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Southeastern Appalachian Ohio has more than double the national average of diabetes and a critical shortage of healthcare providers. Paradoxically, there is limited research focused on primary care providers’ experiences treating people with diabetes in this region. This study explored providers’ perceived barriers to and facilitators for treating patients with diabetes in southeastern Appalachian Ohio.
We conducted in-depth interviews with healthcare providers who treat people with diabetes in rural southeastern Ohio. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 12 software (QSR International, Chadstone, VIC, Australia).
Qualitative analysis revealed four themes: (1) patients’ diabetes fatalism and helplessness: providers recounted story after story of patients believing that their diabetes was inevitable and that they were helpless to prevent or delay diabetes complications. (2) Comorbid psychosocial issues: providers described high rates of depression, anxiety, incest, abuse, and post-traumatic stress disorder among people with diabetes in this region. (3) Inter-connected social determinants interfering with diabetes care: providers identified major barriers including lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. (4) Providers’ cultural understanding and recommendations: providers emphasized the importance of understanding of the values central to Appalachian culture and gave culturally attuned clinical suggestions for how to use these values when working with this population.
Evidence-based interventions tailored to Appalachian culture and training designed to increase the cultural competency and cultural humility of primary care providers may be effective approaches to reduce barriers to diabetes care in Appalachian Ohio.
How do twenty-first century theatre practitioners negotiate the dynamics of tradition and innovation across the works of Samuel Beckett? Beckett's own tendencies toward fluidity of genre, iteration/repetition, and collaboration – modes that also define the 'experimental' – allow for greater openness than is often assumed. Reading recent performances for creative uses of embodiment, environment, and technology reveals the increasingly interdisciplinary, international, and intermedial character of contemporary Beckettian practice. The experimentation of current practitioners challenges a discourse based on historical controversies, exposing a still-expanding terrain for Beckett in performance.
Fossil fishes are among the rarest in volcanic oceanic islands, their presence providing invaluable data for the understanding of more general (palaeo)biogeographical patterns and processes. Santa Maria Island (Azores Archipelago) is renowned for its palaeontological heritage, with representatives of several phyla, including the Chordata. We report on the fossil fishes, resulting in an increase in the number of Pliocene fishes from the Azores to 11 taxa: seven Chondrichthyes and at least four Actinopterygii. The genus Sparisoma is reported for the first time in the fossil record. The presence of fossil remains of the parrotfish Sparisoma cretense in Last Interglacial outcrops is significant, because it posits a setback for the theory that most of the present-day Azorean marine species colonized the area after the last glacial episode. Our multidisciplinary approach combines palaeontological data with ecological and published genetic data, offering an alternative interpretation. We suggest that most of the Azorean shallow-water subtropical and temperate marine species living in the archipelago during the Last Interglacial were not affected by the decrease in sea surface temperatures during the last glacial episode. We also predict low genetic diversity for fish species presently living in the Azores and ecologically associated with fine sediments, as a result of the remobilization and sediment transport to abyssal depths, during the Last Glacial episode; these are viewed as post-glacial colonizers or as ‘bottleneck’ survivors from the Last Glaciation.
This retrospective study highlights the degree of losses and time-course through which the 2015 highly pathogenic avian influenza (HPAI) outbreaks in Ghana were managed. A total of 102 760 birds from 35 farms across five regions in Ghana included in this study were affected. Out of this, 89.3% was from the Greater Accra region. Majority of the birds were culled (94.2%). Adult layers were most affected and destroyed (64.0%), followed by broilers (13.7%). Event initiation to reporting averaged 7.7 ± 1.3 days (range: 1–30 days). Laboratory confirmation to depopulation of birds averaged 2.2 ± 0.5 (0–15) days while depopulation to disinfection took 2.2 ± 0.7 (0–20) days. Overall, some farms took as long as 30 days to report the outbreak to the authorities, 15 days from confirmation to depopulation and 20 days from depopulation to disinfection. On average, outbreak management lasted 12.3 (2–43) days from event initiation to depopulation. The study reveals a significant number of avian losses and delays in HPAI reporting and management by the authorities in Ghana during the 2015 outbreak. This poses a high risk of spread to other farms and a threat to public health. Awareness creation for poultry farmers is necessary for early reporting, while further study is required to set thresholds for the management of such outbreaks by veterinary departments.
This paper studies the propagation of free, long waves on a potential vorticity front in the presence of a vertical coast, using a
-layer, quasi-geostrophic model with piecewise-constant potential vorticity. The coastal boundary induces flow through image vorticity and a Kelvin wave, either of which can reinforce or oppose the Rossby wave dynamics at the front. The behaviour of the front depends strongly on the relative strengths of these three mechanisms, which are explicit in our model. The richest behaviour, which includes kink solitons (under-compressive shocks) and compound-wave structures, occurs in the regime where vortical effects are dominant. The evolution of the front is described by a fully nonlinear finite-amplitude equation including first-order dispersive effects, which is related to the modified Korteweg–de Vries equation. The different behaviours are classified using the canonical example of the Riemann problem, which we analyse using El’s technique of ‘dispersive shock-fitting’. Contour-dynamic simulations show that the dispersive long-wave theory captures the behaviour of the full quasi-geostrophic system to a high degree of accuracy.