The trend in tomato, watermelon, and papaya areas of cultivation, total production, and yield in Mexico country from 2010 to 2017 [13].
\r\n\tAn important part of the book will consider electrodes (materials, configurations, contacts with biological matter) as responsible tools for the acquisition of bioimpedance data correctly. Implementations in wearable and implantable health monitors are the proposed book topics. Detecting of different pathogens by the aid of lab-on-chip (LoC) devices for point-of-care (PoC) and need-of-care (NoC) diagnostics is expected. Also, express analysis of biological matter (blood and other body fluids) is included. Electronics connected to electrodes for receiving the bioimpedance signals for further processing belongs to sensing techniques and will be considered.
\r\n\tDevelopment and application of software tools for information extracting from the acquired bioimpedance data, automatic identification of bioparticles and the decision making for diagnosing and treatment are very welcome chapters in the present book.
In theory, the graft is the union of two or more pieces of living tissue, which once joined together develops as a single plant [1]. This combination of desirable characteristics consists of the removal of buds of a plant that is called graft and the root that is provided by a plant that is called rootstock [2]. The production of plant grafts has been widely expanded for fruit tree and vegetable crops, and different studies have shown that the success of the crop depends on the rootstock selected when compared with non-grafted plants [3].
\nIn some countries, the grafting technique has been integrated into the scheme of agricultural work as an effective alternative in the management of the crops. Therefore, it has been recognized in all agricultural areas, which makes it a technique of horticultural production more respectful with the environment [4]. With this technique, the tolerance of the root system of the rootstock and the favorable productive characters of a susceptible variety are used. In vegetables the same principles applied to the grafting of fruit trees are followed, in addition to controlled environment requirements and greater post-graft care. So, the use of similar rootstocks strengthens and gives vigor to plants, therefore keeping nematodes and diseases controlled for longer than a plant that has not been grafted [5, 6].
\nAlthough there is evidence that the art of grafting was known to the Chinese from 1000 years ago before Christ [1], the grafting technique has its beginnings in the 1920s in watermelon grafted on pumpkin (Cucurbita moschata Duch) as rootstock, to confer resistance to wilt caused by Fusarium. Currently this technology is practiced successfully in Cucurbitaceae and Solanaceae in Asia and in Mediterranean countries [7]. The use of the grafting technique has been aimed at improving crops such as fruit trees and vegetables, to get their development under varied agronomic conditions [8]. It improves the resistance of crops to biotic and abiotic stresses such as salinity [9], drought tolerance [10], and nutrient deficiency [11], and this technique can be an important tool to improve fruit quality.
\nIn Mexico, this technique is recent; however, the advantages of using it as a substitute for fumigants can counteract the main phytosanitary problems that limit the production of crops. Otherwise, in the State of Michoacan, like other states of the Mexico, the various contrasts give rise to different production systems, which favor the establishment of different crops. Despite being a predominantly agricultural territory, it has been severely affected by the production system of the monoculture type and the indiscriminate use of agrochemicals, which has caused resistance of pests and pathogens difficult to control by conventional systems. Therefore, among the management alternatives, we can see the use of the graft. Given the phytosanitary situation presented by Cucurbitaceae and Solanaceae in the State of Michoacan, the use of rootstocks with specific resistance characteristics offers an option for the recovery of soils, without repercussion in the environment. As mentioned, in our country this technique has not been fully exploited, in the State of Michoacan, it is new and innovative in the cultivations of Solanaceae, Cucurbitaceae, and Caricaceae.
\nMexico is located in a privileged geographic position, which favors the environmental conditions for the development of different crops in open field, and where the conditions are restrictive, crops are grown in greenhouses. Among the crops of economic importance and with potential of graft are tomato (Solanum lycopersicum L.), which is the second most important horticultural crop after potato; watermelon [Citrullus lanatus (Thunb.) Matsum. & Nakai], being an herbaceous creeping plant with 6 m in length in its branches and a highly valued product for its quality of freshness, mainly in hot seasons, and palatability in any season of the year; and papaya (Carica papaya L.), of the fast growing fruit species that is widespread in tropical and subtropical regions. The annual consumption per capita in these species is tomato, 14.3 kg; watermelon, 3.7 kg; and papaya, 6.4 kg [12].
\nAccording to SIAP-SAGARPA [13], in the last years at national level, the cultivated area has presented variable trends in tomato and watermelon, with greater amount of hectares cultivated in the year 2010, and as the years pass until the year 2017, they were reduced in 11% and 14%, respectively. However, this trend differs in the total production and the yield per hectare, since percentage of the year 2010 to the year 2017 for the tomato increased 33% and 22%, respectively, and for the vvsituation for papaya, the cultivated area, the total production, and the yield per hectare, the trend always has been increasing from 2010 to 2017 (Table 1).
\nYear | \nTomato | \nWatermelon | \nPapaya | \n||||||
---|---|---|---|---|---|---|---|---|---|
Cultivated area (ha) | \nTotal production (t) | \nYield (t·ha−1) | \nCultivated area (ha) | \nTotal production (t) | \nYield (t·ha−1) | \nCultivated area (ha) | \nTotal production (t) | \nYield (t·ha−1) | \n|
2017 | \n48,394 | \n3,055,861 | \n64.832 | \n42,105 | \n1,296,767 | \n32.015 | \n19,114 | \n964,702 | \n57.82 | \n
2016 | \n48,840 | \n2,769,611 | \n59.336 | \n39,903 | \n1,129,219 | \n30.544 | \n19,442 | \n957,415 | \n56.895 | \n
2015 | \n49,530 | \n2,570,284 | \n56.077 | \n36,197 | \n1,003,213 | \n28.71 | \n17,530 | \n879,363 | \n55.426 | \n
2014 | \n50,850 | \n2,320,109 | \n48.777 | \n35,511 | \n955,186 | \n28.092 | \n16,071 | \n840,497 | \n57.445 | \n
2013 | \n44,504 | \n2,052,126 | \n49.101 | \n37,482 | \n937,378 | \n26.086 | \n15,952 | \n734,522 | \n51.542 | \n
2012 | \n55,504 | \n2,459,874 | \n47.102 | \n38,288 | \n1,011,667 | \n27.307 | \n16,725 | \n680,204 | \n49.241 | \n
2011 | \n56,025 | \n1,670,454 | \n41.758 | \n47,387 | \n1,002,506 | \n25.006 | \n17,142 | \n646,002 | \n44.909 | \n
2010 | \n54,238 | \n2,058,424 | \n42.104 | \n48,667 | \n1,016,215 | \n23.375 | \n16,261 | \n648,235 | \n46.49 | \n
The trend in tomato, watermelon, and papaya areas of cultivation, total production, and yield in Mexico country from 2010 to 2017 [13].
The record of the last years in the State of Michoacan has been unstable in the harvested area, total production, and yield in the three crops. However, from 2010 to 2017, the trend has been mostly upward (Table 2).
\nYear | \nState of Michoacan | \n||||||||
---|---|---|---|---|---|---|---|---|---|
Tomato | \nWatermelon | \nPapaya | \n|||||||
Cultivated area (ha) | \nTotal production (t) | \nYield (t·ha−1) | \nCultivated area (ha) | \nTotal production (t) | \nYield (t·ha−1) | \nCultivated area (ha) | \nTotal production (t) | \nYield (t·ha−1) | \n|
2017 | \n5866 | \n211,100 | \n36.382 | \n990 | \n32,337 | \n32.680 | \n3326 | \n79,207 | \n33.442 | \n
2016 | \n6826 | \n178,252 | \n29.170 | \n679 | \n20,769 | \n31.421 | \n3510 | \n70,198 | \n32.849 | \n
2015 | \n7845 | \n178,931 | \n26.204 | \n888 | \n21,765 | \n24.511 | \n2424 | \n51,714 | \n31.476 | \n
2014 | \n5894 | \n117,710 | \n23.568 | \n507 | \n12,128 | \n23.922 | \n2128 | \n48,605 | \n35.094 | \n
2013 | \n3905 | \n73,253 | \n24.371 | \n676 | \n16,500 | \n24.427 | \n1944 | \n35,401 | \n26.921 | \n
2012 | \n5017 | \n150,690 | \n35.624 | \n604 | \n14,836 | \n24.563 | \n2031 | \n43,935 | \n33.009 | \n
2011 | \n4768 | \n128,367 | \n29.013 | \n618 | \n15,189 | \n24.677 | \n2063 | \n45,002 | \n32.076 | \n
2010 | \n5186 | \n79,291 | \n24.469 | \n696 | \n14,918 | \n25.836 | \n1998 | \n47,947 | \n32.999 | \n
The trend in tomato, watermelon, and papaya areas of cultivation, production total, and yield in the state of Michoacan, from 2010 to 2017 [13].
For its part, the various activities related to the production of tomato, watermelon, and papaya in the State of Michoacan are of great importance because they generate direct and indirect jobs, as well as being the sustenance of many families. Given the economic and social importance of these crops, their production is necessary under efficient and sustainable systems. The choice of genotypes, plantation density, phytosanitary management, and the incorporation of the grafting technique are fundamental practices to achieve higher yields and improve the quality of fruits. Nevertheless, ignorance of the correct application negatively impacts the production.
\nTomato is one of the crops with the greatest phytosanitary problems [14], which have represented a serious problem due to the use of insecticides. This causes the death or many natural parasites of insect pests and creates genetic resistance to insecticides [15, 16]. Diseases are another limiting factor in the production of tomato [17]. Viral pathogens are disseminated by insect vectors, fungal and bacterial. Also, pathogens disseminated by seed, irrigation water and wind mean a potential danger in extensive areas of monoculture.
\nTo achieve health in crops, measures of exclusion, eradication, and protection are used, in the context of an integrated control and use of resistant cultivars. In tomato, the theory on plant resistance has served as the basis for the development of varieties resistant to pathogens and insects, whose main source of resistance is found in wild plants [18, 19, 20]. Among the strategies to induce resistance, the conventional improvement by hybridization [21] and, another perhaps less used, the grafting technique can be distinguished [22].
\nWatermelon is cultivated during two cycles per year (autumn-winter and spring-summer), in irrigation and temporary. Wilt caused by Fusarium is considered a disease that gradually deteriorates the vigor of watermelon [23]. Also, root-knot nematodes are associated with watermelon [24]. Moreover, due to influence of agroclimatic factors and crop management, the production systems are varied [25], so the use of arbuscular mycorrhizae [26] and use of adapted genetic material, diploid or triploid hybrids [27], all contribute to obtain better yields.
\nTherefore, it is feasible that watermelon with management practices such as mulching, technified irrigation, and sowing methods different from the conventional one would considerably improve the productive system and competitiveness [28]. By its nature, watermelon genotypes have a high productive potential, which leads to determine their agronomic behavior to the environmental conditions of each region. Grafting technique is recognized in the agricultural ambit, and effective without negative impact on the environment, this condition is revalued with the imminent prohibition of the use of methyl bromide and its nonpolluting effect [4].
\nPapaya, in some stages within the production process, presents various kinds of problems. There is evidence that over time when the monocultures are continuously established, they bring with them the proliferation and resistance of pests and diseases, in which its management is difficult and has influences in the yield; also this crop requires answers oriented to the high productivity, where the densities and the nutrition play an important role. The alternatives to address the phytosanitary and physiological problems revolve around the improvement of the crop, and this can occur through the hybridization and crossings of materials, also selection of seeds, genetic engineering by including resistance genes, and in vitro propagation, all of them with the complexity of the processes and the response times. Particularly, tissue culture techniques such as micropropagation [29] both for organogenesis [30] and somatic embryogenesis have been considered for the in vitro propagation of this species; however, as biotechnological methods are until the present more expensive in relation to the use of seed, it is limited, only to hybrid genotypes that it justifies [31].
\nIn papaya by its polygamous character, with three basic types of flowers, staminated, pistillate, and hermaphroditic, the typical propagation by seed is hindered by variability in the expression of the sexual characters and subsequent shape of the fruits. Therefore, the asexual propagation through the grafting technique would improve the papaya industry [32], since through the graft it is possible to maintain the original characteristics of the mother plants, in addition, to increase the yield, reduce height, and improve fruiting; some studies support it [33, 34, 35].
\nIn herbaceous plants, the union between the rootstock and graft is carried out by the formation of a callus of parenchymatous tissue, a structure that is differentiated to cambium tissue, which will give rise to the xylem and phloem, with which the union between vascular bundles of both individuals is restored.
\nIt is worth mentioning that the fumigation of the soil with methyl bromide to control some soil pathogens was until recently considered one of the main factors for the success of the production of Cucurbitaceae and Solanaceae. However, the banning of methyl bromide and the lack of tolerant or resistant cultivars to biotic stress have increased the interest by the use of the grafting of vegetables [4, 36].
\nSome cases are mentioned on the use of grafts in the induction of resistance to pests and diseases. From the beginning, the grafting technique was used for the management of soil pathogens; currently it includes Cucurbitaceae and Solanaceae, in species of Citrullus lanatus, Cucumis melo, Cucumis sativus, Solanum lycopersicum, Capsicum annum, and Solanum melongena [37].
\nCucurbitaceae are grafted on pumpkin rootstocks (Cucurbita moschata Duchesne and Cucurbita maxima Schrad) to confer resistance against soil pathogens [38]; Phytophthora capsici is one of the main pathogens of global importance in C. annuum; likewise, its management has been achieved by grafting [39], in S. melongena to control of F. oxysporum f. sp. melongenae [40].
\nOn the other hand, environmental stress represents the condition with the greatest limitation for horticultural productivity and use of plants. The temperature causes economic losses of yield, also the reduction in the growth and development of the plant, caused by wilting and necrosis, affecting delay of floral induction and formation and fruit maturity [41]. According to the species of Cucurbitaceae, the threshold temperature for growth of sensitive cultures is between 8 and 12°C [42]. In the range of 25–30°C, the metabolic rates increase exponentially. Under these thresholds, many horticultural crops suffer physiological disorders which, according to intensity and length of exposure, subsequently lead to irreversible damage and death of the plant [43]. As an efficient alternative to control the temperature, the use of rootstocks is presented; since there are commercial cultivars tolerant to low temperatures, these rootstocks are recognized as a promising tool [44].
\nThe success of the grafting depends on several factors, including union and compatibility of the graft, quality and age of seedlings, quality of the union, and post-grafting management [45]. In herbaceous species several grafting techniques have been used, and most of them coincide in some general criteria, such as performing it in the first stages of development of the plants (presence of cotyledonous leaves or first true leaves), plants under controlled conditions of temperature and environmental humidity during the period of formation of the union callus, and the subsequent acclimatization to environmental conditions.
\nThe most common graft is the approach. The two individuals are sown at the same time, and when they reach 12–15 cm in height (four or five leaves), a cut is made inclined downward with a knife. This cut is made in the space of the stem between the cotyledonal leaves and the first leaves of the rootstock. The cut should be minimal and only reach half of the herbaceous stem. In the same way and in the same position, the stem of the graft is cut; instead, it will be directed upward so that the two small lips can fit as closely as possible. Finally, the grafting point is closed with small pincers or a little aluminum foil like band or some fixation device. To simplify the handling and reduce the time invested in the graft, the plants are removed from their pots before the operation and just after the graft are put back in the same pots to which soil is added, as if it were a transplant. In conditions of temperature of about 20–25°C and with a high humidity (covered with plastic bags), from 8 to 10 days, the graft will have joined, and it can proceed to cut the aerial part of the rootstock and the basal area of the graft [46].
\nSimple splice graft. A diagonal cut is made through the rootstock seedling just above the cotyledons. On the cut end of the pattern, a piece of thin-walled polyethylene pipe, of the appropriate diameter, is slid to give a good fit. The basal end of the scion receives a diagonal cut similar in length and inclination to that made in the pattern. The prong is slid into the plastic tube until the two cut surfaces are in close contact. The tube is held in place until healing occurs, about 12 days after grafting. If there are no leaves and the buds have not grown, the tube can be removed by sliding it over the scion; otherwise it can be cut with a razor blade [1].
\nIn another procedure used to graft on herbaceous rootstocks, the cleft graft is used (but with a single scion), which consists of making a cut in the stem of the variety 1.5 cm below the cotyledons and making a bevel of 0.6–1.0 cm at its extreme; in the rootstock the apical bud is removed, and a slit is made between the cotyledons, to the center of the stem and down to 1–1.5 cm in length; then the graft union is inserted and tied with rubber bands or latex adhesive tape. To prevent the grafted plant from drying out, it is covered with a polyethylene bag, placed in the shade until the graft has healed, and then the plastic cover is removed [1].
\nLateral slit graft. This method is practiced by making a cut in the rootstock above the first leaves and practicing a slight lateral incision directed downward (almost to the middle of the stem) along the space between the leaf that has not been cut and the two cotyledonal leaves (between 1 and 2 cm below the cutoff point). Then, the aerial part of the graft is separated, wedge-shaped and inserted into the lateral crack of the rootstock, and tied. The leaves of the rootstock are left to allow continuity of the absorption activity of the rootstock plant and to favor the union of the scion. Once the graft has been welded, it must be removed with the part of the stem that was left, as it could develop the axillary bud of the leaf and cause the graft to fail [46].
\nGiven the phytosanitary situation presented by the horticultural species in the State of Michoacan, the use of rootstocks with specific characteristics offer an option for the recovery of soils, without repercussion in the environment. So in integrated management, one of the strategies is plant resistance, where the technique of grafting plays fundamental importance; in Mexico, there are few documented works on grafts in vegetables and their resistance to pests and diseases [47, 48]; however, graft tests have been performed on tomato, watermelon, and papaya with spontaneous and cultivated plants and with positive results. Although it is true, in Michoacan, Mexico, this technique has not been fully exploited. In the State of Michoacan, it is new and innovative in the cultivations of Solanaceae, Cucurbitaceae, and Caricaceae.
\nIn Solanaceae, particularly the tomato as a species very susceptible to the attack of phytophagous insects and soil pathogens, apparently Solanum lycopersicum var. cerasiforme as a tomato rootstock shows resistance to the fungus Alternaria solani [49] and tolerance to psyllid Bactericera cockerelli [50] and to the aphid complex [51]. Likewise, although this rootstock comes from different geographical points, it does not demerit the phenological and fruit characteristics of the tomato placed as a graft; it also favors fruit yield [52]. These qualities served as the basis for developing the broader study [53].
\nBased on the above, with the objective of evaluating the incidence of the main diseases in tomato grafts on the rootstock S. lycopersicum var. cerasiforme collected in three regions of Michoacan and a collection from the State of Tabasco, Mexico, the cv. Toro® tomato commercial was used as a graft. The experiment was carried out in the Apatzingan Valley, Municipality of Paracuaro, Michoacan, Mexico. In the management of the plantation, the use of pesticides was avoided. The evaluation integrated six tomato grafts: Grafted Small Apatzingan (G-SAp), Grafted Big Apatzingan (G-BAp), Grafted Acahuato (G-Ac), Grafted Los Reyes (G-LR), Grafted Jiquilpan (G-Jiq), Grafted Tabasco (G-Tab), and Tomato (Tom)-like control. The treatments were established in field, under a completely randomized experimental block design. Weekly samplings were carried out to determine the incidence and distribution of diseases during the cycle. Sick tissue was collected to determine the causative agent. The analysis of plants with virus symptoms threw positive results, where the Geminiviridaegroup was identified. For viral diseases, incidence and severity were considered. The diseases registered were “damping off” caused by A. solani-Fusarium sp. complex and virus. According to the general analysis of the response of the grafts to the incidence of the present diseases, the treatment G-LR showed total resistance to “damping-off,” but not to A. solani-Fusarium sp. complex, since to this disease, only the treatments G-SAp and G-BAp presented resistance. Regarding viral disease, all treatments were susceptible (Table 3). When the incidence of Geminiviridae was evaluated based on severity, the results were different. For example, treatments with degree of severity 3 (medium damage) were the G-BAp, G-SAp, G-Tab, and Tom, with percentages of infected plants from 5.26 to 27.27%. Level 4 (total damage) was not present (Figure 1).
\nTreatment | \nDisease | \n||
---|---|---|---|
Damping-off | \nA. solani-Fusarium sp. complex | \nVirosis | \n|
G-BAp | \n46.00 ± 6.92*ab | \n0.00 ± 0.00*a | \n52.67 ± 21.12*a | \n
Tom | \n25.00 ± 10.00bc | \n16.66 ± 10.40a | \n17.03 ± 13.96a | \n
G-SAp | \n16.66 ± 11.54bc | \n0.00 ± 0.00a | \n30.33 ± 15.17a | \n
G-Ac | \n10.23 ± 11.70cd | \n5.12 ± 4.43a | \n12.93 ± 7.88a | \n
G-Jiq | \n8.33 ± 10.40cd | \n1.66 ± 2.88a | \n19.33 ± 7.37a | \n
G-Tab | \n6.56 ± 6.50cd | \n6.66 ± 6.66a | \n21.00 ± 8.71a | \n
G-LR | \n0.00 ± 0.00d | \n4.44 ± 3.84a | \n15.07 ± 13.79a | \n
Incidence of “damping-off,” A. solani-Fusarium sp. complex and virosis in tomato grafts under field conditions. Paracuaro, Michoacan [53].
Means ± standard deviation, data subjected to arcsine transformation of the square root of the ratio.
Different letters in the same column indicate significant differences between means (Tukey, 0.05).
Distribution of severity levels of Geminiviridae in different epidemics of tomato grafting under field conditions in Paracuaro, Michoacan: 1 = no damage, 2 = start of damage, 3 = medium damage, 4 = total damage [53].
The use of S. lycopersicum var. cerasiforme as rootstock does not influence the physical–chemical characteristics (pH, soluble solids, moisture content) of fruits in grafts compared with tomato. However, these characteristics in ecotypes of S. lycopersicum var. cerasiforme are inferior compared with the grafts and the tomato, that is, the grafted plants and the tomato have pH between 4.45 and 4.52. So, it is suggested that the pH is less acidic than that of the fruits of S. lycopersicum var. cerasiforme, which is between 4.77 and 5.37 [54]. At respect, it has been observed that in grafted tomato plants, the pH was less acidic (4.04–4.30) than in the plants without grafting (4.35–4.47) [55]; however, this variation was minimal because in commercial varieties, the pH is between 4.2 and 4.4 [14]; other authors [56] did not find significant statistical differences between grafts (4.33–4.41) and control 4.34.
\nRegarding soluble solids, the concentration in fruits was higher in S. lycopersicum var. cerasiforme with 7.5–7.75°Brix, unlike the grafts and the tomato with values 6.25–7.0°Brix, respectively [54]. The range of the cultivated varieties is between 4.5 and 5.5°Brix; although more than the varietal character, the agroecological factors influence the content of soluble solids because they can vary the °Brix for fruits of the same variety between 4 and 7 [14]. Other studies have not found differences in the °Brix of grafted and ungrafted plants [52], with values of 3.95–4.7°Brix for grafted plants and 3.95–4.95° Brix for non-grafted plants. Similarly, others report values of 3.1–4.0°Brix in grafts and 3.68°Brix in control [56]. The humidity percentage had a similar behavior only that S. lycopersicum var. cerasiforme presented lower humidity (88.39–91.33%) in comparison to the grafts and the tomato that had values of 93.99–97.44% humidity [54], differences that may be due to the wild origin of S. lycopersicum var. cerasiforme. The humidity values reported for the tomato are 94 and 95% [14, 57], which are similar to those found in our grafts.
\nThe species of Cucurbitaceae that are commonly grafted are watermelon, cantaloupe, and cucumber. There are some rootstocks compatible with the three species [37]. Regarding diseases in cucurbitaceae, of the most important and that has been achieved better by grafting are those caused by pathogenic fungi, the wilt caused by F. oxysporum f. sp. niveum, being the most important. Pathogenic viruses transmitted from the soil and root-knot nematodes [58] are also important. Currently, in several countries hybrid rootstocks of wild origin or cultivated species are resistant to Meloidogyne spp. [4].
\nDuring the 1980s, the region of Apatzingan Valley, Michoacan, was positioned among the seven main states producing watermelon, with the advantage of presenting the ideal environment for cultivation during the autumn-winter cycle; however, their participation gradually decreased by more than 50% of the area originally intended for cultivation [59]. This reduction in agricultural land is attributed to several factors, such as the lack of more information about the evaluation and application of technical components for crop management and sustainable control of pests and diseases. Particularly, the wilt caused by Fusarium is considered a disease that gradually deteriorates the vigor of watermelon and cantaloupe [23]. In the Apatzingan Valley, its control came to represent 60% of the cost of cultivation, the effect of which had an impact on the quality and quantity of the crop, the reason that explains the reduction of the area dedicated to its cultivation. With respect to the root-knot nematode, it has been associated with different crops in the same region; in fact in a reported study [24], Meloidogyne spp. was identified in watermelon and cantaloupe and was considered a potential danger for Cucurbitaceae, since its presence causes galls in roots and decreases production. Therefore, with the objective of evaluating two rootstocks for watermelon, in two plantation distances (densities), tests were developed in a property located in the Apatzingan Valley, Michoacan, with a history of phytosanitary problems. To confirm the above in the selection of the study site in different plots, microbiological soil and root analyses were carried out to determine the existence of nematodes, bacteria, and fungi, particularly Fusarium (Table 4).
\nSampled land | \nNematodes | \nBacteria | \nPresence of Fusarium | \n||
---|---|---|---|---|---|
Presence | \nCucurbitaceae | \n||||
Tolerance limit (No.) | \nEconomic threshold (No.) | \n||||
Crucitas | \n+ | \n2–49 | \n≥50 | \n2.94 × 109* | \n+ | \n
Y Griega Pozos | \n+ | \n2.53 × 107 | \n+ | \n||
Y Griega | \n+ | \n1.39 × 106 | \n+ | \n||
Cd. Morelos | \n+ | \n3.01 × 106 | \n+ | \n
Results of the microbiological analysis of infested soils of agricultural lands of the Apatzingan Valley, Michoacan [60].
CFU/g d.s. = colony-forming units per gram of dry soil.
The experimental design proposed was randomized complete blocks. Six treatments were evaluated, triploid watermelon grafts on two rootstocks and triploid watermelon without grafting, all at two planting densities (4166 and 2083 plants/ha), conforming the following treatments: triploid watermelon graft on “Super Shintosa” rootstock at a density of 4167 plants per hectare (G-RSS 100), triploid watermelon graft on “Super Shintosa” rootstock at a density of 2083 plants per hectare (G-RSS 50), triploid watermelon graft on “Robusta” rootstock at a density of 4167 plants per hectare (G-RR 100), triploid watermelon graft on “Robusta” rootstock at a density of 2083 plants per hectare (G-RR 50), and triploid watermelon at a density of 4167 plants per hectare (C-100) and triploid watermelon at a density of 2083 plants per hectare (C-50) as controls. Regarding the qualitative characteristics of the fruits, the statistical analysis showed significant differences in the variables hardness of pulp, width of bark, and width of pulp, where, with the exception of the width of bark, the control treatments were exceeded in both densities. Although statistically there were differences between rootstocks (G-RSS and G-RR), with the values so close, it is presumed that the use of the graft does not alter the quality of the fruit (Table 5).
\nTreatments | \nTriploid crunchy red | \n|||||
---|---|---|---|---|---|---|
Soluble solids (°Brix) | \nPulp hardness (kg/cm2) | \npH | \nBark width (cm) | \nPulp width (cm) | \nMoisture content (%) | \n|
G-RSS 100 | \n11.72 | \n1.94 bc | \n5.20 | \n1.43 c | \n15.59 b | \n91.13 | \n
G-RSS 50 | \n11.78 | \n2.02 ab | \n5.30 | \n1.45 bc | \n17.63 a | \n91.16 | \n
G-RR 100 | \n11.74 | \n2.12 a | \n5.27 | \n1.50 ab | \n17.29 a | \n90.97 | \n
G-RR 50 | \n11.53 | \n2.11 a | \n5.27 | \n1.45 bc | \n17.27 a | \n90.94 | \n
C-100 | \n11.46 | \n1.86 c | \n5.29 | \n1.53 a | \n10.67 d | \n91.83 | \n
C-50 | \n11.46 | \n1.70 d | \n5.27 | \n1.53 a | \n13.55 c | \n91.27 | \n
P | \n0.17 | \n0.00 | \n0.87 | \n0.00 | \n0.00 | \n0.28 | \n
C.V. | \n1.59 | \n2.79 | \n1.91 | \n1.42 | \n3.93 | \n0.51 | \n
Qualitative aspects of watermelon fruits grafted in two population densities [60].
Regarding the phytosanitary condition, the rootstocks showed tolerance in the presence of Fusarium and nematodes, since in most of the variables the control was exceeded [60]. So, it is important to mention that in watermelon two main phytosanitary problems handled by the grafts are Fusarium wilt and nematode damage. The first case is a disease that gradually deteriorates the vigor of the plant until it is eliminated [61]. The Robusta rootstock followed by the Super Shintosa rootstock in high density favor greater efficiency related to productivity, but between the two rootstocks, Super Shintosa is sensitive to the presence of nematode [62]. It should be mentioned that watermelon is pursued to achieve the management of diseases at ground level. To avoid the use of methyl bromide, the rootstock Cucurbita maxima × Cucurbita moschata has been successfully used. Nevertheless, in the presence of nematodes, this rootstock is usually susceptible [63]. The biotic and abiotic stress of plant species derives from the soils condition and represents the greatest limitation for horticultural productivity, but when risks are minimized, it can be viable. It is important to highlight that the use of specific rootstocks to provide tolerance and/or resistance to limiting factors for the normal development of the plant is largely due to the fact that they provide a more developed and vigorous root system compared to non-grafted plants [64]. As is known, one of the main problems facing the production of watermelon in the world is the damage caused by Fusarium. The disinfection with methyl bromide at first gave good results, but with the time the disease generated resistance, and the use of this product has been banned; currently, the use of the graft as an alternative has reduced the problem.
\nIn Michoacan, ecotypes of papaya have been developed [65]. Being a predominantly agricultural territory, the region has been severely affected by the system of monoculture type and the indiscriminate use of agrochemicals, which has caused resistance of pests and diseases difficult to control through conventional systems [66]. For this reason, the Caricaceae family, particularly papaya, has the potential to be grafted to explore, in addition to the productive and phytosanitary aspect, the appearance of the sexing of plants, knowing that the preferred plants are those that emit the elongata hermaphrodite flower type and that it gives rise to elongated or marketable fruit, which is possible through grafting [67].
\nTherefore, in the Apatzingan Valley, experimental works of grafting in papaya were developed. The region has a semidry warm climate condition (the wettest of the semidry warm ones) with summer rains and a dominant volcanic (clayed) soil type. In order to generate and adapt a grafting method for papaya, experimental trials were carried out. Two grafting methods were tested, along with the strategies employed in vegetables, which were used for the formation of grafted papaya plants. During the development of the trials, modifications were made. In the first evaluation, two grafting methods, approach graft G.A. and cleft graft G.C. [5], and two clamping devices, lead band (G.A.B. and G.C.B.) and plastic clip (G.A.P. and G.C.P.), were compared. The response in the percentage of survival of the methods of approach and cleft grafts and fastening with lead band and clip was variable (Figure 2).
\nMethods of approach and cleft graft and two fixation devices [68].
In the second evaluation, there were two modifications to the first graft method, called modified approach graft (G.A.M.) with two types of cuts (G.A.M.C1 and G.A.M.C2). With respect to the cleft graft, a modification was also proposed (G.C.M.) (Figure 3). As noted, in the second evaluation, two modifications to the evaluated methods arose, and a method called modified cleft graft (G.C.M.) was also incorporated. In Figure 3, the percentage values on the grafting of the graft approach methods are presented (G.A.M.C1 and G.A.M.C2). Due to its high percentage of survival (almost 90%), the treatment G.A.M.C2 is acceptable and exceeds the expectations for its use in papaya, under the conditions evaluated.
\nModified approach and cleft graft methods and two fixation devices [68].
In a third evaluation, the modified approach graft method (G.A.M.C1) was tested in three containers. With respect to the election of containers, it includes the trays of 128 and 200 cavities (G.A.M.128 and G.A.M.200) and the plastic bag (G.A.M.B.). The results showed that the G.A.M.B. achieved 89% of survival (Figure 4).
\nModified graft method in different containers [68].
Recapitulating, of the three evaluations, the approach graft method subjected by lead band (G.A.B.) and the modified method (G.A.M.C2.) were the most effective with 79 and 87% of survival, respectively. As for the containers used, the grafted plant with the highest yield corresponded to the use of a bag (G.A.M.B), surpassing the tray containers [68].
\nIn another experiment, with the objective of evaluating the behavior of grafted plants and the quality of the plants, an experiment was established with five treatments formed by different combinations of rootstock and graft, in commercial genotypes. Two phases were evaluated, before and after the transplant. In the nursery, a papaya seedling was produced in a plastic bag container. The genotypes used were the varieties “Gibara” (G), “BS” (BS), “BS2” (BS2) and “Maradol” (M), and later they would serve as rootstocks (R) and grafts (G). The grafting method used was the modified approach. Five treatments were used: R. G × G. BS, R. BS × G. G, R. BS2 × G. BS, R. BS × G. BS2, and R. BS2 × G. M. The variables evaluated were the percentage of post-graft survival (prior to transplant) and percentage of post-graft survival in the field (after transplant). In the field, to determine the quality of the grafted plant in its post-graft stage, a grading scale designed under three key levels was used: N1 = vigorous, robust plant, upright leaves, normal terminal bud, does not present physical alterations in the union of the graft; N2 = vigorous plant, some leaves upright, slightly physical alterations are perceived in the union of the graft; and N3 = stressed plant appearance, weak terminal bud, contrast in stem coloration near the graft. The results obtained from the survival of the grafted papaya plant before and after the transplant are presented in Figure 5. The modified approach graft method responded positively in both situations, since most of the treatments exceeded well above 80% of survival, which is acceptable for the papaya species, due to its recent exploration on the subject. When making the comparison of survival between the pre- and posttransplant conditions, the values were generally lower when the pretransplant condition was registered.
\nQuality of grafted papaya plant prior and post transplant.
In relation to plant quality, based on the three-level assessment scale, the results are presented in Figure 6. In general, the five grafting treatments presented level 1 (N1 = vigorous, robust plant, upright leaves, bud normal terminal, does not present physical alterations in the union of the graft) in greater percentage than levels 2 and 3; and between treatments, R. G × G. BS, R. BS × G. G., and R. BS2 × G. M were superior with more than 90% in the first level. In level 2 (N2 = vigorous plant, some upright leaves, slightly physical alterations are perceived in the union of the graft), which was desirable to occur in a smaller proportion, only the treatments R. BS × G. G. and R. BS2 × G. BS. presented between 10 and 14%, respectively; in the rest of treatments, it was presented between 4 and 7%. This circumstance can be attributed to the fact that the plants registered under this characterization are possibly still in the postgraft recovery stage, which is caused by defect in the operation of the graft; however the situation can be reversed. Finally, level 3 (N3 = appearance of stressed plant, weak terminal bud, contrast in the coloration of the stem close to the graft), except for the treatments R. BS × G. G., and R. BS2 × G. M., did not have this condition. The other treatments presented between 2 and 5%. Although they are grafted plants that will be discarded, the percentage can be considered tolerant (Figure 6).
\nQuality level of grafted papaya plant [69].
Both the modified approach graft technique and the combination of grafted genotypes in the post-graft stage before and after the transplant expressed the percentage survival condition acceptable. With the technique surpassed of the papaya graft, the bases are established to explore other aspects oriented to the management of the crop.
\nThe species with potential for the use of graft in the Apatzingan Valley Michoacan, Mexico, are from the Solanaceae family, the tomato, the tomato from shell (Physalis ixocarpa), chili pepper, and the eggplant; from the Cucurbitaceae family, watermelon, cantaloupe, and cucumber; and from the Caricaceae family, the papaya, the latter in the first order to attend first to the aspect of sexing plants, where plants of the elongata hermaphrodite flower type should be selected, and in a second order to the incidence of viral diseases.
\nTherefore, the graft in the State of Michoacan is an alternative viable solution for the management of the mentioned crops, since it offers promising results, so its adoption can be a reality. It is also worth mentioning that the advantages of using grafted plants are much, since doing a count, is a non-polluting technique, it gives vigor to the plants, and is possible to lengthen the productive cycle. In general, the root system of the rootstocks is denser and wider; therefore, the plant has greater exploration capacity in the soil and in turn greater absorption of water and nutrients. Also, the fact of tolerating the presence of soil pests such as nematodes and harmful pathogens, plants can produce fruits and in most cases increase yields. By itself, the use of grafted plants helps to improve the conditions of the crop, but also, if this technique is included in a program of integrated management of pests and diseases, it can ensure the success of the production of different crops.
\nThe author wished to express his gratitude to the institutions that supported and solved the development of the research works: the National Polytechnic Institute; the National Technological Institute of Mexico; the National Institute of Forestry, Agriculture and Livestock Research; as well as the team of researchers that participated directly in technical support of projects.
\nThe economic recession in developing countries especially in sub-Saharan region has affected various sectors of the economy. This includes the health sector, leading to low productivity, poor service delivery and poor health outcome [1]. In some of these countries, home services are not available. The health sector is still trying to deliver basic health care services with the collective efforts of government but efforts to accomplish this seem not achievable due to the present state of the economy. Holistic health care is good, both ethically and practically but it is hard to find as any obvious expression of what holistic health care is or any plain explanation of its realistic usefulness especially in terminally ill patients in need of palliative care, which may require home care.
\nIn most developing countries, patients generally report late to health facility due to a sequence response to event: improper health-seeking behaviour, economy and ignorance of the disease, treatment by unqualified and unorthodox medication, non-availability of personnel, equipment, culture/belief and family decisions [2]. Terminal diseases have often been linked with having one of the worst effects on the quality of life among affected patients and their families.
\nThis chapter, therefore, considers what holism is and then what a holistic approach to illness might be, and how this might improve health care at home in a depressed economy.
\nBy the end of this chapter you should be able to:
review holistic care and identify its principles
understand palliative care and its principles
recognise the relevance of spirituality in health care
assess the impact of economic depression on health
assess the home care situation in a depressed economy
discuss the integration of palliative/holistic care in clinical and home-based care in terminally ill patients and the elderly.
Holistic care means reflection of the whole person, physically, psychologically, socially and spiritually, in the care and prevention of disease. These different conditions can be similarly important. They should be managed together so that a person is cared for as a whole. A holistic approach means that the health care providers are well versed with a patient’s whole life situation. Maintaining one’s health requires continuous effort to attain a balance of all aspects of life. To accomplish this balance, an amount of consistent factors must be considered when providing health care to patients/clients. Such factors include age, sex, family relationship, cultural influences and economic status. This broad approach to health care is recognised as holistic health care [3]. In order to have a good understanding of holistic nursing, Katie Eriksson, who is a nurse, came up with the theory of Caritative care that helps distinguish the relationship between a nurse and a patient and the concept of caring principles, which guide the nurses in decision-making. The theory of Caritative care comprises love, which is known as caritas. It shows the significance of regarding the self-esteem of a human being and holiness [4].
\nAlmost all health care professionals would assert to put into practice holistic health care. It is obvious that; no one would declare or have the same opinion that their individual, professional or organisational practice was not holistic. Consequently, few if any of these professions, people or organisations make it apparent what they mean by ‘being holistic’. They do not provide any explanation, or examples of how they manifest their holism. It is difficult to discover any criteria against which their success at being holistic could be measured. I doubt that many of the people, professions or organisations have any comprehensible conceptual understanding of what they mean by ‘being holistic’.
\nThe word holism has its foundation in two Greek words, both of which denote ‘whole’. This first ‘holos’ is the base for holism and the second ‘hale’ is the base for healing and health [5]. Health in general is believed to be concerned with the state of a person’s mind and body, commonly meaning free from illness, injury or pain. Healing is the process of re-establishing health to a diseased, injured or damaged individual. Mariano defines healing as the consolidation of total human being in body, mind, feeling and spirit [6]. Therefore, it is an associate to holism.
\n‘Holism’ in health care is a philosophy that emanates from Florence Nightingale who advocated care that centred on unity, wellness and the interrelationship among human beings, events and the environment [6]. She discerned the importance of such components as the environment, sense of touch, light, smells, music and silent expression in the treatment process [7], hence, reaching patients in fashions that went beyond rendering just physical care. The philosophy behind holistic care is founded on the thought of holism, which stresses that for human beings the whole is greater than the sum of its parts and that mind and spirit affect the body [8]. Holistic nursing has a higher cognizance of self, others, nature and spirit. This is the same approach Florence Nightingale integrated as the first holistic nurse, which centred on harmony, wellness and interrelatedness of human beings, likewise their surroundings. Holistic nurses also have the same self-care and self-awareness of body, mind and spirit as part of their belief structure (\nFigure 1\n). Through caring for themselves, it is believed it gives a holistic nurse the capability to have that same consciousness for the care of others [7]. Florence Nightingale once expressed the role of nurses as ‘to put the patient in the best condition for nature to act upon him’ [9]. She thought that touch, kindness and other measures of comfort, provided within the setting of treatment environment, are essential for nursing care. These assumptions are applied nowadays. Even these days, nurses are educated to deal with the environment and use touch, knead, eye contact, voice and other measures to make patients more relaxed. These nursing actions, known as ‘the art of nursing’, constitute the basis of professional nursing [10]. Currently, different fields, such as physics, mathematics, science, philosophy, sociology, medicine, nursing, etc. endorse the opinion that the honesty of an individual is much more complicated and greater than the sum of their individual parts [10].
\nDiagrammatic presentation of the components of holistic care.
\n
All people have natural healing powers;
The patient is a person, not just a disease;
Suitable healing therapy needs a team approach;
Patient and health care professionals are collaborators in the healing process;
Treatment comprises fixing the cause of the illness, not just reliving the symptoms [5].
The World Health Assembly approved the resolution to integrate hospice and palliative care services into national health services [11]. The body recognises these important health services as an important component of health systems worldwide and therefore calls on national authorities to make sure they be given the awareness they deserve. This is the first time that the World Health Assembly has considered a declaration on palliative care. It endorses that all countries need to take palliative care seriously [11]. The main recommendations to all member states of WHO as seen in the resolution are to integrate palliative care into health care systems, to make sure that palliative care is incorporated into the introductory and continuing education and training for all health care personnel and to make sure that appropriate medications, as well as strong pain medications, are accessible to patients [11].
\nMany individuals, organisations and bodies including the WHO have suggested different definitions of palliative care. WHO revised the meaning of palliative care to be ‘an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’ [12]. WHO further listed the following features of palliative care: ‘provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten nor postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; offers a support system to help the family cope during the patients illness and in their own bereavement; uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; will enhance quality of life, and may also absolutely influence the progression of illness; is applicable early in the course of illness, in conjunction with other treatments that are aimed to prolong life, such as chemotherapy or radiation therapy, and includes those examinations needed to better understand and manage distressing clinical complications’ [12].
\nBoltz defined palliative care ‘as expert curative care of patients with severe disorders, and it emphases providing patients with relief from symptoms, discomfort and worry of serious illness, irrespective of the diagnosis’ [13]. She further explained that the word ‘palliative’ has its origin in the Latin word meaning to ‘cloak or cover’. And upheld that, Viewpoint of how cancer, which is one of the terminal diseases is observed and not properly diagnosed, is suitable description because most cancers progress without warning signs for an extensive period before the individual tries to seek help. The National Consensus Project (NCP) and National Quality Forum (NQF) jointly formulated the concept of palliative care so as to separate it from other types of care [14]. And so they came up with eight domains of palliative care: ‘structure and processes of care; physical aspects of care; psychosocial and psychiatric aspects of care; social aspect of care; spiritual, religious, and existential aspects of care; cultural aspects of care; care of the imminently dying patient and ethical and legal aspect of care’ [14].
\nPalliative care is often misidentified as being the same as care given to the patient approaching death where no cure is expected to be achieved [15]. It is focused on the relief of distress during the advancement of patient’s illness. Even though hospice and palliative care is extensively used in the western world, many patients are seen to register in hospice very close to death, which limits the advantage these services would have obtained.
\nRosser and Walsh cited WHO’s principles of palliative care as follows:
“provides relief from pain and other distressing symptoms;
intends neither to hasten nor postpone death;
integrates the psychological and spiritual aspects of patient care;
offers a support system to help patients live as actively as possible until death;
offers a support system to help the family cope during the patient’s illness and in
their own bereavement;
uses a team approach to address the needs of patients and their families, including
bereavement counselling, if indicated;
is applicable early in the course of illness, in conjunction with other therapies that
are intended to prolong life, such as chemotherapy or radiation therapy, and includes complications” [5].
These principles according to Rosser and Walsh focus on a whole, humanistic method of caring for the total being during the course of their illness, instead of concentrating on the ailment or situation [5]. Palliative care answers to the altering wishes of the patient and family, identifying that the illness development and the related involvements are distinctive to each individual. Rosser and Walsh opined that palliative care is seen as supportive care [5]. They see it as care delivered to patients, friends and family during the course of their illness; this includes the period before diagnosis has been made, as soon as patients start undergoing series of examinations, treatment and home care. The purpose of supportive care is to assist the patients and their families to be able to handle their illness and management at home.
\nBecker also penned principles that are relevant to providing palliative care. These include the following:
Follow-up of all patients diagnosed with terminal illness at any stage of the disease
Competence at putting patients at ease
Listening and attention skills
Questioning techniques [16].
These principles will put humanity back into the care offered by nurses. After physicians, nurses are the most important members of the palliative care team in the sense that they spend 24 hours with the patients and should be able to display the principles [16]. Skill is an important characteristic for ensuring quality, safety and cost-effective health care. The term competence according to the Royal College of Nursing “(RCN) comprises the skills, knowledge, practices, qualities and manners essential for an individual” so as to execute the work successfully [16]. A nurse is said to be competent when she has the skills and talents vital for lawful, safe and effective professional practice without direct guidance [17]. Competence can be said to be basic features of persons that result in effective performance. They can be described as a mixture of knowledge, skills, purposes and personal character traits. It can also be seen as the way someone behaves or acts.
\nAreas of competency include verbal message, written communication, enquiring skills and team skills [17]. Nurses are expected to communicate efficiently, generating talking and listening skills. Nurses should be able to use their knowledge and skills to promote open and honest communication skills to support open and honest interaction that recognises the needs of patients, and also creates a satisfying association in which they are able to apply counselling skills and initiate follow-up programmes to help them to adjust to their illness and care. Their knowledge and skill will also ascertain that patients obtain full evidence-based nursing care. They understand and identify the impact of terminal disease when dealing with clinical or home situation, so that they can be able to assess the outcome of care and give appropriate intervention. Competence also includes the ability of the nurses to use the e11 function health patterns to assess the patient. Gordon Morgan, according to Doenges and Moorhouse, devised 11 functional health patterns to be used by nurses in nursing process to provide more comprehensive nursing assessment of the patient. This will help the nurses to give holistic care to patients [18].
\nThe model of palliative care put together by the Canadian Hospice and Palliative Care Association (CHPCA) [19] is the model that is used to guide this chapter. This model is effective because it was developed to plan, evaluate and develop educational programmes [19]. In adopting this model, the paper considered the prominent position of the hospital management, without which it would be impossible to develop a programme for home care. The key role played by nurses as members of the palliative care team begins as soon as diagnosis is confirmed by the physician. Based on gaps identified after confirmation of diagnosis, the model provides guidance in tracking and tracing each patient, and planning home care. Communicating the true position of diagnoses at this stage is very important as it will help to reduce anxiety—after which, follow-up and home care measures will then be put in place.
\nTwo fundamental elements in the framework as utilised are the ‘square of care’ and the ‘square of organization’. As set out in the model [19], the ‘square of care’ has six components and the ‘square of organization’ has six stages that are relevant to palliative care integration. The composition of the conceptual framework is shown in \nFigure 2\n covers all phases of a palliative care programme, service or group. The patient and family are at the middle of the joint square, and their needs decide the concerns to be covered, the care necessary and the purposes and means to deliver care [20].
\nSquare of care and organisation (Source: adopted from CHPCA).
The Square of Care refers to the six important phases during the process of rendering care to patients and family. The phases of square of care include:
assessment
information sharing
decision-making
care planning
care delivery and
confirmation, and demonstration that they relate to the concerns (or areas) that patients and families usually encounter.
Square of organisation also has six stages, which comprise:
governance and administration
planning
operation
quality improvement communication/marketing
collection and use of data.
The main concepts of the model are the standards and regulatory beliefs that were established and decided upon through a national consensus-based practice [20].
\nThere should be plans for both the health care professional and patients/families to manage physical and psychosocial suffering and to get ready for the likelihood of advanced disease. This aspect of palliative care involves ways to provide physical and emotional care that will help patients to get through treatments. It enhances patients’ compliance with disease management, helps them accept changes in care and prepares patients and their families for the tasks ahead if the disease eventually does not lead to a cure.
\nBased on the model of palliative care as developed by CHPCA, the model takes into consideration the prominent position of the hospital management without which it will be impossible to develop any programme of such magnitude [19, 20]. This is because, a lot of things will be considered, especially, developing human resources example training of palliative care nurses, setting up palliative care team, providing other means of integrating palliative care into daily care of patients. Again, patients and families should also be seen at the centre of developing this programme as compliance is the key to success of any programme.
\nA nurse as an important member of palliative care team has an important role to play as soon as a patient is indicated for home care. Based on the gaps identified, after confirmation of diagnosis, tools that are going to be adapted will be used to track each patient; communication of the true position of diagnoses at this level is very important as this will help to reduce anxiety and follow-up measures will then be put in place. Studies conducted by Temel et al. indicate that patients who had palliative care integrated into normal treatment had a better outcome even when they were diagnosed at the advanced stage of the disease than patients who managed with only normal treatments [21].
\nSpirituality is a part of holistic care for clients and families. Patients getting palliative care benefit much from the special care that is devoted to physical, personal and social needs [22]. Spiritual care is seen as very significant for a lot of terminally ill patients, but professionals have trouble determining what such care they could embrace. From the viewpoints of the patients/clients at the end of life, their family caregivers and health care workers, the main aims are: to search the notion of spirituality and the meaning of this term; to discover beliefs, understandings and prospects with respect to spirituality, spiritual needs, pain or distress and spiritual care and, eventually, to see how spiritual care can best be provided for patients at home in a depressed economy.
\nSpirituality and health is an increasing new area of health care; the first textbook on spirituality and health was published by Oxford University Press [23]. Puchalski et al. established that patients would like their spirituality to be addressed in their health care. As the trends and research developed, ethical queries began to come up as to the definition of spirituality within medical care, its role in patient care and the implementation of spiritual care in the clinical setting.
\nRosser and Walsh are of the opinion that spirituality takes account of an individual’s beliefs, values, identity, a sense of meaning and purpose [5]. Some people see religion as being a component of spirituality. Wright and Neuberger designate spirituality to be pertained to how we see ourselves in the pattern of things, how we relate to other human beings and the wider world and how we ascertain meaning, purpose and association in life [24]. By its very nature, spirituality is often subjective, absolute and personal. In addition to the suggested principles for health care professionals to take care of the whole person, together with the patient’s spirituality, studies have established that patients appreciate a more whole-person emphasis on care and value health care professional’s probe into their spiritual beliefs [25].
\nSpirituality according to some schools of thought covers the confidence in self and others and this may include a belief in a divine being or higher authority [26]. The RCN also describes the following as factors of spirituality:
hope
strength
trust
forgiveness
love
relationships
creativity
self-expression [26].
If patients’ needs could be recognised early and their care adequately planned to include (but not limiting to) follow-up of all patients diagnosed with terminal illness through telephone calls, home visiting, advanced care planning, assessment and treatment of physical, psychosocial and spiritual aspect of patient’s needs, etc., there will be better outcome when the condition reaches advanced stage. Some may reason that because spirituality is so personal, it has no relationship in health care but when the perception of total pain is looked into, it is obvious that spiritual care is a vital element of care [5].
\nEconomic depression is a period of time of economic slowdown presenting low output, not having enough funds and unemployment. It is considered by its length, abnormal upsurges in unemployment, falls in the obtainability of adequate health services, shrinking output and investment, etc.
\nThe major causes of economic depression in any given economy (lessons from great depressions, 1981, 1991, 2008 economic recession) may include:
High inflation, a general rise in price of goods and services—leading to low purchasing power.
Accumulation of debt servicing especially foreign debt.
High-interest rate—discouraging investors.
Fall in aggregate demand; fall in wages, income etc.
Mass unemployment and general loss of confidence in the government [27]
Health is an essential part of man’s existence even in the midst of economic depression. Before the current economic crisis, most present-day societies especially in the developing countries were still suffering disease epidemics while other nations incessantly experienced the endemic diseases affecting millions of lives. The global economic crisis persists to worsen the structure and purpose of the health sector. The economic depression has affected several segments of the economy including the health sector, contributing to low output, poor service delivery and poor health outcome. This has led so many people to resort to home care where so much will not be required from them.
\nThe health sector is still struggling to provide rudimentary health care services with the collaborative efforts of government and individuals but determinations to realise this seem unfeasible due to the current state of the economy especially in the developing countries. The current economic position has affected health care funding and the level of support of the public and private health care services particularly among the rural poor is reduced due to increased proportion of poverty [28]. The economic predicament has contributed essentially to poor health outcome; it offers the occasion for careful government health modifications to improve the health system operation [28]. Health is directly or indirectly connected to other sectors such as food security and nutrition, family income generation, housing, education, employment status and other social security services.
\nFollowing initial treatment for terminal diseases or elderly patients, they are usually given dates for followed-up appointment in hospital outpatient departments at steady intervals for routine checking in order to assess the patient and timely discovery of recurring of the ailment [29]. This method of follow-up places anxiety on the patient and their family members and most of them defaulted due to religious and cultural beliefs. Secondly, they may complain of inability to travel to the hospital, especially patients living in the rural communities. Most of these patients present late in the hospital either because of poor knowledge, cultural/spiritual beliefs and non-availability of resources for prevention, diagnosis and treatment [28]. Patients and families are not well prepared after diagnosis about the diseases or palliation; this has led to most of the patients not responding to check-up appointments because they are not well informed and no form of follow-up programmes are put in place to track these patients [29].
\nBased on the above premise, several countries have been able to put in place measures for providing home care services to a lot of their citizenry so as to alleviate the suffering of the poor masses. Most of the developing countries are still struggling as a result of poor economic position of these nations. Home care cannot be instituted without adequate resources.
\nFrom a nursing viewpoint, it is imperative to have information about the type of care needed, the explanations of care needed and quality of life among the elderly people and those diagnosed with terminal illnesses living in their own homes, in order to sustain their independence and make best use of their quality of life.
\nAt several stages during our lives, we are each dependent on the care of others [30]. For many, that need comes with old age, chronic illness or ill health. In some occasions, the care is provided by a family member or a friend; in other cases, it comes from a paid care worker such as a registered nurse, a registered practical nurse or a personal support worker. Sometimes, the care is given by a combination of both [30].
\nThis chapter describes the involvements of these three care beneficiaries, their family caregivers and their paid care workers in our survey of the direction of the substantial practices of care associations in home care. Current reorganisation of health and social care services means the home is gradually the site of long-term care and is a place where implications of both home and care must be discussed [31]. The focus on the familiar care points up the diverse forces at work of care through which caregivers, care recipients and home space are established.
\nMost nurses have their own individual principles and morals, and there are certain professional standards on which all nurses are anticipated to establish their care. Nurses have a duty to make the care of patients their major concern and to practise care giving without harm and efficiently. They must be ethical and truthful [1]. Patients trust their nurses because they believe that, in addition to being experienced, their nurses will not take advantage of them and will demonstrate character traits such as honesty, straightforwardness, reliability and empathy. Good professional decision and behaviour in clinical practice should be patient-centred. It involves nurses understanding that each patient at the end stage of his or her disorder is exceptional, and working in partnership with their patients to discourse the needs and realistic prospects of each patient. The moral pronouncement as proposed by Plato and Aristotle highlighted the part of purpose both in observing what is fair and in permitting us to act reasonably rather than give in to conflicting desires and feelings [32].
\nHellström and Hallberg examined people aged 75 years and older dependent on care from professionals and/or a next of kin, their functional health, diseases and complaints in relation to quality of life as perceived by themselves [32]. The study revealed that the number of elderly persons in need of support ranged from 18.5 to 79.1% in the different age groups, and that aid came mostly from informal caregivers [32]. The authors also discovered that assistance from formal caregivers was given in combination with that from a next of kin in 38.8% of the cases. Furthermore, next of kin function more than formal carers; they assisted in all Contributory Activities of Daily Living (CADL) and Personal Activities of Daily Living (PADL) chores, with the exclusion of house cleaning and rendering a bath/shower. Although the respondents had supported themselves, they were also of assistance to another person in 6.5% of circumstances [1].
\nFrom the above study, it is seen that care giving at home is mostly carried out by informal caregivers, than the professionals. Patients, therefore, would see care at home more acceptable during this critical period of their lives. Most patients resolved to care at home because their financial status cannot cope with hospital bills, transportation, waiting time in the health care facilities among other reasons that promote home care.
\nNurses are the most valuable member of the palliative care team who are in the best position to look into the physical, purposeful, social and spiritual needs of the patients, but in most situations, they (nurses) are not well-prepared to give the adequate care, especially to elderly and terminally ill patients. The main focus of nursing care as observed is curative approach without taking into consideration effective communication between them and patients/families the truth about diagnosis/prognosis of the disease, lack of patient and family readiness as a result of inadequate training/discharge planning and lack of follow-up [33].
\nSpecifically, since there are no functional palliative care programmes in most health care facilities, the phases being addressed are:
Outpatient clinics
Hospital service
Home care service
Approach to care
\nOutpatient clinics:\n
Staff: Palliative care physician and nurse to be identified
Terminally ill patients identified after diagnosis is confirmed
Visit: To plan routine visit as necessary
Symptom assessment in clinic: Routine assessment during every visit by the nurse and physician
Psychosocial assessment in clinic: Routine assessment and discussion of goal with patient and family, support system, psychosocial distress and discussion on advance care planning according to their willingness
Telephone follow-up: Routine by the nurse after each visit
On-call service: 24 hours on-call service to be clarify during first visit after diagnosis has been established.
\nHospital service:\n
In-patient care: access to palliative care for symptom management
In-patient staff training for nurses: identification of nurses, physician and family caregivers for continued education and training in palliative and home care
Palliative care in-patient follow-up: follow-up by palliative care team when the patient is admitted to other unit of the hospital.
\nHome care:\n
Community care contact health centre service: health centre closer to the patient will be identified for care continuation and this would be reassessed at each visit.
Communication with the family and community health centre: this should be done routinely.
\nApproach to care:\n
All care providers: Multidisciplinary, this is hope to address physical, psychological, social and spiritual needs of both the patient and the family identifying other specialist. The approach to care takes cognizance of the fact that the economic depression affects the type of care the less privileged members of the population attained. This may affect proper access to good health care services and as such provision of home care will be beneficial to them where they will be taken care of in their familiar environment.
\nNurses should strive to always make the most of the short time they have with each patient. As nurses, we need to promote a patient’s psychological and emotional well-being in order to facilitate physical healing, especially in a poor economic situation. When we do this, our relationship with the patient alters and develops into something more encouraging than it was before. This contributes to better patient outcomes and can heighten the happiness and perseverance in our work as nurses. By doing this, informal caregivers would emulate and continue home care.
\nThere are many easy ways to develop relationships with patients and encourage a sound psychological, emotional and spiritual environment.
Learn the patient’s name and use it
Make good, strong eye contact
Ask how a patient is feeling and honestly care
Smile and laugh when suitable
Use relaxing touch
Assist the patient to see themselves as someone who merits self-esteem
Maintain their self-worth
Educate patients on the significance of self-care
Ask the patient how you can decrease their anxiety or pain
Holistic nursing is the concept of caring for a person as a whole. The purpose is to return the patient as a whole to as close to normal as possible even when receiving care at home. Holistic nursing highlights on the nurses considering the link between minds, body, emotion, spirit, social, cultural, environmental and past relationships in order to return the patient to a whole. This however has not always been likely to attain. The idea of caring for the whole person, not just their physical body, is one that dates back to Florence Nightingale. Florence Nightingale devotedness was to care for those who could not care for themselves. Florence Nightingale herself advocated holistic care by recognising the importance of environment touch, light, scents, music and silent reflection in treatment process.
\nThere is a direct relationship between economy and health and by implication of nursing profession. The present economic depression places an enormous threat as its end is not sure. This chapter therefore tried to bridge the gap between holistic care, palliative care, which embodied all the components of spirituality, and the terminally ill patients needing home care. This has a lot to do with economic situation of the populace, especially in the low- and middle-class countries of the world. Since the elderly and the terminally ill patients preferred home care, it is pertinent that all the components of care be provided to take care of the total man.
\nThe authors are grateful to all the authors whose work were cited in this chapter without which it could have been impossible to support the original ideas conceived by the authors.
\nThe authors declare no conflict of interest.
\nAN, EO and BN designed the study, compiled and wrote the manuscript. All the authors reviewed the manuscript and provided critical comments, read and approved the final version of the manuscript.
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