate vulnerability for HIV infection (Melton 2014). However, more determinants would be behavior, genetics, environment, and medical care. Some examples of the behavior determinant would be the use of alcohol and drugs, smoking, and unprotected sex. Behavior is a significant factor when it comes to these women who have the disease. According to the Intervention Strategies for AIDS/HIV Prevention Among African Americans, African American Women are likely to have suffered childhood sexual abuse (Calderia et al., 2009). Women who experienced sexual abuse during their childhood, often live with that for the rest of their lives. Women who are traumatized from the violence, tend to use alcohol and drugs as a way to cope with their emotion or they will turn to prostitution. Another example of behavior would be refusing to get medical attention. Some women refuse to seek help or treatment once they find out they have the disease. They would instead become depressed, struggle, and then eventually end up dying from the disease. However, sex and age would be examples of genetics, meaning a child can develop the infection while still being in her mother’s womb. Examples of environment would be where a person lives or works. Some women could be homeless, living in a poor rural area, or also even incarcerated. Lastly, an example of medical care would be their access to health care such as Insurance. African American women also have a hard time being able to get the medications they need because some are not able to afford Insurance or the medications without insurance. Moreover, all of those determinants of health have everything to do with African American women who have HIV/AIDS.

Even though HIV deals with the social determinants of health, the health systems are doing everything they possibly can to help with this disease. One way is that there are several different prevention groups to help these women. These groups are made to teach young and old adolescents about practicing safe sex. An example of that would be to use a condom whether it is a male or female one. Another factor would be providing free screenings to get tested for HIV. Another example would be social media. A lot of people and businesses use social media to brand themselves and also get the word out. Some media campaigns are designed to promote healthy behaviors such to increase HIV knowledge, encourage testing for HIV, and also help condom use (Calderia et al., 2009). However, there is also a couple of prevention which is for both the woman and her partner. The couple prevention is a safe environment as well as an excellent way to promote practicing safe sex to both the female and male. The prevention is also for being able to talk about specific issues while the male partner is present meaning that if the male partner is forcing the woman to have sex with him. Majority of today’s HIV cases are due to women being afraid to make their male partner use a condom. Women worry that if they ask their partner to use a condom, it will cause them to separate because the male will think the woman will be accusing him of being unfaithful (Bloom-DiCicco, 2017). However, some women choose not to use a condom because they trust that person.  Several women trust their partner well enough that they do not believe in using condoms. Some women put their lives at risk because they feel like if they are in love with each other, then there is no use of using a condom. They expressed that using condoms and protecting themselves from HIV was unnecessary (Bloom-DiCicco, 2017). A woman has the mindset that if she trusts her partner well enough and she knows that he is not messing around then she knows she will never get HIV. However, not using a condom or practicing safe sex does not only causes HIV, but it also causes herpes, chlamydia, syphilis, or even HPV. In the end, the health systems have come up with several different ways to handle and prevent HIV from occurring; however, it is up to the women if they want to be healthy or not.

There are a lot of services that the Healthcare Organization has had to put in place to help address the issue with African American women who have HIV/AIDS. For example, the HRSA which stands for the Health Resources and Services Administration created the AIDS Service Demonstration Grants. However, these grants provided financial and political capital to the people who are delivering HIV care on the ground (Wilson, n.d.). The HRSA was trying to find a way to help support the clinicians who were out helping as many HIV patients as they could; however, to do that, the clinicians need the funding to be able to do so. Furthermore, the Ryan White HIV/AIDS Program has also taken the time out to provide care as well. Many of the provider sites are medical homes which offer patients a continuum of care that includes HIV primary care along with support and services all under one roof (Wilson, n.d.). The program is designed to make sure that every patient dealing with the disease can get the proper help and care that they need. These medical homes, however, are not designed and set up like hospitals because they want their patients to feel comfortable. The HRSA intends to ensure that the people can trust.

In the United States, research states that African American women are disproportionately affected by HIV/AIDS. In the African American community, HIV/AIDS is an epidemic. The CDC used many targeted communication campaigns to combat HIV/AIDs in African American communities. The mass media uses structured measures to spread HIV/AIDS information as sources, media initiatives, and HIV prevention messages. Process measures are needed in research in communities at risk to determine the formats and channels to deliver information to targeted communication campaigns. Outcome measures can help in the multifaceted approach to end HIV/AIDS disparity affecting African American women (Arya, M., Behforouz, H. L., & Viswanath, K.,2009).

In the late 1990’s, President Clinton declared HIV/AIDS to be a crisis in the African American community. In America, African American women infection rates were measured at 60% of HIV/AIDS cases among women. In the U.S. Population, African Americans make up 13% of it and nearly 50% of all HIV/AIDS cases. Groups, teams, and committees were put in place to organize programs to help African American women living with HIV/AIDS. Data in the United States shows that African Americans represent only 13% of women in this country. Healthcare organizations are a resource for people with HIV/AIDS. Statistics show that HIV infection is the leading cause of death for African American women aged 25 to 34 years. Heterosexual transmission is the leading cause of positive infection for African American women in the United States (Arya, M., Behforouz, H. L., & Viswanath, K., 2009).

African Americans affected by HIV disease use healthcare programs to maintain health status. Research data collected shows African Americans comprise 38% of Mississippi’s population. African Americans’ data measured 78% of all newly diagnosed cases in 2010. Disease reports state HIV diagnosis rates of African Americans in 2010 were eight times that of other races. Since 2007, the HIV disease diagnosis among women in Mississippi has steadily decreased. In 2010, Healthcare organizations information shows women represented 23.9% of newly diagnosed HIV disease cases. Mississippi’s advancement in HIV prevention efforts, treatments, and therapies have helped healthcare organizations better structure division of work. In Mississippi between the years 2008-2009, only 42% of residents had insurance through their employers. There are more Mississippians that are on Medicaid compared to other states. Healthcare organizations have to be goal-oriented, coordinated and linked to external environments. African American women living with HIV/AIDS have to have reliable resource programs that work in their everyday lives.  In the state of Mississippi, rates show 22% receiving Medicaid benefits compared to the national average of 16%. Out of all of the rules, Mississippi is one of the states that have the highest percentage of residents living in poverty nationwide and statewide. African American women living with HIV/AIDS who live in poverty have to have government funded programs to maintain treatments.  The median household income was $36,851, and the median family income was $45,484 in Mississippi.

AIDS Diagnosis, 2010, by metropolitan statistical area of residence- United States

Area of residence No.	Estimated No.	Rate Rank	Rank No.
Baton Rouge, LA	245	264	33.7
Miami, FL	1,436	1,681	30.3
Jackson, MS	134	158	29.2
Baltimore-Townsend, MD	514	721	26.8
New Orleans-Metairie-Kenner, LA	279	311	26.2

Source: Centers for Disease Control and Prevention. HIV Surveillance Report, 2010; vol. 22. Published March 2012. Accessed Apr 2012.

Through medical data collected in 2015 in the state of Mississippi, 204 people died of HIV/AIDS. The mortality rate of people with HIV in 2015 per 100,000 people is 8. Programs were put into places such as MBK South and other disease prevention programs to lower the risk. The number of new HIV diagnoses in 2016 reached 424 in the state. More healthcare organizations created jobs to manage the task, maintenance, and personal roles. In the state of Mississippi, the rate of new HIV diagnoses in 2016 per 100,000 people was 17. The percentage of Black females living with an HIV diagnosis is 9.6 times that of White women (“Local Data of Mississippi,” 2018).

HIV Federal Funding/Programs, Federal HIV/AIDS Grant Funding, FY 2016

Centers for Disease Control & Prevention:

$6,592,489

Substance Abuse & Mental Health Services Administration:

$299,319

Ryan White HIV/AIDS Program:

$25,191,248

Housing Opportunities for Persons With AIDS:

$2,456,198

TOTAL FUNDING:

$34,539,254

CDC data collected by programs shows an estimated number of 37,600 HIV/AIDS infections that have been diagnosed each year. The United States government took a federal approach to reduce new HIV infections. The government created scientific evidence using studies to make informed decisions. Resources were used to establish strategies to help the populations at highest risk. The data the government collected was used to create new programs to prevent new HIV infections, lower diagnosis, and create care treatments for those who are living with HIV/AIDS. African American women who have achieved viral suppression live a longer life. Target prevention resources are the most effective prevention strategies if well prioritized and widely implemented (“HIV Prevention Activities,” 2017).

The Federal government strongly supports a range of services for reducing risky behavior.  These government-funded programs include substance abuse treatment, behavioral health services, housing assistance, transportation, and other services to address risks with HIV transmission. State funding is used to create evidence-based approach programs. Mass media campaigns, behavioral interventions, and different strategies are made to increase safe sex. Education and training in management create a culture to help health care providers use activities that can improve community-based organizations (“HIV Prevention Activities,” 2017).

Congress in 1999, created resources for the CDC. The Secretary’s Minority AIDS Initiative Fund (SMAIF) became a resource awarded to agencies. The funding helps community-based organizations improve the quality of care. SMAIF money is there to play a role in developing the prevention and care for ethnic minorities. SMAIF supports demonstrations and projects that serve in innovations (“HIV Prevention Activities,” 2017). The National Minority AIDS Council (NMAC) was created to help minority faith and community-based organizations serve AIDS service organizations and health departments. The mission was to decrease challenges for people with HIV/AIDS in African American communities.  Homelessness, housing, jail and poverty in African American communities are big problems for some people living with HIV/AIDS. The United States government needs more policy reforms that establish routine HIV testing upon prison entry and release (“African American, Health,” 2006).

References:

• African Americans, Health Disparities and HIV/AIDS. (2006).
  
  National Minority AIDS Council.
  
  Retrieved from:
  
  http://www.nmac.org/wp-content/uploads/2012/08/African-American              health-disparities-and-HIV-AIDS.pdf
  
• Arya, M., Behforouz, H. L., & Viswanath, K. (2009). African American women and HIV/AIDS:a national call for targeted health communication strategies to address a disparity.
  
  The AIDS reader
  
  ,
  
  19
  
  (2), 79-84, C3.
• Bloom-DiCicco, B. & Roye, C.F. (2017). Beyond knowledge and agency: HIV risk for women of color in HIV-dense neighborhoods.
  
  J Womens Health, Issues Care,
  
  6(2), 1-7.
• Calderia, N. A., El-Bassel, N., Gilbert, L., & Ruglass, L.M. (2009). Addressing the unique needs of African American women in HIV prevention.
  
  American Journal of Public Health,
  
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Introduction and Discussion

There can be health communication issues among nurses giving care to patients such as for example patients positive with breast cancer. Health communication among nursing care unit is a tough responsibility wherein oncology serves as one underlying factor in determining actual communication process. There can be imperative base of nurses skills in a clinical manner in which several cancer oriented nurses have received formal training in dealing with patients and communicate with them in all care level. Thus, there might have inadequate health related communication provided by nurses, can be due to culture related factors of breast cancer patients themselves like for instance, age and gender factors, family and social economic factors that adhere to the everyday life and work of these patients.

Poor healthcare communication among nurses may come into the picture without spontaneous and precise conformity of both sides. This means that, nurses should overcome culture related hindrances to apply effective healthcare communication mostly to those breast cancer patients living in remote areas and or indigenous sites. Health communication problems that are brought about by certain culture barriers can ideally cause such distressing mood for breast cancer patients as well as with their families, who often want considerable and accurate information coming from nurses and care providers more often as possible. Some of the patients leave consultation unsure about diagnosis and prognosis when culture communication issues strikes in a confusing way and the lack of compelling awareness by nurses in lieu to further diagnostic tests on patients’ situation and true standing of well being, putting communication issues in black and white state can lead to unclear health management plan and in turn, nurses will be uncertain about real therapeutic intent on the breast cancer treatment.

Accordingly, there have been initiatives upon improving health communication skills training for nurses and other care professionals located in the breast cancer field from influencing culture continuum in broader communication stature of nurses giving ultimate patient care and support. Health communication difficulty may slow down conscription of breast cancer patients into clinical trials, delaying introduction of effective innovative treatment into healthcare base.

The shortage of effective health communication among nurse specialists and care setting can cause culture oriented perplexity and such loss of poise amongst nursing care team. Culture disparities can put the scenario on higher assumption, healthcare system advocates will acknowledge insufficient training in health communication and management skills can be served with little dedication thus, contributing to nurses’ stress, lack of job pleasure and poignant burnout in the work area.

Case Study Example

Culturally, there is a stigma associated with the word ‘cancer’ that some cultures perceive such as rude and disrespectful while other cultures think of it as an offensive term. Egyptian breast cancer patients, for example, believe that in dealing with illnesses within a family context they should be dignified (Butow, Tattersall and Goldstein, 1997). Same goes with other cultures such as the Navajo or the Native American tribe in Northern America. Navajo people also illustrate diverse cultural attitudes when it comes to dealing with various illnesses. What is important for these people is the feeling of orderliness and harmony hence disruptions by receiving negative information is frowned upon (Baile et al, 2002). As such, Navajo people perceive adverse diagnosis and prognosis as curse (Mitchell, 1998).

Further, communications pertaining to cancer are also culturally bounded hence there is a need to carefully consider the cultural background of an individual before information about the cancer can be communicated to him/her and the family. As such, there are also familial barriers related to telling the truth (truthfulness) to terminal cancer patients. Taiwanese family members believe that there is no need to tell aged patients about their condition since they can be better-off unknowledgeable of cancer (Hu et al, 2002). On the other hand, Ethiopian refugees with cancer believe that it would be better to tell the family first about their condition. However, information that is unfavorable should not be given at night for the purpose of avoiding the burden of sleepless night (Mitchell, 1998).

When it comes to the breast cancer experiences of Asian American women, Tam Ashing et al (2003) found out that there are cultural factors as well as gender role and family obligations that can contribute to the women’s inadequate involvement in their treatment. This manifests that while there is abundance in the study of cultural standpoints on the disclosure of the diagnosis and in the study of how culture affects the communication process, there is little study on the cultural influences on the interrelationship of patients and health care providers. How culture may affect the information patients might want and their participatory preferences as well as other interactions warrant future study (Tam Ashing et al, 2003).

Cultural Factors

Age, Race, Ethnicity and Communication

Communication problems may emerge because of the differences in communication between nurses and doctors and the patients as well, better patient and nurse communication has been associated with patient choice regarding their treatment, satisfaction level of care and quality of care provided to cancer patients especially for the vulnerable groups like aged and disadvantaged (Liang et al, 2002). It was found out that age and [Latina] ethnicity are negatively associated as older age patients receive less interactive informational support from their respective physicians compared to their younger counterparts (Maly, Leake and Silliman, 2003). As it involves interactive information support, proponents noted that there is a need to improve the quality of communication at the patient-physician level. Proponents also noted that this is a significant venue to reduce age and ethnic treatment disparities among breast cancer patients (Maly, Leake and Silliman, 2003).

In specific cases, breast cancer patients aged 80 years and older are reported to be receiving markedly less information about treatment options as compared to younger patients (Liang et al, 2002). These patients stated that they were communicated with fewer choices for treatments. Likewise, they noted that they were less likely talked to by their surgeons and their surgeons were less like to initiate communicating with them (Liang et al, 2002). Silliman et al (1998) emphasised the significance of communication between older breast cancer patients and their respective physicians. And while older women tend to obtain information from other external resources, these women mostly depend on the informations that their physicians can provide them.

Regardless of expectation and knowledge about the value of communication, breast cancer patients undergo surgery less frequent than younger women. Even though many factors could explain patterns of care, (Zuckerman, 2000) it is possible that quality of communication between patients and their nurses contribute to observed treatment variability though medical standard of care (Zuckerman, 2000).

Socioeconomic Status

When it comes to decision-making about their health, younger and educated breast cancer patients are more ready to take active roles. Nonetheless, it was observed that low income and uneducated women diagnosed with breast cancer are communicating less with their respective physicians. This is more so when it comes to their preferences for treatment and other concerns and fears (Degner et al, 1997; Hietanen et al, 2000; McVea, Minier and Johnson Palensky, 2001; Zuckerman, 2000).

Being unmarried, older women are also diagnosed with the disease also discussed risk factors frequently with their physicians. This group also predicted to prefer to receive conservative therapies as treatment (McVea, Minier and Johnson Palensky, 2001).

Influence of Culture/Ethnicity/Language

In lessening the levels of distress experienced by the breast cancer patients and their families upon learning of the disease, there are culturally appropriate approaches especially in terms of communication. For the clinicians, being aware of these cross-cultural communication practices about disclosing cancer diagnosis means developing sensitivities to the expectations of the involved. As such, during discussions of diagnosis and treatment options for patients from various cultures, clinicians shall consider striking a balance on commitment to straightforward discussion while also respecting the cultural values of the patient (Hern, Jr., 1998).

Commonly, breast cancer patients with Western background tend to conform to certainty, expectedness, power and available outcomes (Mishel, 1990). Such Western philosophies engendered fostering of self-determination and autonomous decision-making (Gordon and Daugherty, 2003). As a cultural prerogative, the need for complete information to make accurate evaluations about their health is reflected as a social value (Hern, Jr. et al, 1998). The Western culture is particular of what is good, just and ethical in receiving health care, this forms part of the principle of self-determination where the goal is to make autonomous decisions about their treatment (Baile et al, 2002).

The Cancer Patient’s Family

Families of the breast cancer patients can aid the patients in making better, informed decisions about their care and treatment (Ballard-Reisch and Letner, 2003). There is a need therefore to shift patient decision-making with family-centered strategies particularly because most decisions in cancer health care are carried out in the familial care and obligation context. Active role of health care practitioners is shaped by their structured and ongoing dialogue with the members of the family of the patients. Dialogues between the two mostly centered on the goals of treatments, care planning and expectations about patient outcomes (Given, Given and Kozachik, 2001).

As an advanced part of the cancer care, caregivers specifically coming from the family should be treated as an integral part of the process (Given, Given and Kozachik, 2001). In the cancer care scenario, while nurses may easily attend to the needs alongside those of cancer patient caregivers should be also given a legitimate place in the medical setting (Morris and Thomas, 2001).

Other Communication Barriers

There are indirect indications that signal emotional needs from the patients than direct requests for informational support. In parallel, health care providers can readily respond to direct expressions of need coming from the patients. The problem lies in the difficulty in detecting and responding to the indirect signals that cues patient needs. Indirect communications that are not immediately and easily identified by the care providers could be allusions as well as paraverbal expressions and nonverbal behaviors (Butow, Brown, Cogar et al., 2002).

It would be easy for the breast cancer patients to assume that their physicians will naturally make them informed of relevant things. However, patients do not necessarily ask for information as this may appear ignorance on their part while some patients may feel guilt when eating most of the busy nurses’ time (Fallowfield and Jenkins, 1999; Maguire, 1999).

Other communication barriers may include the presence of multiple specialists that the patients may see within the treatment team (middle level practitioner, nurse) hence becoming confused. Other than the educational background of the patients, anxiety and medicinal side effects may affect the comprehension and understanding of the patient (Towle and Godolphin, 1999; Ballard-Reisch and Letner, 2003).

Role of Nurses and Communication

Nurses play an important role in communication and supporting breast cancer patients especially that they are a part of a multidisciplinary cancer team. Nurses perform different functions in various stages of the breast cancer trajectory. Nurses served as the initial interface or the first clinical contacts for patients and their respective families (Fallowfield and Jenkins, 1999; Maguire, 1999). Thereby, nurses create a supportive environment throughout the course of the patient’s care. Nurses are also served as critical sources of information particularly on procedures, treatments and other phases of the patient care. Since they spend most time with the patients, nurses are considered to be the most trusted member of the cancer team when it comes to informational support (Fallowfield and Jenkins, 1999; Maguire, 1999).

Nurses, as part of the supportive environment, also deal with the emotional needs of the patients upon learning the diagnosis. As such, nurses are able to witness emotionally draining situations including the anger of the patients as well as their family members or the withdrawal and depression of these people. Nurses acts as physician extenders as they manage most of the daily care of the breast cancer patients. Nevertheless, communicating with them has been acknowledged most important aspect of being a nurse (Armstrong-Esther et al, 1989; Van Cott, 1993).

Furthermore, communication serves as an important aspect of the quality of care, from several studies it appears that poor communication is the largest source of dissatisfaction in patients (Macleod Clark, 1985; Ley 1988; Davies and Fallowfield 1991). As an outcome, the quality of care may improve with effective communication. Effective communication does not just depend on the acquisition of the right communication skills (Wilkinson, 1991). From the preceding account, there appears that time pressure, especially in the residential home, is determinant for the verbal communication of nurses and the topics that come up for conversation. As nurses experience more time pressure they talk less about topics concerning lifestyle and emotions. There can be an important point for consideration because, in nursing, high pressure is often present, appeared that simply employing more staff does not lead to better communication (Pool, 1996; Liefbroer and Visser, 1986; Wilkinson, 1991).

Conclusion

Therefore, poor communication with health professionals and in particular nurses creates the most distressful situations for breast cancer patients and their families. In addition, small research has been undertaken to examine specific culture related problems and challenges that confronts the nursing community There will be a need to conceptualise the perceptions of the nurses about communication as well as how they perceive the potential barriers and strategies of overcoming these communication barriers Thus, it can be that nurses described communication difficulties being encountered when interacting with cancer patient families.

The culture related factors appeared to be central determinant of quality of nurses’ healthcare communication as nurses described difficulties associated with delivery of bad news and treatment plans that are not evidently defined for the breast cancer patient. Indeed, effects of poor communication on nurses were remarkable and brightly described, recommendation for nursing clinical practice and subsequent research are to take place in time. Lastly, upon continuing of nursing education nurses should be trained to be sensitive to the needs of patients and will need to create atmosphere that facilitate cancer patients’ question and express imperative needs. Amicably, nurses should be trained to use their time efficiently thus, appeared that nurses’ verbal communication is hardly connected to patient characteristics. Then, it is important for nurses to learn how to standardize cancer patient needs, in order to offer nursing care that is tailored to effective health communication and the success of it.