The recently published study by Nyamathi et al. (2015) deals with the important issue of the role of nursing care in the prevention of hepatitis A and B infection in a high-risk population. The study investigated the efficacy of three levels of peer coaching and nurse-delivered interventions on the completion of vaccines for hepatitis A and B viruses in homeless men on parole. Vaccination rates were high (over 70%) and not significantly different among the three interventions. The study also identified factors associated with noncompletion of vaccination.
Besides its intrinsic value, the study of Nyamathi et al. (2015) should be viewed in the context of the progressively important role of nursing care in the field of liver diseases. Chronic liver diseases, particularly cirrhosis due to hepatitis C or B infection, alcohol abuse, or nonalcoholic fatty liver disease (NAFLD), are among the most frequent causes of death worldwide and a significant cause of impaired health-related quality of life (Lozano et al., 2012). The public health significance of liver diseases and challenges in clinical care have often been neglected, even by healthcare workers and policy makers, and their frequency has been generally underestimated (Scaglione et al., 2015). In this regard, it is important to emphasize that most chronic liver diseases are associated with well-known modifiable risk factors (especially obesity, alcohol abuse, and viral infections) that are potentially preventable by nursing interventions. The case of NAFLD is particularly illustrative. NAFLD is currently the most frequent mechanism of chronic liver disease worldwide and causes a major clinical and economic burden (European Association for the Study of the Liver, European Association for the Study of Diabetes, & European Association for the Study of Obesity, 2016). Prevalence of NAFLD has reached epidemic proportions in many parts of the world, and a significant proportion of patients with NAFLD eventually develop cirrhosis, hepatocellular cancer, or other severe liver diseases; risk factors for NAFLD are well known and include obesity, Type 2 diabetes, hypertriglyceridemia, and metabolic syndrome (Sayiner, Koenig, Henry, & Younossi, 2016). Nurses have a very important role in the care of patients with risk factors for NAFLD by delivering lifestyle counseling interventions, which have been shown to improve liver disease or prevent its development (European Association for the Study of the Liver, European Association for the Study of Diabetes, & European Association for the Study of Obesity, 2016). Moreover, primary healthcare nurses can also play an important role in early detection of chronic liver diseases, when they are still asymptomatic, by performing specific noninvasive diagnostic procedures, such as transient elastography, a method that measures liver stiffness that correlates with level of fibrosis in the liver (Fabrellas et al., 2013). In conclusion, nurses have to expand their roles, particularly in primary care, to the assessment and care of patients with liver diseases.
Response From the Authors
Dear Editor
We thank Nuria Fabrellas for her thoughtful commentary.
The public health importance of reducing the prevalence of hepatitis infection in the populations at greatest risk is twofold. First, it offers an opportunity to treat those who are most vulnerable, and second, it protects the general population at large. Nurse case management intervention is gaining recognition for its success in tackling long-standing challenges of providing healthcare to homeless individuals who were formerly incarcerated and may be recently reintegrating into their communities. Our success in achieving over 70% completion rate of the Twinrix HAV/HVB vaccine among homeless parolees lends support for how nursing intervention could help to improve the quality of life for this vulnerable population.
Nurse-led interventions are a valuable health promotion strategy as nurses are trained to be cognizant and sensitive to the various challenges that may hinder the access to and use of health resources among some of the highest-risk populations. As trusted health professionals, nurses, along with former parolees serving as peer coaches, have proven to be a dynamic and effective two-pronged approach to establishing a unique bond with recently released homeless individuals, providing them with tools to successfully transition into the community (Nyamathi et al., 2015, 2017). Such high-risk individuals are able to speak candidly with the team and develop individualized and actionable self-empowerment plans to make positive changes in their lives-such as pursuing further education and securing employment.
Additional attempts to reducing the prevalence of hepatitis infection can be also focused on bringing healthcare to the community more directly. For example, efforts can be made to provide the Twinrix HAV/HVB vaccine through mobile healthcare vans. Furthermore, once at-risk individuals do make contact within the healthcare system, a more systematic approach to vaccinating this population is critical. As such, the Twinrix HAV/HBV vaccine can be offered as routine treatment when a homeless individual enters a clinic or hospital setting. In today's society, as formerly incarcerated homeless individuals are highly stigmatized, it is imperative that nurses and other system healthcare professionals continue to use culturally sensitive models of care to reach this vulnerable group.
Adey M. Nyamathi, ANP, PhD, FAAN, Founding Dean and Distinguished Professor, Sue & Bill Gross School of Nursing, University of California, Irvine
Donna Krough, MSN, RN, PhD Student, University of California, Los Angeles
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