Michael E. Thompson

Gender differences in predictors of self-rated health in Armenia: a population-based study of an economy in transition.

IntroductionSelf-rated health is a widely used health outcome measure that strongly correlates with physical and mental health status and predicts mortality. This study identified the set of predictors of fair/poor self-rated health in adult female and male populations of Armenia during a period of long-lasting socio-economic transition to a market economy.MethodsDifferences in self-rated health were analyzed along three dimensions: socioeconomic, behavioral/attitudinal, and psychosocial. The study utilized data from a 2006 nationwide household health survey that used a multi-stage probability proportional to size cluster sampling with a combination of interviewer-administered and self-administered surveys. Both female and male representatives of a household aged 18 and over completed the self-administered survey. Multivariate odds ratios (OR) for fair/poor self-rated health were calculated for different sets of variables and logistic regression models fitted separately for women and men to identify the determinants of fair/poor self-rated health.ResultsOverall, 2310 women and 462 men participated in the survey. The rate of fair/poor self-rated health was 61.8% among women and 59.7% among men. For women, the set of independent predictors of fair/poor self-rated health included age, unemployment, poverty, low affordability of healthcare, depression, and weak social support. For men, the set included age, lower education, depression, weak social support, and drinking alcohol less than once a week. For both genders, depression and weak social support demonstrated the strongest independent association with fair/poor self-rated health.ConclusionsThe prevalence of fair/poor self-rated health was similar among men and women in this study, but the sets of independent predictors of perceived health differed somewhat, possibly, reflecting lifestyle differences between men and women in Armenia. Nevertheless, psychosocial variables were the strongest predictors of fair/poor self-rated health for both genders, indicating the importance of improving the country’s psychosocial environment through social reforms and poverty reduction.

Psychometric value of the Center for Epidemiologic Studies Depression (CES-D) scale for screening of depressive symptoms in Armenian population

BACKGROUND This study examined the psychometric value of the Center for Epidemiologic Studies Depression Scale (CES-D) translated for use with an Armenian population. METHODS Using data obtained from a country-wide health survey of 2310 households involving female and male respondents aged 18 and over, we investigated the response pattern to the CES-D items, the factor structure, internal consistency, inter-item correlations of the total scale and its negatively and positively formulated subscales. We used logistic regression analysis to relate the constructs measured by the CES-D and its subscales to known determinants of depression. RESULTS Armenian respondents of both genders significantly suppressed their positive emotions, thus over-endorsing positively formulated (reverse-coded) items, therefore producing artificially high depression scores. Factor analysis of the scale yielded a three-factor structure (combined Depressed/Somatic, Positive Affect, and Interpersonal). The Positive Affect factor correlated weakly with the other two factors, and its inclusion reduced the internal consistency of the whole scale. Unlike the 16-item subscale of negatively formulated items, Positive Affect was not related to several known determinants of depression and did not reflect known depression-specific differences between genders. The set of determinants of Positive Affect included mainly lifestyle and attitudinal variables. LIMITATIONS This study did not assess the concurrent and discriminate validity of the Armenian CES-D. CONCLUSIONS For Armenians, the construct measured by the four Positive Affect items of CES-D is not related to depressive symptoms as measured by the other items. It introduces ethnical/cultural response bias in CES-D score and reduces the cross-cultural comparability of the latter.

Determinants of Morbidity and Intensive Care Unit Stay after Coronary Surgery

The study evaluated rates and determinants of hospital morbidity, serious morbid events, and prolonged intensive care unit stay associated with isolated coronary artery bypass. The medical records of 391 patients undergoing isolated coronary artery bypass at our center during 2003 were reviewed. The observed crude hospital mortality rate was 2.05%, similar to the EuroSCORE predicted mortality rate of 2.34%. Arrhythmia was the most frequent postoperative complication (17.6%). The serious hospital morbidity rate was 5.9%. The final logistic regression model of serious morbid events identified the following predictors: drug allergy, diabetes, and EuroSCORE. Prolonged intensive care unit stay (≥ 3 days) was observed in 9.5% of patients. Multivariable logistic regression analysis revealed age, preoperative rhythm disturbances, previous cardiac operation, and hypertension as independent predictors of prolonged intensive care unit stay. The rates of hospital mortality, morbidity, and prolonged intensive care unit stay were comparable to those of other major international cardiac surgery centers. These data can be used as a benchmark for further self- and peer-assessment quality improvement activities.

Impact of a community-based integrated management of childhood illnesses (IMCI) programme in Gegharkunik, Armenia

BACKGROUND Maternal and child health status in the Martuni region of Gegharkunik marz, Armenia, precipitously declined following Armenias independence in 1991. In response, the American Red Cross (ARC) and the Armenian Red Cross Society (ARCS) implemented the WHO community-level Integrated Management of Childhood Illnesses (IMCI) strategy, complementing recent clinical IMCI training in the region in which 387 community health volunteers from 16 villages were trained as peer educators, and approximately 5000 caretakers of children under age 5 were counselled on key nutrition and health practices. METHODS A pre-post independent sample design was used to assess the programmes impact. The evaluation instrument collected respondent demographic characteristics and knowledge, attitudes and practices consistent with 10 health indicators typical of child survival interventions. At baseline and at follow-up, 300 mothers were interviewed using a stratified simple random sampling of households with at least one child less than age 2. RESULTS The assessment confirmed the populations poor health status and limited knowledge and application of recommended child care practices. The campaign reached its target: at follow-up, 67% had seen media messages within the past month, 82% had received the IMCI informational booklet, and 30% had seen other materials. Evidence of the success of the programme included the following: exclusive breastfeeding increased 31.4%, maternal knowledge of child illness signs increased 30%, knowledge of HIV increased 28.5%, and physician attended deliveries increased 15%. CONCLUSIONS This evaluation documented the significant and substantial impact of the community IMCI programme on both knowledge and practice in rural areas of Armenia. Consideration should be given to continuing and expanding this project as a complement to health sector development activities in this region.

Does Amount of Weight Gain During Pregnancy Modify the Association Between Obesity and Cesarean Section Delivery

BACKGROUND Two-thirds of reproductive-aged women in the United States are overweight or obese and at risk for numerous associated adverse pregnancy outcomes. This study examined whether the amount of weight gained during pregnancy modifies the prepregnancy body mass index (BMI)-cesarean delivery association. METHODS A total of 2,157 women aged 18-45 who participated in the 2008-2009 North Carolina Pregnancy Risk Assessment Monitoring System had complete information on prepregnancy BMI, maternal weight gain, and mode of delivery on infant birth certificates. Logistic regression was used to obtain odds ratios (ORs) and 95 percent confidence intervals (CIs) to model the association between prepregnancy BMI and cesarean delivery, and a stratified analysis was conducted to determine whether maternal weight gain was an effect modifier of the prepregnancy BMI-cesarean delivery association. RESULTS Obese women had 1.78 times the odds of cesarean delivery as compared with women with a normal BMI (95% CI: 1.44-2.16). When adjusted for race/ethnicity, live birth order, household income, and education, the association increased in magnitude and remained statistically significant (OR = 2.01, 95% CI: 1.63-2.43). In stratified analyses, the obesity-cesarean delivery association persisted and remained statistically significant among all maternal weight gain categories. CONCLUSIONS Health care practitioners should stress the importance of achieving a healthy prepregnancy weight and gaining an appropriate amount of weight during pregnancy to reduce the risk of cesarean delivery and other adverse pregnancy outcomes.

Serum Micronutrient Concentrations and Risk of Uterine Fibroids

BACKGROUND Although uterine fibroids are among the most common gynecologic conditions affecting women in the United States, research on uterine fibroids is sparse. This study explored the association between micronutrients and uterine fibroids. METHODS We conducted a population-based, cross-sectional analysis of 887 women aged 20-49 who participated in the 2003-2004 National Health and Nutrition Examination Survey (NHANES). Serum micronutrient levels were collected during the health examinations, and information on uterine fibroids was assessed on self-reported questionnaires. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) while controlling for confounders. RESULTS A statistically significant dose-response relationship was observed between vitamin A and uterine fibroids, after adjustment for age, race, education, body mass index (BMI), and oral contraceptive (OC) use (middle vs. low: OR 2.43, 95% CI 1.35-4.37; high vs. low: OR 2.66, 95% CI 1.16-6.10, p for trend=0.02). After adjustment, a dose-response relationship also emerged for vitamin C, although these associations were not statistically significant. CONCLUSIONS It is possible that certain micronutrients affect uterine fibroid development. If this is confirmed in large prospective studies, clinicians could advise susceptible populations on dietary changes to reduce their risk of uterine fibroids.

Associations Between Social Relationships and Emotional Well-Being in Middle-Aged and Older African Americans

Social relationships may enhance emotional health in older age. The authors examined associations between social relationships and emotional health using data from the Milwaukee African American sample of the second Midlife Development in the United States (MIDUS II) study, 2005-2006 (n = 592). Self-reports indicated good, very good, or excellent emotional health, distinguished from fair or poor. Social relationships were measured by relationship type (family or friend), contact frequency, and levels of emotional support and strain. Control variables included demographic characteristics, types of lifetime and daily discrimination, neighborhood quality, and other social factors. In adjusted results, each increase on a family emotional support scale was associated with 118% greater odds of reporting better emotional health (odds ratio [OR] = 2.18, 95% confidence interval [CI] [1.43, 3.32]). Friend emotional support also was associated with better emotional health (OR = 1.59, CI [1.07, 2.34]). Daily discrimination substantially reduced reported emotional health; family and friend support buffered this effect.

Patient satisfaction with primary care in Armenia: good rating of bad services?

The study assessed the level of patient satisfaction at selected primary health-care facilities in Lori and Shirak provinces of Armenia. Self-administered questionnaires were distributed to 684 recent clients at primary health-care facilities. The majority of patients were satisfied with their provider (mean satisfaction score of 1.75 out of maximum 2). Most patients (89.0%) would visit the same provider again, and would recommend the provider to friends (85.6%). Satisfaction with other aspects of care, including waiting time, accessibility of services, confidentiality and cleanliness of the facility, was also high (mean score of 1.70 out of 2). Seventy-eight percent of respondents considered the care they received to be ‘excellent’ or ‘good’. The less educated and those in rural areas were more likely to be satisfied with the providers quality. Despite the fundamental problems now challenging the Armenian primary health-care sector, patient satisfaction remains high. Given the high level of reported satisfaction, more focused satisfaction research tools and alternative approaches to patient assessments of care are needed to inform quality improvement in the Armenian setting.

Effects of Social Ties on Self-rated Physical Health Among African American Adults

OBJECTIVES To examine associations between social ties and self-rated physical health among midlife and older African Americans. METHODS Cross-sectional analysis of the 2005-2006 Milwaukee African American oversample of the second Midlife Development in the United States (MIDUS II) study. Multivariate logistic regression examined associations between type of social ties (family or friends), their frequency (number of contacts), and their quality (support and strain) with betterself-rated physical health (SRPH). We defined better SRPH to include self-reports of good, very good, or excellent SRPH: this category was compared with fair or poor SRPH. Control variables included demographic factors; social engagement characteristics such as working, volunteering, and caregiving; and measures of social structure such as types of discrimination experience and ratings of neighborhood quality. RESULTS In adjusted results, each additional degree of family support was associated with better self-rated physical health (odds ratio [OR], 1.59; 95% confidence interval (CI], 1.14-2.22). Each additional reported incident of daily discrimination was associated with 9% lower odds of reporting better SRPH (OR, 0.91; CI, 0.83-0.99). DISCUSSION Results suggest quality of family support may contribute importantly to the health of African Americans. When working with midlife and older African Americans, providers should engage and support families as a vital resource to improve health.

Identifying priority healthcare trainings in frozen conflict situations: The case of Nagorno Karabagh.

IntroductionHealth care in post-war situations, where the systems human and fixed capital are depleted, is challenging. The addition of a frozen conflict situation, where international recognition of boundaries and authorities are lacking, introduces further complexities.Case descriptionNagorno Karabagh (NK) is an ethnically Armenian territory locked within post-Soviet Azerbaijan and one such frozen conflict situation. This article highlights the use of evidence-based practice and community engagement to determine priority areas for health care training in NK. Drawing on the precepts of APEXPH (Assessment Protocol for Excellence in Public Health) and MAPP (Mobilizing for Action through Planning and Partnerships), this first-of-its-kind assessment in NK relied on in-depth interviews and focus group discussions supplemented with expert assessments and field observations. Training options were evaluated against a series of ethical and pragmatic principles.Discussion and EvaluationA unique factor among the ethical and pragmatic considerations when prioritizing among alternatives was NKs ambiguous political status and consequent sponsor constraints. Training priorities differed across the region and by type of provider, but consensus prioritization emerged for first aid, clinical Integrated Management of Childhood Illnesses, and Adult Disease Management. These priorities were then incorporated into the training programs funded by the sponsor.ConclusionsProgramming responsive to both the evidence-base and stakeholder priorities is always desirable and provides a foundation for long-term planning and response. In frozen conflict, low resource settings, such an approach is critical to balancing the communitys immediate humanitarian needs with sponsor concerns and constraints.