HIV/AIDS patients in Zambia; Are they cared for? Essay

Executive summary Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) pandemic has created terrible burden for millions of individuals, families and communities worldwide. All sorts of exertions have been tried to curtail this tormentor and yet no known cure or vaccines have been discovered to prevent it. Religious prayers and even rituals have also seemed futile. However, the only option now is to only provide tender care, love and even nurture for those that are infected and consequently affected. This might prevent further spread and in turn minimise further impacts. This study seeks to improve on the care that should be rendered to HIV/AIDS patients and even strategize on how to improve the well-being of these ill-fated people. This study is a combination of situational analysis through a scientific study to understand various dynamics of management of HIV/AIDS patients in Zambia accompanied by formulation of strategies based on findings of the study. Background The HIV/AIDS prevalence rate in Zambia has even become one of the highest in the world. The prevalence rate in the general population is estimated to be 14.3 per cent with approximately 930, 000 people living with HIV/AIDS. Generally, despite all the campaigns, the stigma associated with HIV/AIDS still exists. On one hand, patients who are infected and have all the symptoms claim to be neglected at the hospitals and are not given the best services. It may not be out of order to query whether these health care providers are really taking care of HIV/AIDS patients. Several interventions have been staked so far but they do not seem to adequately address and even assess if HIV/AIDS patients are fully attended to by health care providers. For example, though not very successful, the National HIV/AIDS/STI/TB intervention strategy plan 2002–2005 was developed with providing care to people living and affected by HIV/AIDS as one of the strategies of reducing the spread of AIDS. This research endeavours to provide a fundamental overview of how best the society at large can prevent further spread of HIV through care. This is deemed necessary for the implementation of an HIV/AIDS free management policies. If it comes out necessary to quarantine HIV patients, we will not hesitate to articulate that. Rationale This study aims at creating space for all people living with HIV/AIDS in different settings; especially in hospital environment, where most of them seek medical advice. This study shall improvise core framework for any change/s at the institutional and individual levels and across all sectors that in turn shall help create an environment of understanding, empathy, love, trust, hope, human rights and dignity for those most in need, that is, HIV/AIDS patients. Problem The major problem is the increased levels of stigmatization, discrimination and violation of human rights of HIV/AIDS patients in various settings. Minor problems include: * Lack of better strategies to deal with matters of HIV/AIDS * Lack of consistency in delivery of health care * Lack of friendly or social relationship between HIV/AIDS patients and care takers Objectives In addressing the problems stated above, the following specific research objectives have to be achieved: i. To investigate the extent to which patients are cared for by health care providers and relations. ii. To investigate the nutritional well-being of HIV/AIDS patients. iii. To identify factors leading to stigma, discrimination and human rights violation of HIV/AIDS patients. iv. To frame recommendations/strategies for policy makers and other influential groups for improvements in social well-being of HIV/AIDS patients. Methodology Participants Our sample size is 150 and these consist of all HIV/AIDS patients in the selected hospitals within Lusaka. The number of patients to approach per hospital will be determined on the total number of admitted patients at the time of data collection. Our target population is all HIV/AIDS patients that have been admitted to the selected hospitals for at least one week. However, since it will be impossible to survey all HIV/AIDS patients in all hospitals in the City of Lusaka, our study population will be patients admitted to University Teaching Hospital (UTH) and Levy Mwanawasa General Hospital. These patients are to be found on weekdays/weekends during the stipulated visiting hours per hospital. Data Analysis Data will be entered in excel and analysed using SPSS version 16 and descriptive statistics will be computed using the same software. SPSS will be selected because it is user friendly. Research Method Our research method is to perform a situational analysis study using a questionnaire capturing the HIV/AIDS patients’ nutritional status, social relationship with care takers and how often they are visited by their relations. The questionnaire is as simple as possible to avoid frustrating the patients. Our sampling method will be convenience sampling where we would simply visit HIV/AIDS patients in hospitals under study. Convenience sampling will be used because this method would not impose a huge cost. Due to confidentiality and ethical considerations, the then main clinicians during data collection, at the hospitals under study will help to distribute questionnaires to those HIV/AIDS patients willing to participate. Currently, at UTH, we have Dr Nyirenda and Dr Musonda who are willing to administer the questionnaires in clinic five of UTH and Dr Alfred at Levy Mwanawasa General Hospital. We will simply approach any HIV/AIDS patient and ask them to volunteer in our survey. We will conduct an in-person survey by briefly introducing to them the purpose of our survey and explain why their participation will be valuable to the public. We will ask them if they have 3 minutes to do our survey. By having given them a brief introduction before we interview them, we can have a better sense of whether or not our survey is applicable to them. All non-HIV/AIDS patients in the stated hospitals will be ineligible to participate in the survey. In addition, a focus group will also be used to discuss the perceived prejudices that HIV/AIDS patients face. We will simply ask two HIV/AIDS patients, one representative from UNZA HIV/AIDS response office and one representative from the Ministry of Health to volunteer to give us one hour on one evening to get their opinions about the current levels of stigmatization, discrimination and violation of human rights of people living with HIV/AIDS. A facilitator will be present to conduct the group discussion and ask several open-ended questions while another representative will record the respondents’ answers during the discussion. The advantage of this focus group study is that it is not costly, not time consuming and we can get in-depth information and opinions from people who are directly and frequently affected by the problem. Anticipated Results Expected Outcomes: Mounting evidence suggests that no known cure for HIV/AIDS has been unearthed so far. This simply entails that we can only reduce further spread of the pandemic by improving the lives of the people who are infected and affected by the pandemic. Consequently, this study will not only enlighten the policy makers on the real strategy of reducing the further spread of HIV/AIDS but also propose measures that may deal with the problem more effectively. It is further expected that this study will generate a research report and a fact sheet on the dynamics and impact of stigmatization and discrimination on those infected and affected by HIV/AIDS in Zambia. In the final analysis, it is expected that Government through the Ministry of Health and indeed the donors will be better informed, and could adopt some of the findings and recommendations in their policies. Impact: Results from this study are expected to feed into policies aimed at improving the well-being of HIV/AIDS patients in the country. From these, it is expected that the policies can be inferred to other countries facing HIV/AIDS. Utilisation: It is expected that findings from this study will be utilised by policy makers and implementers to enhance health care planning and ensure that the scarce national resources are allocated efficiently on projects that give the highest social and economic returns to HIV/AIDS patients. Dissemination Findings from this study will be disseminated through workshops that will be held so that all the stakeholders are informed about the viability of report findings as a remedial measure to the spread of HIV/AIDS in Zambia. Lastly, the study report will be available on the UNZA website and at UNZA HIV/AIDS response office for all to read.

Business Gross and Net Profit

Gross and Net profit Gross profit A company’s revenue, minus the business’ costs of goods For example: If I sold 5000 cheese sandwiches for ? 1 each my total revenue would be 50 x ? 1 = ? 5000 It costs 25p per sandwich to purchase bread, butter and cheese. My gross profit = Revenue – Costs of sales (25p x 5000= ? 1250. 00) = ? 3750. 00 Net profit The business’ gross profit minus expenses For example: My gross profit from my sandwiches is ? 3750. 00 to calculate my Net profit I need to minus the rest of my expenses †¢ ? 385 on rent †¢ ? 80 on advertising †¢ ? 950 on staff salaries My total expenses are ? 1,415 My net profit= Gross profit (? ,750) – Expenses (1,415) = ? 2,335 The difference between gross and net profit The difference between gross and net profit is that gross profit is merely a stepping stone to work out the net profit. Say at the end of a month a business has ? 5000 in the bank, we need to work out the gross profit to know exactly how much we have to pay to the manufacturer and to cover the costs of materials. The same goes for net profit. Say after the business had worked out the gross profit and we had ? 4250 left in the bank, we still wouldn’t know exactly how much money we had made that month until we had worked out the net profit. Cost of salesCost of sales is the cost of the materials used to produce a product. This includes any costs included in making the product, this includes: †¢ Shipping costs †¢ Cost of containers †¢ Overhead costs linked directly to the manufacture, like rent for the manufacturing facilities Costs vary dependant on the industry. For example a retail business buys products to resell them at a higher price, but a manufacturer either buys raw materials and turn them into finished products, or buy parts and just assemble them, ready for sale. Expenses Expenses are all the costs that a business or organization has to pay out, this includes †¢ Fi xed costs Variable cost †¢ Taxes †¢ All other operating costs How to maximise profits There are several different ways a business or organization can maximise profits, these include: †¢ Lowering the costs of sales by using cheaper materials †¢ Lowering the costs of sales by minimizing manufacturing costs Nike Sports wear and Primark got a lot of bad press by moving their manufacturing factories abroad. They did this to lower their manufacturing costs as the workers have no minimum wage, or even minimum age so they can have their goods made at a very low price. †¢ Increasing the price of sales, (making your product more expensive)

Design and Construction of the Museum of Acropolis

Since the 1970s, the Museum of Acropolis could non get by satisfactorily with the big crowds of visitants. The insufficiency of infinite caused jobs and downgraded the sense that it was achieved by the exposure of chef-d'oeuvres from the Acropolis Rock. Apart from the fact that the bing museum was deemed deficient to house and expose the celebrated findings of the Acropolis, it could non expose all the sculptures that were needfully moved from their place for the care work. For all these grounds, two architectural competitions took topographic point in 1976 and 1979, but without success. On March 12Thursday, 1989, Melina Mercouri initiated an international design competition that as Minister of Culture inextricably identified her policy with the demand for the return of the Elgin Parthenon Marbles from the British Museum. This competition was canceled after the disclosure of a big residential country at Makriyianni site, dating from Prehistoric to Byzantine times. The digging should be included in the New Museum. Bernard Tschumi faced a immense challenge, when he won the competition for the Acropolis Museum in Athens and he was called to plan a new landmark for the metropolis. Greece had been fighting to go portion of Europe in all possible ways ( politically, culturally, etc. ) since the ‘70s, and that museum would be the chief ally to back up this end. Grecian political system had since the really get downing focused its attempts on puting up a state that expresses the ideals of a European cultural heritage. The efforts to suit in the western society had started since the terminal of nineteenth century, after the declaration of independency from the Ottoman Empire, and during the period that followed there was a changeless attempt discard all the residues of East civilization. The purpose was to repossess the ancient yesteryear alternatively, and define national individuality and civilisation on that portion of history. Therefore, the remains of the Grecian antiquity became really of import in the defining of the province and society. The Museum of Acropolis is a political statement of Greece and an instrument for Grecian authorities to send on to western society a new national individuality. This is an individuality that promotes Grecian ancient heritage and preserves it in a high tech twenty-first century shell. Those elements combined, organize a clear position of how Grecian society wants to be perceived today. The purpose is to organize an substructure of equal value with Western Europe, of rich cultural civilisation and high engineering resources which are demonstrated on Tschumi ‘s museum. At this phase the writer would wish to clear up that this is an attempt to interpret and analyse the new Museum of Acropolis, non aesthetically and even more non from a personal point of position, but as a political and cultural statement of what Greek society is seeking to reflect and advance of Greece in the twenty-first century, to western Europe and globally. Significant location The site of New Acropolis Museum is the edifice block surrounded by Dionysius Areopagite, Makriyannis, Chatzichristou and Mitseon roads. As a consequence, visitants while researching the archeological sites of the environing countries are of course guided towards the museum, and unconsciously experience a connexion between the antediluvian and modern-day Greece. The land of the site has a smooth incline, about 8 % downward to the South, and portion of its surface is covered by public edifices, which due to its historical, architectural and morphological involvement have identified as monumental by the Ministry of Culture. Three architectural parametric quantities reverse the restrictions of the site, in a challenge to make a simple and precise museum uncovering the mathematical and limpid lucidity of ancient Greece the Light, the Movement and the Structure of the edifice. More than any other type of museums, the information of the new Archaeological Museum of Acropolis are based around the visible radiation. It is chiefly a museum of natural visible radiation with the cardinal intent of â€Å"the presence of sculpture† . The three chief stuffs of the museum isglass,which is used largely for frontages and some floors,concretefor the nucleus and columns andmarblefor some floors. The columns of the E and West facade and the Parthenon Gallery have been constructed from steel. There is a harmoniousness of proportion between the graduated table of the infinite that leads to the edifice and the graduated table of the edifice itself. Equivalent graduated tables of â€Å" emptiness † and of â€Å" non-emptiness † are developed in two axes, one horizontal and one vertical. If the edifice was losing the journey to the entryway, the whole feeling of the museum and particularly the first reaction to it, would be diametrically opposite. Now the visitant is prepared easy and phased into a whole experience which starts before come ining the museum. Monumental graduated table There is a relationship of volume between the New Museum of Acropolis and the Parthenon which is really noticeable when reading the site program, every bit good as when populating the part. In an country where the graduated table of environing edifices is much smaller, as the site is located in a domestic zone, those are the lone two elements that stand out, which both are of monumental graduated table. The ocular relationship to the Parthenon and the landscape On the degree between the Roman period exhibition and the Parthenon ‘s Gallery there is a communal infinite which includes a bookstore and a dining country. Right in forepart of the eating house a canopy unfolds, which is supported by â€Å" powerful columns † that define the chief entryway placed right below. The canopy extends from the edifice towards the antediluvian Rock of Acropolis. The position from the eating house ‘s balcony to the Parthenon is partially blocked because of two neoclassical edifices that stand in forepart of the museum. Tchumi ‘s planning includes the destruction of those which has caused a great field of argument for designers and critics in Greece. Some argue that the canopy is â€Å" absolutely positioned as if to pound into the demolition-endangered abodes and so onto the stone of the Acropolis itself † as Dr Alexandra Stara says in the Architectural Review, no. 1348, June 2009. Any solution to this quandary will be harmful merely to architectural creative activity. If the two preserved neoclassical edifices in Aeropagitou Street are demolished, Athens will lose two great pieces of its architectural heritage. If they are non, Tschumi ‘s coveted contradictions will non take topographic point and his architecture will non be completed. The portion of the museum that contains the most obvious political and cultural statement is the Parthenon gallery. It was a vision by Melina Merkouri, Greek actress and politician ( chief female Minister for Culture of Greece ) , who was the first individual to claim back the Parthenon marbles from the British authorities. Her dream was that the most impressive room of the new museum of Acropolis should remain empty until the marbles go back to Greece. The creative activity of this gallery opens once more the conversation between United Kingdom and Greece for the return of the marbles. The Parthenon Gallery is a representation of the temple including a big rectangular infinite where the carved marble panels that decorated the original are exposed. The marbles face the issue of heterotopia ( malposition or supplanting of a bodily organ ) , and the Parthenon gallery is designed by the designer with an evident purpose to make similar fortunes between the topographic point of displaced marbles and the existent location where they used to be displayed one time. Cost The building of the undertaking started at a cost of ˆ130 million in November 2004, and it was completed within the period of three old ages. The Ministry of Culture continued its most of import work ; the exposure of valuable and invaluable exhibits. The transportation of major exhibits to the museum began in the fall of 2008 and it was completed in May 2009. On June 20th, 2009 the Museum opened its Gatess to the citizens of the universe. Within one twelvemonth from the bright gap twenty-four hours, the new Acropolis Museum has made great feeling, with the figure of visitants making two million. However, it has outstanding issues such as non secured a fiscal independency, legislative acts and assortment of merchandises in the museum store. Harmonizing to Mr. D. Pantermalis, Director of the Construction of the New Acropolis Museum and subsequently Director of the Museum itself, The Acropolis Museum as a self-funded organisation is confronting fiscal jobs which struggles to be solves. With about 5.5 million income, the museum needs to cover the wages of 90 – 95 % of the staff and functional costs such as electricity, gas etc. which is about 1 Euros. As the Director of the Museum provinces, the economic crisis requires flexibleness and thoughtful version to enable the Museum to travel in front. Due to the economic crisis and the debt â€Å"haircut† the assets of the Museum have been reduced by 3 million Euros and among other things, this caused a long hold to the digging at the base of the Museum, something that it’s pending for the hereafter. Decisions The whole museum is a statement, a changeless statement of the coexistence of antediluvian with modern-day Greece. Tshcumi ‘s design makes the visitant experience a portion of a monumental piece of architecture, of import and alone, about as the Parthenon. This edifice offers Greece a new national individuality. It demonstrates and promotes what Greece is most proud of, the ancient Grecian civilisation. And all this is placed in one of the most of import technological accomplishments of our times. But the inquiry that remains is if the museum still expresses the same significances under the current economic crisis that Greece is traveling through. Mentionshypertext transfer protocol: //www.theacropolismuseum.gr/hypertext transfer protocol: //www.greekarchitects.gr/en/architectural-review/the-new-acropolis-museum-a-triumph-of-sophistry-id2431hypertext transfer protocol: //en.wikipedia.org/wiki/Acropolis_Museumhypertext transfer protocol: //tschumi.com/projects/2/hypertext transfer protocol: //www.archdaily.com/61898/new-acropolis-museum-bernard-tschumi-architects/hypertext transfer protocol: //www.arcspace.com/features/bernard-tschumi-architects/new-acropolis-museum/hypertext transfer protocol: //www.melinamercourifoundation.org.gr/index.php? option=com_content & A ; view=article & A ; id=62 & A ; Itemid=114 & A ; lang=enhypertext transfer protocol: //www.theparliament.com/latest-news/article/newsarticle/eu-funding-for-new-acropolis-museum-branded-inappropriate/ # .UxzcK_l_uRYhypertext transfer protocol: //www.youtube.com/watch? v=B6Ca21dCmhIImages

Precisionism, the effect of independent gallery exhibitions, the role Personal Statement

Precisionism, the effect of independent gallery exhibitions, the role of Photography in the art of the early 20th century - Personal Statement Example They were after producing images that had details (Marien 6). Independent gallery exhibitions have had a lot of effect of on photography. Independent gallery exhibition has encouraged the sprouting of young photographers with talents. It is at these exhibitions that photographers become encouraged on their work. In addition, they also get to compare notes with their fellow photographers and get some tips on how to improve (Marien 23). Independent gallery exhibitions give a photographer confidence in his or her work as he or she learns if he or she is on the right track. In addition, one could also be able to establish connections while there and be able to market some of his or her photographs. Photography has had an impact in the 20th century. In fact, many pictorialists feel that the photographs have improved their artistic merit and degree of resemblance to drawings, paintings, mezzotints (Marien 45). Photographs these days display mood and the sense of lighting using softly-focused images that have primary concern. Sometimes, photographers have been able to add some additional â€Å"handiwork† to certain images through printing techniques, for example, gum-bichromate printing, where images can be transferred onto a soft, malleable coating. Photography has proven to go in hand with technology and utilized some of its aspects to bring the imagery and innovation at new heights. All in all, photography has proven to have an enormous role in the 20th century (Marien

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Rimsky-Korsakov Essay Example | Topics and Well Written Essays - 750 words

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Three Events That Changed America Essay Example for Free

Three Events That Changed America Essay The United States has changed a lot since its â€Å"Birth† in 1776. The United States changed for better or worse from The Great Depression, The Vietnam War, and The Attacks of 9/11. These life altering events formed America with tragedy, and destruction. Being the land of the free and the home of the brave. We rose up stronger and with hope. That’s what makes America great. The Great Depression all started when the stock’s value started to plummet with no hope of recovery (Black Tuesday), people started to panic. Everyone who owned stock was trying to sell, but no one was willing to buy. This caused the stock market to suffer even more. The Stock Market Crash was only the beginning. Almost all the banks at this time put their clients’ money into the stock market. When the stock market crashed, this made the banks go bankrupt. When news got around, anyone who had money in the bank was immediately withdrawing all the money they could. All the money being taken out caused any bank left to close permanently. The Great Depression had such a huge impact on the way America is today because it destroyed our economy. We were forced to grow together as a country and rebuild. I think Dennis Hastert says it best â€Å"What makes America great is that we can come together during times of national tragedy†. The Great Depression also change how we run our banks. The government now has a program in place called FDIC Insurance. They will insure you for up to 250,000 per insured bank account. The fee is included in your normal taxes. This was put in place because of the Great Depression. â€Å"The Vietnam War† At the end of World War II Military and Political tensions between the USSR (Russia) and the US greatly increased. Communism in the USSR presented itself as a big threat to the US’s national security. Fearing that the Communism would spread to Vietnam and other countries, the US opposed the independence movement there. The US first began by financially supporting France in the first Indochina War. The French defeat in Dein Bien Phu led to a peace conference in Geneva. This conference resulted in splitting the former French colony Indochina into three separate countries, Cambodia, Laos and Vietnam. Vietnam was divided at the 17th parallel into the Communist North and anti-Communist South. There was a plan for a nationwide election to unify North and South Vietnam. However, in 1956, South Vietnam backed by the US refused to hold the election. The US supported South Vietnam by sending 2,000 military advisors-which grew to over 16,000 by 1963. In 1960, the National Liberation Front (Viet Cong) began to attack the South Vietnamese government. After two attacks on U.S Navy vessels, the Gulf of Tokin Resolution was passed by the US Congress to give the US more powers to fight the war in Vietnam. The first US Combat troops were sent a year and a half after it was passed. In 1968 over 540,000 troops were in the countries of Vietnam. That same year the Viet Cong launched a massive surprise attack. This is now known as the â€Å"Tet Offensive†. This attack threatened the US’s position in South Vietnam. This had a huge impact on the outcome of the war. President Richard Nixon proposed the â€Å"Vietnamization† project. It gave South Vietnam more responsibility in fighting the war while still receiving American aid. The US would also provide air and naval support if necessary. In 1972 the Easter Offensive made people think if the policy was effective. They were suggesting that South Vietnam could not wage a full scale war against North Vietnam without the US’s full support. The 1970’s brought anti-war protests because Nixon tried to destroy the Viet Cong supply bases. In 1973, the war started to come to an end. The Paris Peace Accord was signed. This established a ceasefire and allowed the exchange of war prisoners. Also the withdrawal of US forces from Vietnam. This officially ends the US’s and its ally’s involvement in the Vietnam War. The US did still contribute monetarily to South Korea until its official ending in 1975. South Korea lost, and Vietnam was unified as one communist country. The Vietnam War not only changed how we fight, but it changed who we draft and length of the tour. In the Vietnam War the US learned a lot about jungle warfare. Towards the end the US got very proficient at it. Some historians believe that if the US would have kept the troops for four years instead of one the US would have gotten better quicker. They say that as soon as the troops got good, they were given the option to go home, which they did. The US also learned a lot about chemical warfare. The US learned how it affects the surrounding people. The US also learned how people in their own country felt about it. The war also changed our drafting system. The US in now on a volunteer basis. The Vietnam had many deaths on both sides and it has affected the world forever. â€Å"Pearl Harbor† Early morning on December 7th, 1941, the Japanese launched a surprise torpedo attack on the US Naval Base Pearl Harbor in Hawaii. The following day President Franklin D. Roosevelt delivered a speech to the American citizens. This speech was informing the people that this all happened during the midst of talks to keep peace. That same day America entered WWII. Pearl Harbor held a 22,000 acre naval base. Admiral Husband E. Kimmel of the Navy and Lt. General Walter C. Short of the Army were in command of the fleet and troops on the ground the day of the attack. The majority of the Pacific area’s military commands were headquartered there because of growing apprehensions regarding an aggressive Japanese presence. Since the Japanese wanted to expand their territory and power, they had to search for natural resources. America was a likely target. America was a barrier between Java’s oil fields and the Japanese fleets. Also with America around, Japan could not conduct military strategies against the Netherlands and territories of the United Kingdom. Early on in the morning on December 7th, 1941, Japanese planes attacked about thirty-three American ships on orders of Vice-Admiral Chuichi Nagumo. America sustained a loss of one hundred seventy aircrafts that morning as well as eighteen ships. Three thousand seven hundred Americans lost their lives in one day but only very few Japanese died. Pearl Harbor changed America because it brought us to join WWII. This decision had an impact on who won the war. Who knows, if the US didn’t join the war we could all be speaking German or Japanese right now. This also led to the use of the first and last detonation of a nuclear bomb in warfare. So there are definitely pros and cons to Pearl Harbor. The loss of all the men in the attack was horrible, but if that never happened Hitler might have won. All in all, these events changed the course of history. The Great Depression taught us a lesson about how to handle stocks and money. It also gave us hope and brought us together as a country. The Vietnam War showed us how to fight jungle warfare. It also showed us the effects of chemical warfare (years after the Vietnam War). Pearl Harbor brought us to the very important decision to join WWII. For better or worse America is what it today because of these things.

Effect of THNPs on Heroin OD Mortality | Methodology

Effect of THNPs on Heroin OD Mortality | Methodology Chapter 2. Methods 2.1 Introduction This chapter contains a precise description of the process used to search and appraise the evidence for this systematic literature review. The search was carried out during August and September 2014. An in-depth description of how evidence and research available related to the PICO question were generated, will be discussed. As mentioned in the previous chapter, the aim of this dissertation is to determine the effect of THNPs to heroin users, on heroin OD mortality. The analysing process of the PICO question, whether THNPs reduces the incidence of fatal heroin OD deaths, will be amplified through a description of the actual search strategy, and the methods used to appraise the retrieved studies. Through specific criteria, a systematic approach was applied in obtaining and selecting the relevant literature. Identified keywords used for the search syntaxes will be presented, together with the databases used for the retrieval of evidence, and the number of hits produced from each database. Search syntax is the relationship of a sequence of words used in a search strategy. A discussion of the inclusion and exclusion criteria set for this systematic review (SR) will follow, together with the methods of appraisal chosen to evaluate the studies. 2.2 Keywords and databases used PICO Element Description Keywords Population Heroin injection users in the community heroin users, injection drug users, drug users, opioid users Intervention Take-home naloxone program take-home naloxone program, naloxone distribution program, Comparison No comparison Outcome Reduced incidence of fatal heroin OD deaths OD reversal, OD prevention, opioid OD prevention, heroin OD prevention, harm reduction According to Timmins and McCabe (2005) the cornerstone of an effective search strategy is the use of proper keywords. A number of keywords were formulated from the PICO question elements, and from the preliminary search of the literature. These were mainly identified from titles and keywords used in articles found from the preliminary search. Table 2.1 below, shows the keywords used in relation to each PICO element. Table 2.1 Keywords developed to describe the PICO framework The main electronic systematic search with the search syntaxes explained further on in this chapter was carried out using different databases accessed from the Hybrid Discovery (HyDi) available from the online library at the University of Malta. Relevant databases were found on HyDi by choosing the category ‘Health Sciences’ and sub-category ‘Nursing’ since the other sub-category is ‘Midwifery’ which is unrelated. Six databases were used to conduct a search for the literature. These were Academic Search Complete, Cumulative Index to Nursing and Allied Health CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, and Cochrane Database of SRs; via EBSCO host search engine together with Medline via ProQuest search engine, and Science Direct. In addition to these databases Google Scholar was also utilised, but the search syntaxes combinations could not be used since the search engine does not have an advanced search strategy, a nd the search resulted in large thousands of articles. Therefore simple keywords alone were used to search for any other relevant studies, or to obtain full text versions which are not available in other databases. Strengths and limitations of each database are described below in table 2.2. Database Strength Limitation Academic Search Complete Daily updates Provides full text journals Available only from EBSCO host CINAHL Plus with Full Text Weekly updates Over 950 journals Covers references and abstracts from 1982 onwards Available only from EBSCO host English and American language bias Cochrane Library Cochrane Central Register of Controlled Trials Cochrane Database of SRs Research analyzed using trustworthy methods Large source of literature Up-to-date Complete text reviews Limited by restrictions Medline Records indexed with Medical Subject Heading (MeSHÂ ®) Provides a large source of life sciences evidence needed by health professionals Limited by restrictions Science Direct Provides full text from Elsevier Science journals Provides full text articles Limited by restrictions Google Scholar Free access web based search engine Large amount of results due to lack of an advanced search strategy Table 2.2 Databases strengths Limitations 2.3 Inclusion and Exclusion Criteria For readers to assess reliability and validity of a SR they have to be provided with a set of inclusion and exclusion criteria (Cronin, Ryan, Coughlan, 2007). Furthermore, Torgerson (2003) suggests that a set of inclusion and exclusion criteria are important so that throughout the search, only the articles that will answer the PICO question are extracted while others are eliminated. During the preliminary search it was noted that literature about the subject lacks randomized controlled trials (RCTs’), meta-analysis, and SRs. As shown in figure 2.1, these study designs are found at the top of the hierarchy of evidence as described by Aslam et.al (2012). Hence, all types of study designs were part of the inclusion criteria. Sibbald Roland (1998) said that clinical trials are known to be a gold standard to perform good evidence based practice and although they were in the inclusion criteria, the results were negative since up-to date no RCTs have taken place. Although this is a major limitation for this literature review, one must keep in mind that currently, the first and largest RCT is being carried out as described in chapter 1. Source type selected in all databases was ‘Academic Journals’ since books, newspaper articles, and magazines are not of strong evidence for evidence based healthcare because sometimes they do not have any type of study design, and may be narrative. Each search was limited to English language literature only. Studies that administered intranasal (IN) naloxone were excluded since this method is an off-label method (Doe-Simkins, Walley, Epstein, Moyer, 2009), and in an RCT by Kelly et al. (2005) it was found that IM naloxone was clinically more effective than IN naloxone (6 minutes vs 8 minutes). Table 2.3 and table 2.4 below describe further in detail the inclusion and exclusion criteria respectively. Figure 2.1 The Hierarchy of Evidence Pyramid (adapted from Aslam et al. 2012, p.3) Table 2.3 Inclusion Criteria Inclusion Criteria Rationale Literature had to be in English language Not possible to translate to English Studies published from 1980’s till September 2014 Studies about THN commenced in the 90’s, and so all studies are obtained (Darke Hall, 1997) Involving heroin injection drug users above 18 years of age Since the population are adults injecting heroin, and in all studies found, drug users were of 18 years and above Involving THNP Since this review concerns the outcome of THNP Experimental studies including RCTs’, reviews, observational studies including cohort studies and longitudinal studies To include all study designs and to not eliminate valuable literature Study needed to have an outcome of survival rates or OD reversals associated to THNP If outcomes were different, studies would not answer the PICO question Exclusion Criteria Rationale Studies researching attitudes, views and opinions of health care practitioners providing THN and other stakeholders such as police Outcome of studies unrelated to PICO question Studies about experiences of fatal OD victims where naloxone was not provided to heroin users as a preventive measure of fatal OD Studies had to have THNP studied as a preventive measure rather than other measures Development of instrument tools for THNP evaluation These instruments do not answer the PICO question Users of prescription opiates including methadone Since population is specifically heroin injection drug users Studies including HIV, AIDS, buprenorphine, methadone, and supervising injecting facilities as a main topic For the fact that THNP is the main subject and intervention of this SR Studies were intra nasal naloxone was used Naloxone nasal spray is not yet approved or licensed anywhere in the world Studies where naloxone was not administered by any of the participants The outcome was not attributed directly to naloxone administration Studies not published in English Not possible to translate to English Table 2.4 Exclusion Criteria 2.4 Search Strategy The keywords mentioned in table 2.1 were developed so that each PICO element has its own search syntax as identified by Bettany-Saltikov, (2012). The use of search syntaxes has assisted in narrowing the search to the most relevant studies to the PICO question. Table 2.5 below, shows the search syntax used for each PICO item. PICO element Search syntax number Search syntax Population Search syntax 1 heroin users OR injection drug users OR drug users OR opioid users Intervention Search syntax 2 take-home naloxone program OR naloxone distribution program Outcome Search syntax 3 overdose reversal OR overdose prevention OR opioid overdose prevention OR heroin overdose prevention OR harm reduction OR overdose mortality Table 2.5 Search syntaxes Search syntaxes were combined as described here: Population (syntax 1) AND Intervention (syntax 2) Population (syntax 1) AND Outcome (syntax 3) Intervention (syntax 2) AND Outcome (syntax 3) Boolean logic operator ‘OR’ was used to combine each keyword of each PICO element syntax, while the operator ‘AND’ was used to combine the PICO elements together as described above. In all search fields of the databases used except Google Scholar, ‘In All Text’ was selected for all searches. In Google Scholar the keywords searched independently were ‘take-home naloxone’ and ‘naloxone distribution’. These keywords were searched in titles only, since when searched for anywhere in the article the results were over 50,000 with most of them irrelevant to the dissertation. As shown in table 2.6 below, the defined search resulted in 2,260 articles. After the titles were evaluated whether they fit with the inclusion and exclusion criteria mentioned previously, and removing duplicate articles the search results were reduced to 160 articles by reading through the titles. The abstracts of these 160 articles were read and consequently 25 articles were noted to be directly related to the PICO question addressed in this dissertation, as they all met the inclusion criteria. One of the 25 articles which is a study by Lenton Hargreaves (2000) was not available online for free. The author, Professor Lenton was contacted via e-mail. Fortunately there was an immediate response, and the article was provided for free. However, after reading these 25 articles, 15 were eliminated because they had one or more of the exclusion criteria fit. The remaining 10 articles were identified and had fit all of the inclusion and exclusion criteria and were chosen for the critical a ppraisal of this systematic literature review. Furthermore the search was enhanced by looking up at all the reference lists of the final articles chosen for critical appraisal, but no new studies were found. Identified studies for critical appraisal are the following: Strang et al. (2008), Piper et al. (2008), Tobin, Sherman, Beilenson, Welsh, Latkin (2009), Enteen et al. (2010), Wagner et al. (2010), Bennett, Bell, Tomedi, Hulsey, Kral (2011), Bennett Holloway (2012), Lankenau et al. (2013), Banjo (2014), and Clark, Wilder, Winstanley (2014). In addition to the electronic search, a hand search was done within the University of Malta library which did not produce any results. Table 2.6 below presents the number of hits obtained from each of the databases above and the different search syntaxes combination. Database Keywords Number of hits Academic Search Complete search syntax 1 AND search syntax 2 274 search syntax 1 AND search syntax 3 272 search syntax 2 AND search syntax 3 55 CINAHL Plus with Full Text search syntax 1 AND search syntax 2 7 search syntax 1 AND search syntax 3 114 search syntax 2 AND search syntax 3 10 Cochrane Central Register of Controlled Trials search syntax 1 AND search syntax 2 0 search syntax 1 AND search syntax 3 0 search syntax 2 AND search syntax 3 0 Cochrane Database of SRs search syntax 1 AND search syntax 2 0 search syntax 1 AND search syntax 3 1 search syntax 2 AND search syntax 3 0 Medline search syntax 1 AND search syntax 2 31 search syntax 1 AND search syntax 3 228 search syntax 2 AND search syntax 3 28 Science Direct search syntax 1 AND search syntax 2 532 search syntax 1 AND search syntax 3 485 search syntax 2 AND search syntax 3 145 Google Scholar take-home naloxone, naloxone distribution 78 Total number of literature found = 2,260 Table 2.6 Number of articles found from each search 2.5 Refining of the research question After finding the relevant literature to the original PICO question, and considering properly the population being studied, the research question was duly refined since this systematic literature review will be based on the impact of THNP effect on heroin OD deaths amongst heroin injection drug users. Initial PICO question was: ‘Do naloxone take-home programs provided to drug users in the community reduce the incidence of fatal opioid OD?’ The question was refined to: Do naloxone take-home programs reduce the incidence of fatal heroin OD amongst heroin injection users? The refining of the PICO question was essential since some of the literature concerned prescription opioid users or general drug users, but the reviewer’s main interest is heroin injection users. 2.6 Methods of Appraisal After identifying the relevant studies and refining the PICO question, the next step for this dissertation was to critically appraise the literature. This will be covered in chapter 3. Critical appraisal is the evaluation of strength and quality of research studies in order to deliver evidence-based clinical decisions and after determining the worthiness of different studies through the use of different critical appraisal tools, multiple research findings can be synthesized together to develop evidence-based-practice (LoBiondo-Woods Haber, 2013). Furthermore, Burls (2009) argues that studies being biased can result in false outcomes and conclusions, because they are not composed of an acceptable quality. A bias is an orderly deviation of the results occurring from the way that a study is led, investigated or reported. In light of this, critical appraisal tools were developed to help researchers in identifying valid and reliable studies. Specific critical appraisal tools in the form of checklists are used to analyse different study designs. Commonly used appraisal tools are: Critical Appraisal Skills Programme (CASP) Scottish Intercollegiate Guidelines Network (SIGN) Centre for Evidence Based Mental Health (CEBMH) Critically Appraise Topic (CAT) After studying and considering all of the above methods of appraisal, together with other appraisal tools, it was decided that the CASP appraisal tools are to be used for critically appraising the identified studies relevant to the PICO question. The reason for choosing the CASP appraisal tools is because it is clear, concise, and easy to understand. CASP offers different checklists appropriate for different research designs where one can critically evaluate research through a set of questions and helps in determining the quality of the literature being appraised. At this phase, the studies were also rated and arranged according to the hierarchy of evidence adopted from Aslam (2012) as shown in figure 2.1. 2.7 Conclusion In conclusion, the study’s main objective is to determine whether THNPs reduces the mortality rate of heroin OD. Several keywords were identified from the PICO question elements, and from preliminary search results. These keywords were systematically searched in different databases using different search syntaxes combinations. A set of inclusion and exclusion criteria were then set up in order to get to the studies relevant to the PICO question. PICO question was then refined and then it was decided to use the CASP appraisal tools for evaluating the relevant studies which will be discussed in the next chapter. Words 1763