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Biomedical subjects

Gretchen L Birbeck

Publications and source records attributed to Gretchen L Birbeck.

17 recordsLinked to original sources
PubMed2006

Zambian health care workers' knowledge, attitudes, beliefs, and practices regarding epilepsy.

OBJECTIVE: Zambia suffers from a physician shortage, leaving the provision of care for those with epilepsy to nonphysician health care workers who may not be adequately trained for this task. These individuals are also important community opinion leaders. Our goal in this study was to determine the knowledge, attitudes, beliefs, and practices of these health care workers with respect to epilepsy. METHODS: Health care workers in urban and rural districts of Zambia completed a self-administered, 48-item questionnaire containing items addressing demographics, personal experience with epilepsy, social tolerance, willingness to provide care, epilepsy care knowledge, and estimates of others' attitudes. Analyses were conducted to assess characteristics associated with more epilepsy care knowledge and social tolerance. RESULTS: The response rate was 92% (n=276). Those who had received both didactic and bedside training (P=0.02) and more recent graduates (P=0.007) had greater knowledge. Greater knowledge was associated with more social tolerance (P=0.005), but having a family member with epilepsy was not (P=0.61). Health care workers were generally willing to provide care to this patient population, but approximately 25% would not allow their child to marry someone with epilepsy and 20% thought people with epilepsy should not marry or hold employment. Respondents reported that people with epilepsy are feared and/or rejected by both their families (75%) and their community (88.8%). CONCLUSIONS: Knowledge gaps exist particularly in acute management and recognition of partial epilepsy. More recent graduates were more knowledgeable, suggesting that curriculum changes instituted in 2000 may be improving care. Health care workers expressed both personal and professional reservations about people with epilepsy marrying. In addition to improving diagnosis and treatment skills, educational programs must address underlying attitudes that may worsen existing stigmatizing trends.

Adult↗
PubMed2006

Zambian teachers: what do they know about epilepsy and how can we work with them to decrease stigma?

PURPOSE: Teachers play a central role in determining access to education and may mediate epilepsy-associated stigma. We developed and administered a teacher-specific survey to assess teachers' knowledge, attitudes, behaviors, and practices (KABPs) regarding epilepsy in Zambia and social and demographic determinants of KABPs. METHODS: In 2004, we surveyed 171 teachers in urban and rural regions using a 46-item questionnaire. Knowledge and tolerance composite scores were developed and analyses completed to identify demographic and social determinants of KABPs and evaluate whether generic tolerance questions were associated with stigmatizing practices. RESULTS: The response rate was 93% (n=159). Knowledge regarding epilepsy ranged broadly. Misattribution was evident for etiology (spirit possession 17.3%; contagion 28.2%; witchcraft 16.8%), and individuals with poorer knowledge were more likely to recommend traditional healers (p=0.0004) rather than physicians for epilepsy care. Higher knowledge was associated with higher tolerance (p=0.01). Tolerance was highest among urban residents (p=0.002) and individuals with personal familiarity/experience with epilepsy. More tolerant teachers were less likely to report stigmatizing practices, such as ejecting children with seizures from school. CONCLUSIONS: Teacher-targeted interventions aimed at reducing epilepsy-associated stigma and its sequelae in Zambia should include both an educational component and a social component in which teachers are exposed to a person or persons with the condition. Education programs led by person(s) with epilepsy may be ideal.

Adult↗
PubMed2006

Multispecialty stroke services in California hospitals are associated with reduced mortality.

OBJECTIVE: To evaluate whether 1) a dedicated, multispecialty service, 2) a distinct hospital ward, 3) protocols, and 4) a specialist are associated with reduced mortality among patients with stroke. METHODS: The authors reviewed data (1998 and 1999) from all acute, non-federal hospitals in California, including administrative discharge databases for patient and hospital-level information, mortality data through 1 year post discharge, and a hospital-level survey regarding structural elements of stroke care. The impact of a dedicated, multidisciplinary stroke service and of stroke wards, protocols, and specialists on odds of death among patients with ischemic and hemorrhagic stroke were each examined using logistic regression models. How these elements of care impacted outcome at teaching vs non-teaching hospitals was also examined. RESULTS: A 67.5% response rate (257/381) from surveyed hospitals provided data for 61,541 patients with stroke. A dedicated, multispecialty stroke service was available at 7.4% of hospitals. Twelve percent of hospitals had a stroke ward, 62.3% used protocols, and 16% had neurologists with specialty training in stroke. Patients cared for at hospitals with a dedicated stroke service had significantly lower odds for death at 30 days, and reduced mortality was maintained through 365 days after admission. Stroke wards, protocols, and specialists were not associated with reduced mortality. Having a dedicated stroke service was associated with reduced mortality at both non-teaching and teaching hospitals. CONCLUSIONS: Dedicated, multispecialty stroke services are underutilized despite their association with reduced stroke mortality at both academic and non-academic hospitals.

Adult↗
PubMed2005

Lipid testing and lipid-lowering therapy in hospitalized ischemic stroke and transient ischemic attack patients: results from a statewide stroke registry.

BACKGROUND AND PURPOSE: Recent recommendations call for in-hospital initiation of lipid-lowering therapy (LLT) for most ischemic stroke (IS) and transient ischemic attack (TIA) survivors; however, little is known about actual use. This study describes use of and predictors for in-hospital lipid testing and LLT using data from a statewide stroke registry. METHODS: In 2002, the registry ascertained cases from a stratified sample of 16 hospitals. This study includes only IS and TIA cases discharged alive. RESULTS: In 1907 study subjects, 30.2% (27.2% to 33.5%) were on LLT at admission. In 1399 subjects not on LLT at admission, 37.2% (30.2% to 44.9%) underwent lipid testing, and 12.9% (7.2% to 22.1%) received LLT at discharge. Use of testing and LLT varied widely between hospitals (P<0.001). In-hospital lipid testing was positively associated with large teaching hospitals (P=0.029), and neurologist or neurosurgeon (P=0.004); and negatively associated with increasing age (P=0.002), being female (P=0.020), a previous medical history of atrial fibrillation (P=0.002), nonambulatory status (P=0.005), and poor prognosis (P<0.001). LLT at discharge was positively associated with a previous medical history of dyslipidemia (P<0.001), lipid testing (P=0.004), and elevated low-density lipoprotein levels (P<0.001). Among subjects who were not on LLT at admission but who had Adult Treatment Panel III-based indications for use of LLT, only 31.2% (20.5% to 44.5%) received LLT at discharge. CONCLUSIONS: Many hospitalized acute IS and TIA patients with indications for LLT are untreated at discharge. Efforts to close treatment gaps in lipid evaluation and treatment require sustained quality improvement efforts and should pay particular attention to high-risk patients.

Aged↗
PubMed2005

Epilepsy-associated stigma in sub-Saharan Africa: the social landscape of a disease.

Many studies in developed regions of the world have confirmed that stigma contributes substantially to the psychological and social burden of epilepsy. Relatively few studies of epilepsy-associated stigma have been conducted in Africa, where much of the world's burden of epilepsy exists. In sub-Saharan Africa (SSA), particularly in rural regions, close family ties, communal living situations, and traditional belief systems undoubtedly influence the expression of stigmatization. A review of the epidemiologic, anthropologic, and sociologic studies of epilepsy in SSA provides significant insights into how people with epilepsy (PWE) are perceived by their communities and families and how these perceptions translate into limited social and economic opportunities and possibly worsen the physical vulnerability of PWE in this region. The medical community is not exempt from the social process of stigmatization, and poor public health infrastructure and medical services undoubtedly contribute to the cycle of epilepsy-associated stigma through wide treatment gaps, poor seizure control, and high rates of seizure-related injury. In this review, we extrapolate data from existing studies of epilepsy in SSA coupled with our own experience providing epilepsy care in the region to give an overview of the social landscape of this common, devastating condition.

Africa South of the Sahara↗
PubMed2005

Human immunodeficiency virus dementia patients in Africa: How many? Who cares? And where to from here?

Dementia was a frequent consequence of human immunodeficiency virus (HIV) in developed countries before antiretroviral therapy (ART) became available and remains a common neurologic complication of acquired immunodeficiency syndrome (AIDS) among patients receiving appropriate therapy. The epidemiology of HIV dementia (HIV-D) in Africa remains unclear 20+ years into the AIDS epidemic. Early studies of cognitive impairment in HIV-positive populations in Africa were limited by vaguely defined criteria for cognitive impairment, inadequate assessment tools lacking ecologic validation, and the absence of normative population data. More recent studies have clarified definitions of impairment, utilized more sophisticated measures, and included normative comparisons. Unfortunately, these detailed neuropsychiatric assessments are not feasible for population-based studies or routine clinical implementation. Therefore, the prevalence data available for HIV-D in Africa represents rates found in people presenting to tertiary care centers and are unlikely to reflect HIV-D rates in the general population. As ART becomes available in Africa, future research efforts must provide a better understanding of the epidemiology of HIV-D, the effects of available ART regimens on HIV-D in this population, and the impact of HIV-D on ART adherence. Universally accepted terminology and criteria for HIV-D are needed. Population-based studies will require the development of neuropsychiatric batteries that can be adapted across a range of African environments. Ideally, these measures will be viable for nonphysician care providers to use as screening tools in the first stage of epidemiologic studies. Such screening tools could also serve as clinical indicators of possible HIV-related cognitive impairment facilitate implementation of ART adherence.

AIDS Dementia Complex↗
PubMed2005

Potential impact of adjustment policies on vulnerability of women and children to HIV/AIDS in sub-Saharan Africa.

This paper evaluates the potential impact of adjustment policies of the International Monetary Fund and the World Bank on the vulnerability of women and children to HIV/AIDS in sub-Saharan Africa. A conceptual framework, composed of five different pathways of causation, is used for the evaluation. These five pathways connect changes at the macro level (e.g. removal of food subsidies) with effects at the meso (e.g. higher food prices) and micro levels (e.g. exposure of women and children to commercial sex) that influence the vulnerability of women and children to HIV/AIDS. Published literature on adjustment policies and socioeconomic determinants of HIV/AIDS among women and children in sub-Saharan Africa was reviewed to explore the cause-effect relationships included in the theoretical framework. Evidence suggests that adjustment policies may inadvertently produce conditions facilitating the exposure of women and children to HIV/AIDS. Complex research designs are needed to further investigate this relationship. A shift in emphasis from an individual approach to a socioeconomic approach in the study of HIV infection among women and children in the developing world is suggested. Given the potential for adjustment policies to exacerbate the AIDS pandemic among women and children, a careful examination of the effects of these policies on maternal and child welfare is urgently needed.

Acquired Immunodeficiency Syndrome↗
PubMed2004

Epilepsy prevalence in rural Zambia: a door-to-door survey.

OBJECTIVES: To identify people with epilepsy (PWE) in our Zambian catchment area of 55,000 people. METHODS: A nine-item, previously validated screening instrument for detecting epilepsy in developing countries was forward-and-back translated into Chitonga. Early piloting indicated poor specificity among children, so three questions were added. Local census data were used to estimate the population at risk. Community health workers conducted screening interviews with household heads. All positive screens were referred for physician assessment. A blinded neurologist assessed a randomly selected subset (100 positives, 50 negatives) to determine screening instrument characteristics. RESULTS: We identified 799 people with possible epilepsy (unadjusted prevalence 14.5/1000). The adapted instrument exhibited 86% specificity (adjusted prevalence 12.5/1000). False positives occurred primarily among children who had experienced multiple malaria-associated seizures. Age-specific rates were highest for children aged 5-15 years (26.2/1000) and for people over 65 years (15.9/1000). Males were disproportionately represented (55.8%vs. 44.2%, P<0.05), although this trend reversed after childbearing age. CONCLUSION: Even using a relatively conservative definition, we identified almost 700 PWE. Use of the recommended epidemiological definitions would likely have yielded higher prevalence rates. The age-specific prevalence did not follow patterns described where neurocysticercosis is the commonest cause of epilepsy. Trends in age- and gender-specific prevalence may offer a clue to the aetiology of epilepsy in this region.

Adolescent↗
PubMed2003

The functional status of people with epilepsy in rural sub-Saharan Africa.

PURPOSE: Little data is available regarding the impact of epilepsy on the functional status of people with epilepsy (PWE) in developing countries. In sub-Saharan Africa, limited medical services and social stigmatization subject PWE to substantial physical, psychological and social deprivation. To better delineate the overall burden and distribution of epilepsy-associated disability in sub-Saharan Africa, we assessed the functional status of PWE in a rural, population-based sample and made comparisons to published reports from urban Zimbabwe. METHODS: A population-based survey of PWE with epilepsy in rural Zambia utilizing WHO questionnaires. RESULTS: Among 86 PWE in 3 rural Zambian communities, 67% participated in the interviews. Only 62% of PWE were receiving treatment. Five to seven percent of rural PWE reported problems with basic hygiene and 9-14% were unable to fulfill work demands, attend social events or enjoy leisure activities. In contrast, 95% of urban PWE denied any problems with social functioning, work performance or relationships. Compared to the urban population, rural PWE had a greater seizure burden (2.3/month vs. 1/month, p=0.007) and reported more difficulties with activities of daily living, including problem solving (70% vs. 54%, p=0.02), speed of thinking (70% vs. 59%, p=0.02) and relationships with co-workers (68% vs. 26%, p< or =0.005). CONCLUSIONS: A significant proportion of PWE in rural sub-Saharan Africa report problems fulfilling both social and professional functions. These results also suggest that rural PWE may have poorer functional status than their urban counterparts.

Activities of Daily Living↗
PubMed2003

Responsiveness of the quality of life in epilepsy inventory (QOLIE-89) in an antiepileptic drug trial.

This study examined relationships among responsiveness indices for health-related quality of life (HRQOL) measures administered to adults with epilepsy enrolled in an antiepileptic drug trial. The Quality of Life in Epilepsy (QOLIE)-89 was completed at baseline and at a 28-week follow-up. Six responsiveness indices (effect size (ES), standardized response mean (SRM), responsiveness statistic, paired t-test, area under receiver operating characteristic curve or ROC, F-statistic) were calculated for each of the 16 QOLIE-89 scales, using two different external criteria for clinically significant change: (1) attainment of freedom from seizures with altered awareness, and (2) a two-category improvement between baseline and follow-up in a self-rating of the subject's overall condition. Spearman correlations among the six responsiveness indices for the 16 QOLIE-89 scales tended to be moderate to large (Spearman's p = 0.53-1.00; p's < 0.05 for 29 out of the 30 correlations). Rankings of the 16 scales across the two external criteria for change were similar for the responsiveness statistic (Spearman's p = 0.62; p < 0.05), but dissimilar for the other responsiveness indices (all p > 0.05). Both ES and SRM were well predicted by the other indices, except for ROC, using regression modeling. In conclusion, results using different responsiveness indices are comparable for a given external criterion. However, only the responsiveness statistic yielded robust results across two different external criteria. Responsiveness of this HRQOL measure can be reported in terms of previously established benchmarks for ESs, which can be predicted from other indices.

Adult↗
PubMed2002

Neurologic services in sub-Saharan Africa: a case study among Zambian primary healthcare workers.

INTRODUCTION: In many parts of the developing world, access to physician consultation and neurologic expertise is limited or nonexistent. We conducted a survey among non-physician, primary healthcare workers (PHCWs) to determine the neurological needs and services in rural Zambia. METHODS: Semi-structured written questionnaire utilizing fill-in-the-blank, multiple-choice likert-scaled questions, and open-ended questions. RESULTS: Seizures were reported as the most common neurologic disorder by 66% of the PHCWs. Only 1/3 of PHCWs reported feeling adequately trained to care for seizures and seizure disorders. PHCWs reported even less expertise for other neurologic conditions. Over 40% of PHCWs surveyed work in primary care clinics without a physician available for consultation. Their patients must travel a median of 50 km to access a physician and geographic barriers are a frequent problem. In addition to difficulty physically accessing care, PHCWs reported that financial barriers to physician referral are substantial. Expenses cited include additional user fees for physician-level care, transportation costs, and the cost of maintaining the patient and/or family at a site distant from the home village. Traditional beliefs, social stigma, and discriminatory healthcare policies associated with neurologic conditions were also noted to deter and defer care and care seeking. CONCLUSIONS: PHCWs lack sufficient training and experience to care for the neurologic disorders in their patient populations, although such disorders are relatively common. Geographic, financial and cultural barriers substantially limit physician referrals. To assure at least a minimal quality of care for people with nervous system disorders in Zambia, PHCWs' neurologic education must be increased and barriers to physician referral decreased.

Africa South of the Sahara↗
PubMed2002

A neurologist in Zambia.

Those uninitiated to medicine in the tropics may consider neurology and neurologists superfluous in this environment. In actual fact, the high burden of neurologic disorders combined with a dearth of physician-level care providers brings such expertise into high demand. Clinical work in sub-Saharan Africa offers the neurologist an opportunity to care for a wide range of conditions, including disorders Westerners may only be familiar with via historical accounts. Physicians starved of academic exchange and paramedical-care providers who frequently function without physician-level support are equally enthusiastic for additional training in the diagnosis and treatment of the nervous system disorders which are encountered daily.

Female↗
PubMed2002

Seizure reduction and quality of life improvements in people with epilepsy.

PURPOSE: Previous research suggests that seizure freedom may be necessary to improve health-related quality of life (HRQOL) for epilepsy surgery patients, but little is known regarding the seizure-frequency reduction needed to improve HRQOL among medically treated individuals. METHODS: With data from 134 adults with refractory complex partial seizures participating in a randomized controlled antiepileptic drug (AED) trial, we compared the change in HRQOL across groups having different levels of change in seizure frequency: 100%, 75-99%, 50-74% reduction, and 0-50% increase or decrease. Changes over time within each seizure-reduction group also were assessed. HRQOL was measured by the QOLIE-31, QOLIE-89, and SF-36. RESULTS: Subjects who became seizure free reported significantly more positive change than those who did not on the QOLIE-31 and QOLIE-89 overall scores, the QOLIE-89 mental health, physical health, and epilepsy-targeted composites, as well as the SF-36 mental health summary score. Changes over time in overall QOLIE-31 and QOLIE-89 scores were significantly more positive for subjects who achieved seizure freedom (i.e., 100% reduction in seizure frequency) than for those who did not. No significant change in QOLIE-31 and QOLIE-89 overall scores was observed for subjects who did not achieve seizure freedom. CONCLUSIONS: In this study, HRQOL improvement occurred primarily among patients who achieved complete seizure freedom. Many AED trials use a 50% seizure-frequency reduction criterion as a trial end point, but measurable impacts of this degree of reduction in seizure frequency on HRQOL in this sample were not observed. These results further support striving for seizure freedom as an epilepsy care goal.

Adolescent↗
PubMed2002

User fees impact access to healthcare for female children in rural Zambia.

The World Bank and International Monetary Fund favor healthcare user fees. User fees offer revenue and may decrease inappropriate care. However, user fees may deter needed care, especially in vulnerable populations. A cross-sectional analysis of healthcare utilization in a large Zambian hospital was conducted for children 3-6 years of age during a 1-month observation period. Diagnoses and treatments were compared using paired t-tests. Chi-squared tests compared outpatient service use. The relative risk of admission was determined for each stratum. Logistic models were developed to evaluate the impact of age, gender, and the age-gender interaction on hospital admissions. Trends suggest female children may be less likely to present for care when user fees are imposed. However, treatment type, treatment number, and number of diagnoses did not differ between genders. The relative risk of admission was highest for males 5-6 years old. Neither age nor gender alone was a significant determinant of hospital admission. However, the age-gender interaction was significant with female admissions least likely when costs were incurred. We conclude that user fees appear to decrease differentially utilization of inpatient care for female children in rural Zambia.

Ambulatory Care↗