Safety and efficacy of basal bolus and premixed insulin intensification regimes in the management of type 2 diabetes mellitus : A 13 year narrative review of literature

Background: Type 2 Diabetes Mellitus (T2DM) is a chronic condition due to insulin resistance or relative insulin deficiency. Although insulin intensification regimens are commonly prescribed for the management of T2DM, there is uncertainty regarding their optimal use. We conducted a 13 Year narrative review to compare outcomes of these regimens in the treatment of T2DM. Method: We searched electronic databases (PubMed, Scopus, Proquest and Google Search), and “grey literature” from January 2000 to December 2013 to identify studies comparing insulin intensification regimens. Results: Out of 17 studies identified, we only included 10 studies specifically comparing Basal-Bolus regimens (BB) versus Pre-mixed Insulin Regimens (PM). Seven trials comparing regimens other than the studied regimens; with study duration lesser than 12 weeks; or involving Type 1 diabetes mellitus patients were excluded. The outcomes measured were divided into safety and efficacy parameters. Among the safety outcomes measured were Hypoglycemia, Weight Gain, Quality of Life (QoL), and other Adverse Events (AE). Whereas, efficacy outcomes measured were Glycosylated Haemoglobin (HbA1c), Fasting Plasma Glucose, Daily Plasma Glucose, Post Prandial Plasma Glucose, Carotid Intima Media Thickness (IMT), Adinopectin Level, 1-5-anhydroglucitol(1,5-AG),Total Daily Insulin (TDI) Dose and Cost. Mixed results were discovered among all the parameters measured favoring in between BB and PM regimens. Conclusion: We found that BB regimens showed better glycemic control especially in terms of the primary endpoint of HbAlc but at the expanse of significantly higher TDI dose, weight gain, and further increase in cost of treatment. Whereas, all other parameters measured were comparable between regimens. Locally, conventional human insulin is still the mainstay of insulin therapy in health facilities nationwide. Yet, none of the identified studies compared head-to-head human insulin in both arms. Thus, future researches comparing non-analogue insulin may be conducted to gather new evidence in the field of diabetes locally

Healing Spaces

The field of design and health, formerly known as the domain of healthcare design professionals, has now reached a turning point with the proliferation of a plethora of non-invasive wearable technologies, to provide the objective and near-real-time measurement of the impact of many features of the built environment on aspects of health, wellbeing and performance. In turn, new materials and the Internet of Things are allowing the development of smart buildings, which can interact with occupants to optimize their health, wellbeing, performance and overall experience. Companies that have previously focused on positioning themselves as “green” are now turning to positioning themselves in the marketplace as both green and healthy. This Special Issue will include articles that address new cutting edge technologies and materials at the interface between design and health, and review some of the latest findings related to studies which use these technologies. This SI will also suggest exciting future directions for the field. It will include articles which focus on the objective data gathered to document the effects of the built environment on health. Importantly, it will focus on the use of innovative methods of measurement, such as state-of-the-art wearable and environmental sensors, quantifying some aspects of health, such as stress and relaxation responses, activity, posture, sleep quality, cognitive performance and wellbeing outcomes. It will also examine the impacts of different elements of the built environment on these health and wellbeing outcomes. The published articles will focus on the design interventions informed by these measurements, along with innovative integrated building materials that can shape the design of built environments for better health, productivity, and performance. It will also address the return on investment (ROI) of such design interventions. This Special Issue will provide both the foundational knowledge and fundamentals for characterizing human health and wellbeing in the built environment, as well as the emerging trends and design methods for innovations in this field

VR in Nursing Facilities - A randomized controlled multicenter pilot study analyzing the changes in the state of mind of seniors in nursing facilities through the viewing of 360° videos

Context: VR as an application to enhance well-being is sparsely researched in the elderly population. The aim of the pilot study was to analyze the effect of 360° videos of different categories on the state of mind of seniors in nursing facilities. Furthermore, for the implementation in everyday life, the usability of the system and the experience for seniors should be evaluated. Methods: The VR experience was used as a supplement to existing care services in three facilities on eight subjects. Mood state was assessed using the Questionnaire for the Assessment of Happiness before and after the intervention. Demographic data and technology acceptance were collected beforehand. After the intervention, subjects were interviewed about confounding factors and side effects, and nursing home staff were interviewed about the usability of the system and the organizational concept of implementation. Results: There was a positive effect on state of mind. Gender and spatial mobility turned out to be influencing factors. Categories containing people, animals and action achieved the highest increases in the state of mind. Interest in using technical devices correlated negatively with the change in mood state. None of the subjects found the VR goggles distracting or reported motion sickness. Very good usability was indicated by the employees. Conclusion: A very high willingness to use this technology was found among nursing staff and residents. The tendencies of the positive effect of 360° videos on the state of mind, as well as differentiation based on the mentioned characteristics gender and spatial mobility, should be verified by a larger sample to empirically validate the use of this technology to increase the quality of life

WHAT DO COMMUNITY HEALTH WORKERS NEED TO PROVIDE COMPREHENSIVE CARE THAT INCORPORATES NON-COMMUNICABLE DISEASES?

Non-Communicable Diseases (NCDs) such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes are the leading cause of premature death and disability worldwide, accounting for 60% of all deaths globally and 80% of NCD related mortality occurring in low and middle-income countries (LMICs). Health systems in LMICs have been oriented toward maternal and child health, and infectious illnesses as these were the main causes of morbidity and mortality until recently. Over the last decade, health systems in LMICs have recognized the need to address NCDs, and have restructured health services to include relevant prevention and control strategies. Health workforce is one of the key building blocks of health systems; however, most LMICs have a shortage of physicians. In addition, the available health care providers are unevenly distributed within countries with the majority concentrated in urban regions compared to rural regions where large proportions of the population reside. This poor distribution and shortage of physicians has led some countries to rely on task shifting, where tasks normally performed by qualified health professionals are transferred to other health providers with a lower level of education and professional training. In 1978, the Declaration of Alma-Ata included trained community health workers (CHWs) and traditional medical practitioners as part of the health team as a fundamental step towards comprehensive primary care. Since then, CHWs have been a cornerstone of health systems in several countries with over 26 different CHW programs identified in the literature across more than 24 LMICs. Traditionally, CHWs do not hold formal professional certification but receive job-related pre-service training. However, there is a lot of variation across countries where some countries require CHW certification before they can start performing their roles. CHWs reside in the community where they work, and are usually volunteers and sometimes receive financial compensation for receiving training and performance-based incentives for health related activities. CHWs can enable essential health care services to be provided in a cost-effective manner. They have been instrumental in reducing maternal and neonatal mortality rates through their presence for home births and making referrals for emergency obstetric care, and by promoting vaccination uptake, breastfeeding, and education about infectious disease. More recently, CHWs have been useful in HIV/AIDS prevention and control, educating communities and performing tasks such as screening, counselling and supplying antiretroviral drugs. With the increasing prevalence of NCDs and to meet changing community health needs, CHWs are sought to provide a similarly appropriate care for NCD risk factors control. While CHWs may not replace qualified health providers, they can play a considerable role in improving health outcomes by educating, screening, referring and following-up individuals at high risk of NCDs. CHWs have been trained in some settings to screen, educate and follow-up patients with NCDs or people at increased risk of NCDs. However, there is a need to better understand how to support CHW programs to be more effective and sustainable. There is knowledge gap in terms of the CHWs current capacity, working conditions, training provided for NCD prevention and control, remuneration, supervision and other upstream challenges facing CHWs and the health systems. The literature suggests that the there is a range of context-specific factors which can have an impact on the performance of CHWs and the quality of the care they provide. Some of these factors include the remuneration schemes employed, the workload, task complexity, lack of clarity in job description, and other essential factors such as interpersonal relationships between CHWs and other members of the primary health care team. CHW programs operate differently across and within countries. Evidence-based policy interventions are required to inform policy decision to ensure effective CHW program implementation. This thesis applies a mixed-methods approach to explore the capacity of the CHWs and the system support necessary to facilitate the CHW’s role in providing comprehensive, community-oriented, continuous primary health care which includes prevention and control strategies for NCDs. Part One provides an insight into the historical background of CHWs and how their role has evolved due to global health needs. With the expanding role of CHWs to incorporate NCDs, part two throws light on training of CHWs for NCDs in LMICs. Chapter two presents results of a systematic review about the effectiveness of training CHWs for cardiovascular disease prevention and management in LMICs. The chapter findings demonstrate the importance of having interactive and culturally adapted training sessions to make the training easier to follow and understand by the CHWs. The findings also highlight the need for evaluating the knowledge and skill-set of the CHWs to capture the training impact; and the necessity of scheduling refresher training at regular intervals to ensure knowledge retention. Chapter three demonstrates the importance of using an evaluation framework such as Kirkpatrick’s evaluation model to evaluate the effectiveness of training among CHWs. Using an evaluation framework, not only assesses the knowledge change but rather employs multiple measures to assess knowledge, skills and behaviour change of the CHWs. This allows for a more comprehensive interpretation of the training outcomes. The qualitative data involved in Chapter three provided insight on the low morale and discontent of the CHWs with their working conditions. In part three, I use a discrete choice experiment (DCE) to provide evidence of effective interventions that can keep the CHWs motivated and retain them in the workforce. Chapter Four explains the process of designing a DCE for Accredited Social Health Activists (ASHAs), who are CHWs in India. It also provides evidence of the feasibility of using Android computer tablets to display the DCE for the CHWs. In chapter five, I examine the relative importance of stated preferences of ASHAs to remain in service using a DCE survey. Career progression was found to be the main influencing factor for ASHAs in addition to fixed salary and other non-financial factors such as priority free family health-check and reduced workload. The findings demonstrated that the ASHAs sociodemographic characteristics such as their education level plays a key role in shaping their preference profile. These findings can inform future policy decisions of evidence-based recruitment and retention strategies that are applicable to the local context. CHWs have proven to be effective in providing a wide range of services including NCDs care. However to optimize the performance of CHW programs, we need to understand the system level support needed and the strategies necessary to be considered in the design and operation of CHWs’ programs. Part four, investigates the policy and implementation elements and system level support needed to enable the CHWs in rural India to provide comprehensive primary health care that incorporates NCDs. Chapter six uses policy review and qualitative research to understand the policy and implementation gaps, current capacity, working conditions and challenges faced by ASHAs in providing NCDs care to their community. It provides an overview of the perspectives of the key stakeholders of the ASHA program including ASHAs, ANMs, primary care doctors, community members, and district medical officers. Findings revealed that ASHAs are unrecognised as formal members of the NCDs delivery team, however they are overburdened with extensive NCDs tasks without receiving training or remuneration for these tasks. ASHAs remain to be volunteers that receive performance based remuneration and are not covered by any of the workers’ rights or laws. However, ASHAs remain enthusiastic about helping their communities and aspire to be recognised as formal employees of the health system with a potential career progression pathway. The concluding chapter summarises the key findings, discusses the main themes emerging from the thesis and outlines the future research directions and policy recommendations