Integration Of Health Interventions Research Articles

Feasibility of Implementation Mapping for Integrative Medical Group Visits.

Objectives: Implementation science is key to translating complementary and integrative health intervention research into practice as it can increase accessibility and affordability while maximizing patient health outcomes. The authors describe using implementation mapping to (1) identify barriers and facilitators impacting the implementation of an Integrative Medical Group Visit (IMGV) intervention in an outpatient setting with a high burden of patients with chronic pain and (2) select and develop implementation strategies utilizing theory and stakeholder input to address those barriers and facilitators. Design: The authors selected a packaged, evidence-based, integrative pain management intervention, the IMGV, to implement in an outpatient clinic with a high burden of patients with chronic pain. The authors used implementation mapping to identify implementation strategies for IMGV, considering theory and stakeholder input. Stakeholder interviews with clinic staff, faculty, and administrators (n = 15) were guided by the Consolidated Framework for Implementation Research. Results: Based on interview data, the authors identified administrators, physicians, nursing staff, and scheduling staff as key stakeholders involved in implementation. Barriers and facilitators focused on knowledge, buy-in, and operational procedures needed to successfully implement IMGV. The implementation team identified three cognitive influences on behavior that would impact performance: knowledge, outcome expectations, and self-efficacy; and three theoretical change methods: cue to participate, communication, and mobilization. Implementation strategies identified included identifying and preparing champions, participation in ongoing training, developing and distributing educational materials, and organizing clinician implementation team meetings. Conclusions: This study provides an example of the application of implementation mapping to identify theory-driven implementation strategies for IMGV. Implementation mapping is a feasible method that may be useful in providing a guiding structure for implementation teams as they employ implementation frameworks and select implementation strategies for integrative health interventions.

Effectiveness of Complementary and Integrative Approaches in Promoting Engagement and Overall Wellness Toward Suicide Prevention in Veterans.

Objective: Suicide is a major public health problem, specifically among U.S. veterans, who do not consistently engage in mental health services, often citing stigma as a barrier. Complementary and Integrative Health (CIH) interventions are promising alternatives in promoting patient engagement and further, they may play a critical role in transitioning people into mental health care. Toward this goal, the Resilience and Wellness Center (RWC) was developed to break through the stigma barrier by addressing risk factors of suicide through multimodal CIH interventions via cohort design, promoting social connectedness and accountability among participants.Design: This is a program evaluation study at a large urban VA medical center, where assessments were evaluated from pre- to post-program completion to determine the effectiveness of an intensive multimodal CIH 4-week group outpatient intervention for suicide prevention.Outcome measures: Primary outcomes measured included group connectedness, severity of depression and hopelessness symptoms, suicidal ideation, sleep quality, and diet. Secondary outcomes included measures of post-traumatic stress disorder (PTSD), generalized anxiety severity stress/coping skills, pain, and fatigue.Results: The RWC showed high participant engagement, with an 84%–95% attendance engagement rate depending on suicide risk history. Data from 15 cohorts (N = 126) demonstrate favorable outcomes associated with participation in this comprehensive program, as evidenced by a reduction in suicidal ideation, depression, and hopelessness, but not sleep quality and diet. In addition, in a subset of veterans with a history of suicidal ideation or attempt, significant improvements were noted in pain, PTSD/anxiety symptoms, and stress coping measures.Conclusions: The RWC shows that an intensive complement of CIH interventions is associated with a significant improvement with high veteran engagement. Findings from this program evaluation study can be used to aid health care systems and their providers in determining whether or not to utilize such multimodal CIH integrated interventions as an effective treatment for at-risk populations as a part of suicide prevention efforts.

Black Women’s Preferences for Embedding Mental Health Services in An Obstetrics Setting

Background: Untreated perinatal depression is a significant public health issue that disproportionately affects low-income black women and may lead to higher maternal mortality rates and disparate birth outcomes. Despite the growing literature documenting prevalence and risk for perinatal depression among black women, our knowledge of patient preferences of mental health interventions in obstetrical (OB) settings among this population is limited. This study explored mental health treatment preferences among black pregnant and postpartum women in an urban OB practice, serving predominantly black women with public insurance. Subjects and Method: The study sample consisted of 14 perinatal women at an urban obstetrics practice in Washington, DC. Semi-structured interviews were conducted to gain insight into their emotional experiences during pregnancy and postpartum, and to obtain patient recommendations for mental health interventions within an obstetrics setting. Patient interviews were audio-recorded, transcribed, and analyzed by two coders using inductive thematic analysis and consensus procedures. Results: Participants reported several general content themes: provider- patient relationship and intervention topic feedback. Within the overall content theme of provider-patient relationship, black women noted differences in their overall levels of comfort in discussing stress and mental health issues. Subthemes of authentic connection and perceived stigma emerged. Relevant subthemes on intervention topic preferences discussed content, modality, and logistics. Conclusion: Our findings support the importance of offering integrative, culturally competent, and accessible mental health interventions in order to prevent and treat perinatal depression among low-income black women in OB settings. Keywords: pregnancy, perinatal, depression, black women Correspondence: Courtney Glickman. Dept of Counseling and Human Development, The George Washington University2134 G St NW, Washington, DC 20052. Email: Cglickman22@gmail.com. Mobile: 727-324-3606. Journal of Maternal and Child Health (2020), 5(4): 352-362 https://doi.org/10.26911/thejmch.2020.05.04.02

Integrated health intervention on polypharmacy and inappropriate prescribing in elderly people with multimorbidity: Results at the end of the intervention and at 6 months after the intervention

Background and objectiveTo analyse the impact of an integrated health intervention focused on polypharmacy and inappropriate prescribing (IP) in elderly people with multimorbidity. Material and methodsPatients were referred for assessment and intervention from primary care or hospital to an interdisciplinary team composed of primary and hospital medical staff and nurses. Pharmacological assessment was centred on polypharmacy and IP using the STOPP/START criteria. Changes in polypharmacy and in IP were analysed at the end of the intervention and at 6 months. ResultsOne hundred consecutive patients (mean (SD) age 81.5(8.0) years, 54(54%) male) were analysed. Mean prescribed medicines at baseline was > 10. There were no significant changes at the end of the intervention and at 6 months. The proportion of patients with two or more STOPP criteria reduced from 37% at the beginning of the intervention to 18% at the end (p< .001), and the proportion of those with START criteria from 13% to 6% (p = .004). These differences persisted at 6 months. The number of STOPP and START criteria before the intervention was associated with a decrease in the STOPP and START criteria at the end of the intervention and at 6 months. A reduction in polypharmacy (p= .041) and in falls (p= .034) was observed at 6 months in those with a decrease in the STOPP criteria at the end of the intervention. ConclusionsAn integrated health intervention centred on polypharmacy and IP in elderly people improves inappropriate prescribing that persists beyond the intervention.

Reducing Cardiac Radiation Dose From Breast Cancer Radiation Therapy With Breath Hold Training and Cognitive Behavioral Therapy.

The delivery of radiation therapy shares many of the challenges encountered in imaging procedures. As in imaging, such as MRI, organ motion must be reduced to a minimum, often for lengthy time periods, to effectively target the tumor during imaging-guided therapy while reducing radiation dose to nearby normal tissues. For patients, radiation therapy is frequently a stress- and anxiety-provoking medical procedure, evoking fear from negative perceptions about irradiation, confinement from immobilization devices, claustrophobia, unease with equipment, physical discomfort, and overall cancer fear. Such stress can be a profound challenge for cancer patients' emotional coping and tolerance to treatment, and particularly interferes with advanced radiation therapy procedures where active, complex and repetitive high-level cooperation is often required from the patient.In breast cancer, the most common cancer in women worldwide, radiation therapy is an indispensable component of treatment to improve tumor control and outcome in both breast-conserving therapy for early-stage disease and in advanced-stage patients. High technological complexity and high patient cooperation is required to mitigate the known cardiac toxicity and mortality from breast cancer radiation by reducing the unintended radiation dose to the heart from left breast or left chest wall irradiation. To address this, radiation treatment in daily deep inspiration breath hold (DIBH), to create greater distance between the treatment target and the heart, is increasingly practiced. While holding the promise to decrease cardiac toxicity, DIBH procedures often augment patients' baseline stress and anxiety reaction toward radiation treatment. Patients are often overwhelmed by the physical and mental demands of daily DIBH, including the nonintuitive timed and sustained coordination of abdominal thoracic muscles for prolonged breath holding.While technologies, such as DIBH, have advanced to millimeter-precision in treatment delivery and motion tracking, the "human factor" of patients' ability to cooperate and perform has been addressed much less. Both are needed to optimally deliver advanced radiation therapy with minimized normal tissue effects, while alleviating physical and cognitive distress during this challenging phase of breast cancer therapy.This article discusses physical training and psychotherapeutic integrative health approaches, applied to radiation oncology, to leverage and augment the gains enabled by advanced technology-based high-precision radiation treatment in breast cancer. Such combinations of advanced technologies with training and cognitive integrative health interventions hold the promise to provide simple feasible and low-cost means to improve patient experience, emotional outcomes and quality of life, while optimizing patient performance for advanced imaging-guided treatment procedures - paving the way to improve cardiac outcomes in breast cancer survivors.

Integrated Health Interventions for Improved Livelihoods: A Case Study in Ethiopia

Smallholder farmers in sub-Saharan Africa (SSA) face multifaceted and co-existing risks, such as human and animal diseases and pests. Even though smallholder farmers often experience these challenges simultaneously, interventions to address these challenges are often implemented in a piecemeal fashion. However, managing agricultural production constraints without alleviating human and livestock health burdens might not generate significant and sustained benefits to achieve the desired development outcome (e.g., reducing hunger, malnutrition, and poverty). As such, building farmers’ resilience and adaptive capacity to co-existing production constraints and health burdens may require an integrated and holistic approach. Understanding the potential benefits of an integrated approach would provide critical information, for example, for revisiting the extension systems and for designing pro-poor holistically integrated interventions to tackle interrelated challenges facing smallholder farmers. In this paper, we examined the economic benefits of integrated human–plant–animal health interventions aimed at controlling malaria, stemborer infestations of crops, and trypanosomiasis, along with beekeeping as a livelihood diversification option in rural Ethiopia. We developed a whole-farm multiperiod mathematical linear programming model to examine the economic consequences of the interventions. Our results suggest that relaxing livelihoods and the human–plant–animal health constraints that farmers face has the potential to at least double income. The results further show that exploiting the potential synergies among interventions can generate higher economic benefits. The annual income from the combined interventions is 35% higher than the sum of the income gains from each intervention alone. Our results support an integrated approach to achieve holistic outcomes in areas where these development constraints co-exist.

The Trials and Tribulations of Selecting Comparison Groups in Randomized Trials of Nonpharmacological Complementary and Integrative Health Interventions.

Editor's Note: For over two decades, JACM Editorial Board member Karen Sherman, PhD has been among the most respected clinical trialists in complementary and integrative health research. The epidemiologist and Senior Researcher at Kaiser Permanente Washington Health Research Institute has focused on pain conditions and has led or been part of teams exploring the roles of such therapies as yoga, acupuncture, mind-body and manual therapies. In this Invited Commentary, Sherman shares wisdom gleaned from the process: trial designs, principles for selecting controls, benefits and liabilities of placebo and sham controls, attention controls, usual care controls, and more. She also discusses the effects of comparison groups on sample sizes, comparison groups for mechanistic studies, and other comparison groups' considerations. This commentary should prove a useful primer wherever research methods in complementary and integrative health are taught. We are pleased to offer it here through JACM. -John Weeks, Editor-in-Chief, JACM (johnweeks-integrator.com).

Impairments to Thermoregulation in the Elderly During Heat Exposure Events.

Heat waves represent a public health risk to elderly people, and typically result in an increased rate of hospital admissions and deaths. Studies of thermoregulation in this cohort have generally focused on single elements such as sweating capacity. Sweating capacity and skin blood flow reduce with age, reducing ability to dissipate heat. Perception of effort during heat exposure is emerging as an area that needs further investigation as the elderly appear to lack the ability to adequately perceive increased physiological strain during heat exposure. The role of the gut and endotoxemia in heat stress has received attention in young adults, while the elderly population has been neglected. This shortcoming offers another potential avenue for identifying effective integrated health interventions to reduce heat illnesses. Increasing numbers of elderly individuals in populations worldwide are likely to increase the incidence of heat wave-induced deaths if adequate interventions are not developed, evaluated, and implemented. In this narrative-style review we identify and discuss health-related interventions for reducing the impact of heat illnesses in the elderly.

Complementary and integrative health interventions and their association with health-related quality of life in the primary brain tumor population

Background and purposeLittle is known about complementary and integrative health intervention usage in the primary brain tumor population. We aimed to identify the percentage of patients using these practices and explore the impact on quality of life. Materials and methodsClinical records from patients seen in clinic between December 16, 2013 and February 28, 2014 were reviewed retrospectively. The questionnaires used were a modified version of the International Complementary and Alternative Medicine Questionnaire, the Functional Assessment of Cancer Therapy- Brain Cancer and the Functional Assessment of Chronic Illness Therapy- Fatigue. Results76% of patients utilized a complementary and integrative health modality. The most frequently reported modalities used were vitamins, massage, and spiritual healing, prayer, diet and meditation. ConclusionThese results confirm the usage of complementary and integrative health practices within the primary brain tumor population; however, there was no evidence of association between use and quality of life.

Study protocol for a non-inferiority randomised controlled trial of SKY breathing meditation versus cognitive processing therapy for PTSD among veterans

IntroductionPost-traumatic stress disorder (PTSD) is a debilitating, highly prevalent condition. Current clinical practice guidelines recommend trauma-focused psychotherapy (eg, cognitive processing therapy; CPT) as the first-line treatment for PTSD. However, while...

Tele-yoga for Chronic Pain: Current Status and Future Directions.

Pain is a pervasive, debilitating disorder that is resistant to long-term pharmacological interventions. Although psychological therapies such as cognitive behavior therapy demonstrate moderate efficacy, many individuals continue to have ongoing difficulties following treatment. There is a current trend to establish complementary and integrative health interventions for chronic pain, for which yoga has been found to have exciting potential. Nevertheless, an important consideration within the field is accessibility to adequate care. Telehealth can be used to provide real-time interactive video conferencing leading to increased access to health care for individuals located remotely or who otherwise have difficulty accessing services, perhaps through issues of mobility or proximity of adequate services. This article assesses the current status and feasibility of implementing tele-yoga for chronic pain. Methodological limitations and recommendations for future research are discussed.

Child diarrhoea and nutritional status in rural Rwanda: a cross-sectional study to explore contributing environmental and demographic factors.

ObjectiveTo explore associations of environmental and demographic factors with diarrhoea and nutritional status among children in Rusizi district, Rwanda.MethodsWe obtained cross‐sectional data from 8847 households in May–August 2013 from a baseline survey conducted for an evaluation of an integrated health intervention. We collected data on diarrhoea, water quality, and environmental and demographic factors from households with children <5, and anthropometry from children <2. We conducted log‐binomial regression using diarrhoea, stunting and wasting as dependent variables.ResultsAmong children <5, 8.7% reported diarrhoea in the previous 7 days. Among children <2, stunting prevalence was 34.9% and wasting prevalence was 2.1%. Drinking water treatment (any method) was inversely associated with caregiver‐reported diarrhoea in the previous 7 days (PR = 0.79, 95% CI: 0.68–0.91). Improved source of drinking water (PR = 0.80, 95% CI: 0.73–0.87), appropriate treatment of drinking water (PR = 0.88, 95% CI: 0.80–0.96), improved sanitation facility (PR = 0.90, 95% CI: 0.82–0.97), and complete structure (having walls, floor and roof) of the sanitation facility (PR = 0.65, 95% CI: 0.50–0.84) were inversely associated with stunting. None of the exposure variables were associated with wasting. A microbiological indicator of water quality was not associated with diarrhoea or stunting.ConclusionsOur findings suggest that in Rusizi district, appropriate treatment of drinking water may be an important factor in diarrhoea in children <5, while improved source and appropriate treatment of drinking water as well as improved type and structure of sanitation facility may be important for linear growth in children <2. We did not detect an association with water quality.

Potentials of nutritional therapy, phytopharmaceuticals and phytomedicine in the prevention and control of Ebola virus in Africa

With more than 15000 people infected with Ebola Virus Disease (EVD) leading to more than 7000 deaths in Liberia, Serra Leone, Guinea, Nigeria and Senegal, Ebola Virus Disease remains one of the most dreaded scourges and concerns in contemporary international health (CIH). We note in this essay, that current intervention strategies for the containment of emerging infectious diseases such as Ebola may remain inadequate unless an integrated health intervention (IHI) strategy is adopted. Focus on vaccine development is, undoubtedly, critical but unlikely soon. Synthetic antiviral therapy (AVT) or antifiloviral therapy (AFT) such as using Zmapp, Favipiravir and Brincindofovir amongst others may remain therapeutically inadequate to contain not only Ebola but future scourges. For one fact, as already observed, Zmapp, TKM-Ebola and Favipiravir are hopeful but clouded with toxicity concerns and like any antibiotic of single molecular base likely to be resisted by the bug over time. In this article, our position is that, the medical approach to confront Ebola should be a multidisciplinary approach with equality. This will mean providing a medical care that protects health care workers, searching for an effective vaccine and antiviral therapy that is cost effective, weaving cultural, environmental and community based approaches to preventing the spread as well as fostering and incorporating nutritional therapy, traditional medicine as an integrative package for infectious diseases control. We attempted to highlight that african nutriceticals and phytomedicine could be useful in the control of infectious diseases such as Ebola through the use of medicinal plants such as Garcinia kola extracts and the exploitation of mushroom extracts such as Ganoderma lucidum containing selenium, Iron, zinc, 7-8% crude protein, 26-28% carbohydrates and a range of bioactive protein that can boost the immune system of patients with Ebola virus hemorrhagic fevers. Evidence in grey literature demonstrates profound antiviral activities from extracts of Garcinia kola on a range viruses including Ebola virus. Kolaviron, a class of flavonoids from garcinia kola, have been found with profound antiviral activity while compounds from cordycep mycelium such as beta glucans also reported in Ganoderma lucidum and some mushroom species have profound immune boosting potentials against many viral infections. A computerized data base for these compounds for drug development could be generated for use by pharmaceutical companies. It is concluded that, nutritional therapy, phytopharmaceuticals from medicinal plants, could be used not only as drug leads but could clinically complement current management of Ebola virus diseases in African hospitals.

Green &amp; Healthy Homes Initiative: Improving Health, Economic, and Social Outcomes Through Integrated Housing Intervention

Poor quality housing is an ongoing environmental injustice placing a significant burden on low-income and minority families. The Green & Healthy Homes Initiative (GHHI) in Baltimore, MD, grew out of the historical healthy homes work of the Coalition to End Childhood Lead Poisoning, an organization dedicated to using housing as a platform for health to ensure environmental and social justice for families and children in low-income communities. GHHI's Healthy Homes Demonstration Project utilized the standards and practices created by GHHI: A Holistic Housing Assessment coupled with environmental health education and combined as an integrated environmental health and energy housing intervention for children with asthma, ages 2–14. The project braids resources from healthy homes, lead hazard reduction, weatherization, and energy efficiency projects to form a single multi-component, multi-factorial intervention. Findings from the health surveys at intake and six months after the intervention provide evidence of the impact on the reduction of asthma symptomatic episodes, emergency room visits, and hospitalizations, while showing improvements in school attendance and parents' work attendance. Findings will provide evidence that improved health outcomes and more stable and productive homes in primarily African American, low-income neighborhoods are related to the mitigation of asthma triggers and home-based environmental health hazards. Upstream integrated housing interventions are an effective means to improve health, economic, and social outcomes for children diagnosed with asthma.

Is the burden of oral diseases higher in urban disadvantaged community compared to the national prevalence?

BackgroundThe urban low income has often been assumed to have the greatest dental treatment needs compared to the general population. However, no studies have been carried out to verify these assumptions. This study was conducted to assess whether there was any difference between the treatment needs of an urban poor population as compared to the general population in order to design an intervention programme for this community.MethodsA random sampling of living quarters (households) in the selected areas was done. 586 adults over 19 years old living in these households were clinically examined using World Health Organization (WHO) Oral Health Survey criteria 4th edition (1997).ResultsThe overall prevalence of dental caries, periodontal disease, denture wearers and temporomandibular joint problems were 70.5%, 97.1%, 16.7% and 26%, respectively. The majority (80.5%) needed some form of dental treatment. The highest treatment needs were found in the oldest age group while the lowest were in the youngest group (19-29 years) (p = 0.000). The most prevalent periodontal problem was calculus; regardless of gender, ethnicity and age. Significantly more females (20.5%) wore prosthesis than males (11.1%) (p = 0.003). Prosthetic status and need significantly increased with age (p = 0.000). About one in four adults had Temporo-Mandibular Joint (TMJ) problems. Overall, it was surprising to note that the oral disease burden related to caries, prosthetic status and treatment need were lower in this population as compared to the national average (NOHSA, 2010). However, their periodontal disease status and treatment needs were higher compared to the national average indicating a poor oral hygiene standard.ConclusionsThe evidence does not show that the overall oral disease burden and treatment needs in this urban disadvantaged adult population as higher than the national average, except for periodontal disease. The older age groups and elderly were identified as the most in need for oral health intervention and promotion. An integrated health intervention programme through a multisectoral common risk factor approach in collaboration with the Faculties of Medicine, Dentistry and other agencies is needed for the identified target group.

The Present State of Diabetes Mellitus in Korea

Diabetes mellitus has approached to us as a social epidemic in Korea. The prevalence of diabetes in Korea has increased five to six-fold from 1.5% to 7~9% during the past 30 years. This increasing rate is remarkably high in comparison with those of developed countries such as the USA-doubled during the past 30 years. In addition, diabetic complication is very common in Korean diabetic patients. For example, a total of 70.5% among new patients who were started with renal replacement therapy had diabetes mellitus. Furthermore, diabetes-related mortality has rapidly increased over the last 20 years. The age-sex adjusted mortality rate of diabetic patients was about three-fold higher than those of general population. As a result, medical cost of diabetes mellitus covered by the national health insurance corporation was 3.2 trillion won and accounted for 19.2% of all medical costs. On the other hand, the rate of awareness and treatment in diabetic patients has improved from 1998 to 2005. However, the proportion of adequate glycemic control (HbA1c < 7%) among the treated diabetic patients was only 40%. The comprehensive and integrated health intervention including public approach is urgently needed to control the increasing prevalence of diabetes mellitus and its related undesirable outcomes.