In an intention-to-treat analysis, patients treated with an MV-targeted ASV device demonstrated a significant decrease in mean AHI from 25 to 5/h, improved Oxford sleep resistance test results, and decreased plasma brain natriuretic peptide (BNP) and urinary metnorepinephine levels compared with those receiving sham ASV. However, LVEF and subjective daytime sleepiness did not change significantly. Adherence to ASV use was lower in the sham group, with four patients not using the device at home at all.

The surprising disparity between objective and subjective measures of sleepiness may be explained by previous reports that patients with heart failure and sleep apnea frequently do not complain of subjective daytime sleepiness. In three early studies of SRBD52-54 in patients with heart failure, the prevalence of subjective sleepiness was similar between those with and those without sleep apnea, despite some patients having severe SRBD. This lack of subjective daytime sleepiness is mysterious because patients with heart failure objectively studied for sleepiness with either the Multiple Sleep Latency Test or the Osler test18 demonstrate significant degrees of hypersomnia.

Furthermore, a significant inverse linear correlation exists between AHI and mean sleep latency on the Multiple Sleep Latency Test, and with treatment of sleep apnea, objective sleepiness improves without a change in subjective daytime sleepiness. The lack of subjective daytime sleepiness in patients with CHF and SRBD may account for the under diagnosis of sleep apnea in these individuals and poor CPAP compliance, even when the disorder is properly diagnosed and treated. The aforementioned studies focused on patients with predominantly CSA/HCSB. However, because of the frequency of coexisting OSA and CSA/HCSB, identi- fying viable treatment options in these more complex patients is very important. An 8-week prospective observational study in 10 consecutive male patients with coexisting OSA and CSA/HCSB and with and without heart failure found that flow-targeted ASV with manual titration of EPAP achieved suppression of all types of SRBDs and improved sleep architecture and frequency of arousals regardless of whether the patients had coexisting cardiovascular disease.5 The more novel combination of MV-targeted ASV with automatically titrating EPAP was tested in a similar population during a short-term pilot study.

Sixteen patients with an AHI comprising , 80% obstructive events were included. The device normalized AHI and effectively suppressed both central and obstructive events; arousals were significantly reduced as well. In a randomized prospective study comparing CPAP with ASV by Randerath et al,47 26 of 36 patients with heart failure and coexisting OSA and CSA demonstrated acceptable adherence to ASV at 12 months and exhibited a substantial improvement in both types of SRBDs, BNP level, and sleepiness and attention on a self-administered questionnaire. Patients randomized to CPAP exhibited a similar dropout rate but experienced lesser degrees of SRBD control and higher BNP levels at 12 months. In addition to the study by Randerath et al,47 several long-term observational studies of ASV devices in patients with HFrEF and sleep apnea had significant rates of PAP device nonadherence. This may not only reflect a behavior of nonadherence to other medical therapies as well but also may be characteristic of patient resistance to PAP.

In a study of Japanese patients with an average age of 72 years and LVEF of 41%, Takama and Kurabayashi reported significantly improved 1-year survival in those who successfully adhered to MV-targeted ASV using default settings and no titration. Patients using ASV for . 4 h/night were compared with patients who were not considered adherent. All patients had severe sleep apnea comprising both obstructive and central sleep-disordered breathing. However, 42% of the patients were on a b-blocker in the adherent group compared with 29% in the nonadherent group, a potential confounder. In a second study, Jilek et al reported significantly improved survival in 91 patients who used flow-targeted ASV compared with 85 untreated patients. The patients had severe sleep apnea, predominantly central sleep-disordered breathing, with a mean AHI of about 44/h. More than 85% of these patients were taking b-blocker medication consistent with current standards of care. The adjusted hazard ratio was 0.3 in favor of ASV.

Following were the objectives of the study: (a) assessing baseline knowledge and skill regard- ing management of acute diarrheal diseases (ADDs) among mothers of children <5 years of age; (b) imparting knowledge and skill regarding management of ADD to the mothers; and (c) assessing the impact of education in the form of gain in knowledge and skills of these mothers in preparing oral rehydration salt (ORS).

Study was conducted at Thakkerbapanagar area, which is located in the north zone of the Ahmedabad Municipal Corporation area. Target group for the study comprised mothers of children <5 years of age.

Mothers who were permanent residents of the area and were willing to participate were enrolled for the study whereas those likely to shift from the cluster either to some other places or back to their native villages or those working in out states were excluded.

With the help of health functionaries of the area, a sketch of the area was made. Sampling units con- sisted of households with children <5 years of age. Sampling units were identified as per standard technique of identifying the point of random start by preparing a sketch of the study area. After the start of the survey as soon as the households having children <5 years were identified, the purpose of the study was explained to mothers and other family members. Once they agreed, written consent in the local language was obtained; the mother was enrolled for the study; and the house was marked with an identification sign. A total of 56 mothers agreed to participate in the study.

The study was carried out in three phases: baseline survey, intervention, and end-line survey. During the baseline survey, pretested and semi-structured questionnaire was used for collecting information on knowledge and skills of mothers regarding ADD. With respect to ADD, the ques- tionnaire included questions regarding the knowledge of moth- ers about importance and need of ORT during ADD; correct method of preparation, usage, and feeding of ORS available as packets and HAF; and continuation of breastfeeding during ADD. Knowledge related to management of ADD was assessed using three-point Likert scale. It had three categories of responses: complete knowledge (2 marks), some knowledge (1 mark), and no knowledge (0 mark).

After the completion of the baseline survey, key diarrhea-related issues that needed intervention were identified and the intervention was planned accordingly. For ADD, the main objectives were to sensitize mothers regarding the necessity of oral rehydration, the importance of continuing breastfeeding during ADD, and most importantly, how to prepare and use ORS from the packets available and HAF.

To impart skill-based health education, we held personal discussions with each mother and each session lasted for 30–45 min. It also included demonstrating how to prepare ORS and HAF for the management of ADD. Baseline survey and intervention phase lasted for 2 months.

After imparting skill-based health education, end-line survey was carried out after an interval of 6 months from the baseline survey.

Methods for imparting skill-based health education

Skill-based health education was imparted using demonstration and carrying out focus group discussions. In addition, available educational material, in the form of posters, flips charts, and flash cards, was used. The prepa- ration of ORS was demonstrated, and the quantity required as per age of the child was explained. The usage of HAF as emphasized, and its preparation was demonstrated by involving the peripheral health worker (link worker) in the community.

Data were entered in an MS Excel worksheet, cleaned, and analyzed in SPSS software, version 19.0. The results were expressed in mean, median, and percentages. Data during the pre- and post-intervention phases were compared to assess the effect of skill-based health education regarding management of ADD in mothers of children <5 years of age.

Ethical consideration

Before the start of the study, requisite permissions were obtained from the department as well as medical officer of Thakkerbapanagar ward. Informed written consent was obtained from all the participants, ensuring confidentiality.

Nearly 60 million residents of the United States are enrolled in that country’s Medicaid program. The Medicaid program, jointly funded and administered by the federal and state governments, provides health insurance and financial access to qualified low-income individuals and families. Medicaid enrollees are among the poorest and sickest of the population, and without this program many would not have access to needed health care services. Meeting the health needs of this population can be difficult, in part due to their vulnerability. Yet, relatively little is known about how Medicaid beneficiaries view their health, the healthcare delivery system, or their own abilities to participate in activities or actions that would help them control or improve their health.

“Health” has been described and defined in a number of ways. Specifically, health has been described in terms of a physical or biological manifestation; the extent to which an individual is able to maintain functioning within their social context; or the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” as articulated by the World Health Organization (WHO). These definitions of health are varied. However, no research has assessed whether consumers, and in particular Medicaid beneficiaries, share these same definitions.

Theories of individual health behaviors classify and explain factors which will influence individual health actions. According to the Health Belief Model and the Theory of Planned Behavior, factors that can influence an individual’s decision to act or engage in their health or health care include an individual’s sense of whether the benefits outweigh barriers, a belief in their own competency or ability to take action, and access to necessary resources. Individuals with this belief in their ability to act are likely to have a high degree of perceived and actual behavioral control.

Focus groups and in-depth interviews with Medicaid beneficiaries were conducted in order to gain an understanding of their definitions of health and their ability to control their health. Such an understanding is key to the successful development and implementation of health promotion and healthcare access strategies for this vulnerable group of individuals.