“I Do Feel Like a Scientist at Times”: A Qualitative Study of the Acceptability of Molecular Point-Of-Care Testing for Chlamydia and Gonorrhoea to Primary Care Professionals in a Remote High STI Burden Setting

Background

Point-of-care tests for chlamydia (CT) and gonorrhoea (NG) could increase the uptake and timeliness of testing and treatment, contribute to improved disease control and reduce reproductive morbidity. The GeneXpert (Xpert CT/NG assay), suited to use at the point-of-care, is being used in the TTANGO randomised controlled trial (RCT) in 12 remote Australian health services with a high burden of sexually transmissible infections (STIs). This represents the first ever routine use of a molecular point-of-care diagnostic for STIs in primary care. The purpose of this study was to explore the acceptability of the GeneXpert to primary care staff in remote Australia.

Methods

In-depth qualitative interviews were conducted with 16 staff (registered or enrolled nurses and Aboriginal Health Workers/Practitioners) trained and experienced with GeneXpert testing. Interviews were digitally-recorded and transcribed verbatim prior to content analysis.

Results

Most participants displayed positive attitudes, indicating the test was both easy to use and useful in their clinical context. Participants indicated that point-of-care testing had improved management of STIs, resulting in more timely and targeted treatment, earlier commencement of partner notification, and reduced follow up efforts associated with client recall. Staff expressed confidence in point-of-care test results and treating patients on this basis, and reported greater job satisfaction. While point-of-care testing did not negatively impact on client flow, several found the manual documentation processes time consuming, suggesting that improved electronic connectivity and test result transfer between the GeneXpert and patient management systems could overcome this. Managing positive test results in a shorter time frame was challenging for some but most found it satisfying to complete episodes of care more quickly.

Conclusions

In the context of a RCT, health professionals working in remote primary care in Australia found the GeneXpert highly acceptable. These findings have implications for use in other primary care settings around the world.     

“I Spent a Full Month Bleeding,I Thought I Was Going to Die…” A Qualitative Study of Experiences of Women Using Modern Contraception in Wakiso District,Uganda

Introduction

There is high unmet need for family planning (FP) in Uganda as well as high contraceptive discontinuation rates. These contribute to the high fertility rates that in part are due to unplanned pregnancies. There are gaps in knowledge about experiences that couples go through while using contraceptives in their lives. This study explored women’s experiences during the course of their contraceptive use.

Methods

We conducted a qualitative study involving 30 women who had used modern contraception for at least one year in Wakiso district, central Uganda. We used in-depth interviews to obtain their personal accounts. Index women were approached through health officers at four health centres in the district. All ethical approvals and informed consent were obtained. We used conventional content analysis; identifying codes through open coding, on which basis categories were developed and grouped into overarching themes.

Results

Women’s accounts were summarised in the following themes: negative experiences with modern contraceptive use, motivation to continue using FP in spite of these negative experiences, the role of influential people, and discontinuation of use. Negative accounts dominated the experiences of most women but they expressed strong desire to continue using modern contraception even amidst all challenges. Health workers emerged as the most influential people that played a vital role in women’s decisions.

Conclusion

Varied negative experiences with modern contraception and misperceptions exist amidst a determination to continue use. Partner engagement, health service strengthening to improve side effects management and health worker skills, and engaging older women that have successfully used contraception as community champions, are potential strategies to support women’s contraceptive decisions.     

Introducing a Mobile-Connected Umbilical Doppler Device (UmbiFlow?) into a Primary Care Maternity Setting: Does This Reduce Unnecessary Referrals to Specialised Care? Results of a Pilot Study in Kraaifontein,South Africa

Objectives

UmbiFlow™ is a mobile-connected Doppler device that utilises a continuous waveform to measure resistance in the umbilical artery. The main aim of this pilot study was to determine whether the use of UmbiFlow™ for umbilical artery Doppler in patients with a suspected decreased symphysis fundal (SF) growth could safely lead to a decreased number of patients requiring referral to a more specialised level of care. A secondary aim of the study was to evaluate the effectiveness of UmbiFlow™ Doppler as a screening tool for concealed placental insufficiency in late bookers by using a single screening cut-off value that will be abnormal for any gestation >28 weeks.

Methods

The cohort comprised two groups of patients: The first group included all follow-up patients with suspected intra-uterine growth restriction (a decreased symphysis-fundus measurement based on serial assessment) who underwent on-site UmbiFlow™Doppler testing performed by the midwife directly after the clinical examination. The second group included late bookers, where gestation was uncertain; but estimated >28 weeks based on clinical grounds. This group was comprised of unselected patients who report to antenatal care late for the first time and received an UmbiFlow™Doppler test for concealed placental insufficiency.

Results

UmbiFlow™Doppler could reduce the number of false referrals to hospital by 55%. A single UmbiFlow™Doppler test in late bookers appeared to identify a group of women at moderate risk of lower birth weight babies.     

“Wrong,but Useful”: Negotiating Uncertainty in Infectious Disease Modelling

For infectious disease dynamical models to inform policy for containment of infectious diseases the models must be able to predict; however, it is well recognised that such prediction will never be perfect. Nevertheless, the consensus is that although models are uncertain, some may yet inform effective action. This assumes that the quality of a model can be ascertained in order to evaluate sufficiently model uncertainties, and to decide whether or not, or in what ways or under what conditions, the model should be ‘used’. We examined uncertainty in modelling, utilising a range of data: interviews with scientists, policy-makers and advisors, and analysis of policy documents, scientific publications and reports of major inquiries into key livestock epidemics. We show that the discourse of uncertainty in infectious disease models is multi-layered, flexible, contingent, embedded in context and plays a critical role in negotiating model credibility. We argue that usability and stability of a model is an outcome of the negotiation that occurs within the networks and discourses surrounding it. This negotiation employs a range of discursive devices that renders uncertainty in infectious disease modelling a plastic quality that is amenable to ‘interpretive flexibility’. The utility of models in the face of uncertainty is a function of this flexibility, the negotiation this allows, and the contexts in which model outputs are framed and interpreted in the decision making process. We contend that rather than being based predominantly on beliefs about quality, the usefulness and authority of a model may at times be primarily based on its functional status within the broad social and political environment in which it acts.     

Collaborative Care for Depression in Primary Care: How Psychiatry Could “Troubleshoot” Current Treatments and Practices

The bulk of mental health services for people with depression are provided in primary care settings. Primary care providers prescribe 79 percent of antidepressant medications and see 60 percent of people being treated for depression in the United States, and they do that with little support from specialist services. Depression is not effectively managed in the primary care setting. Collaborative care based on a team approach, a population health perspective, and measurement-based care has been proven to treat depression more effectively than care as usual in a variety of settings and for different populations, and it increases people’s access to medications and behavioral therapies. Psychiatry has the responsibility of supporting the primary care sector in delivering mental health services by disseminating collaborative care approaches under recent initiatives and opportunities made possible by the Affordable Care Act (ACA).     

General Practitioners’ Experiences of,and Responses to,Uncertainty in Prostate Cancer Screening: Insights from a Qualitative Study

BackgroundProstate-specific antigen (PSA) testing for prostate cancer is controversial. There are unresolved tensions and disagreements amongst experts, and clinical guidelines conflict. This both reflects and generates significant uncertainty about the appropriateness of screening. Little is known about general practitioners’ (GPs’) perspectives and experiences in relation to PSA testing of asymptomatic men. In this paper we asked the following questions: (1) What are the primary sources of uncertainty as described by GPs in the context of PSA testing? (2) How do GPs experience and respond to different sources of uncertainty?MethodsThis was a qualitative study that explored general practitioners’ current approaches to, and reasoning about, PSA testing of asymptomatic men. We draw on accounts generated from interviews with 69 general practitioners located in Australia (n = 40) and the United Kingdom (n = 29). The interviews were conducted in 2013–2014. Data were analysed using grounded theory methods. Uncertainty in PSA testing was identified as a core issue.FindingsAustralian GPs reported experiencing substantially more uncertainty than UK GPs. This seemed partly explainable by notable differences in conditions of practice between the two countries. Using Han et al’s taxonomy of uncertainty as an initial framework, we first outline the different sources of uncertainty GPs (mostly Australian) described encountering in relation to prostate cancer screening and what the uncertainty was about. We then suggest an extension to Han et al’s taxonomy based on our analysis of data relating to the varied ways that GPs manage uncertainties in the context of PSA testing. We outline three broad strategies: (1) taking charge of uncertainty; (2) engaging others in managing uncertainty; and (3) transferring the responsibility for reducing or managing some uncertainties to other parties.ConclusionOur analysis suggests some GPs experienced uncertainties associated with ambiguous guidance and the complexities of their situation as professionals with responsibilities to patients as considerably burdensome. This raises important questions about responsibility for uncertainty. In Australia in particular they feel insufficiently supported by the health care system to practice in ways that are recognisably consistent with ‘evidence based’ professional standards and appropriate for patients. More work is needed to clarify under what circumstances and how uncertainty should be communicated. Closer attention to different types and aspects of the uncertainty construct could be useful.     

Partner Experiences of “Near-Miss” Events in Pregnancy and Childbirth in the UK: A Qualitative Study

Objective

Severe life-threatening complications in pregnancy that require urgent medical intervention are commonly known as “near-miss” events. Although these complications are rare (1 in 100 births), there are potentially 8,000 women and their families in the UK each year who live through a life-threatening emergency and its aftermath. Near-miss obstetric emergencies can be traumatic and frightening for women, and their impact can last for years. There is little research that has explored how these events impact on partners. The objective of this interview study was to explore the impact of a near-miss obstetric emergency, focusing particularly on partners.

Design

Qualitative study based on narrative interviews, video and audio recorded and transcribed for analysis. A qualitative interpretative approach was taken, combining thematic analysis with constant comparison. The analysis presented here focuses on the experiences of partners.

Participants

Maximum variation sample included 35 women, 10 male partners, and one lesbian partner who had experienced a life-threatening obstetric emergency.

Setting

Interviews were conducted in participants’ own homes.

Results

In the hospital, partner experiences were characterized by powerlessness and exclusion. Partners often found witnessing the emergency shocking and distressing. Support (from family or staff) was very important, and clear, honest communication from medical staff highly valued. The long-term emotional effects for some were profound; some experienced depression, flashbacks and post-traumatic stress disorder months and years after the emergency. These, in turn, affected the whole family. Little support was felt to be available, nor acknowledgement of their ongoing distress.

Conclusion

Partners, as well as women giving birth, can be shocked to experience a life-threatening illness in childbirth. While medical staff may view a near-miss as a positive outcome for a woman and her baby, there can be long-term mental health consequences that can have profound impacts on the individual, but also their families.     

Patients’ Knowledge,Attitudes, Behaviour and Health Care Experiences on the Prevention,Detection, Management and Control of Hypertension in Colombia: A Qualitative Study

Hypertension is a leading cause of premature death worldwide and the most important modifiable risk factor for cardiovascular disease. Effective screening programs, communication with patients, regular monitoring, and adherence to treatment are essential to successful management but may be challenging in health systems facing resource constraints. This qualitative study explored patients’ knowledge, attitudes, behaviour and health care seeking experiences in relation to detection, treatment and control of hypertension in Colombia. We conducted in-depth interviews and focus group discussions with 26 individuals with hypertension and 4 family members in two regions. Few participants were aware of ways to prevent high blood pressure. Once diagnosed, most reported taking medication but had little information about their condition and had a poor understanding of their treatment regime. The desire for good communication and a trusting relationship with the doctor emerged as key themes in promoting adherence to medication and regular attendance at medical appointments. Barriers to accessing treatment included co-payments for medication; costs of transport to health care facilities; unavailability of drugs; and poor access to specialist care. Some patients overcame these barriers with support from social networks, family members and neighbours. However, those who lacked such support, experienced loneliness and struggled to access health care services. The health insurance scheme was frequently described as administratively confusing and those accessing the state subsidized system believed that the treatment was inferior to that provided under the compulsory contributory system. Measures that should be addressed to improve hypertension management in Colombia include better communication between health care professionals and patients, measures to improve understanding of the importance of adherence to treatment, reduction of co-payments and transport costs, and easier access to care, especially in rural areas.     

“I Try and Smile,I Try and Be Cheery,I Try Not to Be Pushy. I Try to Say ‘I'm Here for Help’ but I Leave Feeling… Worried”: A Qualitative Study of Perceptions of Interactions with Health Professionals by Community-Based Older Adults with Chronic Pain

Background

Over 50% of community-dwelling older adults experience chronic pain, which threatens their quality of life. Of importance to their pain management is older people''s interaction with health professionals that, if unsatisfactory, may impair the outcome.

Aims

To add to the limited research specific to older people living with chronic pain in the community, we explored how they perceive their experiences of interacting with health professionals, seeking factors that might optimise these interactions.

Methods

Purposive sampling was used to recruit men and women >65 years with self-reported musculoskeletal chronic pain. Qualitative individual interviews and one group interview were undertaken with 23 participants. Data were transcribed verbatim and underwent Framework Analysis.

Results

Three themes were identified. Seeking help illustrates issues around why older people in the community may or may not seek help for chronic pain, and highlights the potential involvement of social comparison. Importance of diagnosis illustrates the desire for professional validation of their condition and an aversion to vague explanations based on the person''s age. Being listened to and being heard illustrates the importance of empathic communication and understanding expectations, with due respect for the person''s age.

Conclusions

In common with people of all ages, an effective partnership between an older person in pain and health professionals is essential if pain is to be reported, appropriately assessed and managed, because of the subjective nature of pain and its treatment responses. For older people with pain, perception about their age, by both parties in the partnership, is an additional factor that can unnecessarily interfere with the effectiveness of this partnership. Health professionals should engage with older adults to clarify their expectations about pain and its management, which may be influenced by perceptions about age; and to encourage expression of their concerns, which may also be affected by perceptions about age.     

“If One Does Not Fulfil His Duties,He Must Not Be a Man”: Masculinity,Mental Health and Resilience Amongst Sri Lankan Tamil Refugee Men in Canada

Refugee men face unique mental health stressors in the pre- and post-migratory periods. However, there has been little in-depth research on the mental health of refugee men in Canada. Given this situation, the overall aim of this study is to explore the psycho-social experience of Sri Lankan Tamil refugee men in Canada. Particular objectives include better understanding any inter-relationship between war-trauma, migration, concepts of masculinity and mental health. The study employed a two-phase participatory action research design based on the grounded theory approach. Phase 1 involved an 8-month ethnography conducted in Sri Lanka. Phase 2 consisted of qualitative interviews with 33 Sri Lankan Tamil refugee men living in Canada. Consistent with grounded theory, analysis was conducted inductively and iteratively. Four specific themes emerged from the data (i) gendered helplessness of war: participants commonly reported ongoing negative rumination regarding experiences where they were unable to adequately protect loved ones from physical suffering or death; (ii) reduced capacity: participants frequently felt unable to fulfill culturally sanctioned duties, such as supporting their family, due to ongoing pre- and post-migratory stress; (iii) redundancy: many participants felt that they were useless in Canada, as they could not fulfill typical masculine social roles (e.g. provider) due to factors such as unemployment and underemployment; (iv) intimate criticism: some participants reported that their spouses would often attempt to ‘shame’ them into greater achievement by constantly reminding them of their ‘failures’. Many found this distressing. These various failures culminated in a state that we label “depleted masculinity”, which participants linked to emotional and behavioural problems. Participants reported that they actively tried to rebuild their masculine identity, for example by adopting leadership roles in community organizations, which fostered resiliency. Results suggest a need to review and rebuild masculine identity to support the mental health of refugee men.     

“I Can Also Serve as an Inspiration”: A Qualitative Study of the TB&Me Blogging Experience and Its Role in MDR-TB Treatment

Background

In 2011, Médecins Sans Frontières (MSF) established a blogging project, “TB&Me,” to enable patients with multidrug-resistant tuberculosis (MDR-TB) to share their experiences. By September 2012, 13 MDR-TB patients had blogged, either directly or with assistance, from the UK, Australia, Philippines, Swaziland, Central African Republic, Uganda, South Africa, India, and Armenia. Due to the lack of research on the potential for social media to support MDR-TB treatment and the innovative nature of the blog, we decided to conduct a qualitative study to examine patient and staff experiences. Our aim was to identify potential risks and benefits associated with blogging to enable us to determine whether social media had a role to play in supporting patients with MDR-TB.

Methods and Findings

Participants were identified and selected purposively. TB&Me bloggers, project staff, MSF headquarters staff involved with TB and WHO European Region TB policy advisors were invited to participate in a semi-structured interview. Twenty interviews were conducted (five with bloggers). Data analysis drew upon principles of grounded theory, with constant comparison of data, cases and categories, and attention to deviant cases. We found that the TB&Me blog was associated with identified health benefits, with no reported instances of harm. There were three main findings: blogging was reported as useful for adherence to DR-TB treatment and supportive of the treatment-taking process by all bloggers and project staff; blogging provided support to patients (peer support, shared experience and reduction in isolation); and the blog was perceived as giving patients strength and voice.

Conclusion

The TB&Me blog was seen to be associated with positive identified health and emotional benefits. Component 5 of the Stop TB Global Plan highlights the importance of empowering TB patients and communities. Blogging could be a useful tool to help achieve that ambition.     

HIV Self-Testing Could “Revolutionize Testing in South Africa,but It Has Got to Be Done Properly”: Perceptions of Key Stakeholders

South Africa bears the world’s largest burden of HIV with over 6.4 million people living with the virus. The South African government’s response to HIV has yielded remarkable results in recent years; over 13 million South Africans tested in a 2012 campaign and over 2 million people are on antiretroviral treatment. However, with an HIV & AIDS and STI National Strategic Plan aiming to get 80 percent of the population to know their HIV status by 2016, activists and public health policy makers argue that non-invasive HIV self-testing should be incorporated into the country HIV Counseling and Testing [HCT] portfolios. In-depth qualitative interviews (N = 12) with key stakeholders were conducted from June to July 2013 in South Africa. These included two government officials, four non-governmental stakeholders, two donors, three academic researchers, and one international stakeholder. All stakeholders were involved in HIV prevention and treatment and influenced HCT policy and research in South Africa and beyond. The interviews explored: interest in HIV self-testing; potential distribution channels for HIV self-tests to target groups; perception of requirements for diagnostic technologies that would be most amenable to HIV self-testing and opinions on barriers and opportunities for HIV-linkage to care after receiving positive test results. While there is currently no HIV self-testing policy in South Africa, and several barriers exist, participants in the study expressed enthusiasm and willingness for scale-up and urgent need for further research, planning, establishment of HIV Self-testing policy and programming to complement existing facility-based and community-based HIV testing systems. Introduction of HIV self-testing could have far-reaching positive effects on holistic HIV testing uptake, giving people autonomy to decide which approach they want to use for HIV testing, early diagnosis, treatment and care for HIV particularly among hard-to reach groups, including men.     

Me,Myself, and Semiotic Function: Finding the “I” in Biology

This essay argues that stable, heritable, habituated semiotics on one scale of life allows for opportunism, origination, and the solving of novel problems on others. This is grounded in how interpretation is neither caused nor determined by its object, such that success at interpretation simply cannot be defined by any comparison between an interpretation and its object. Rather, an interpretation is a reciprocated incorporation of a living thing and its environment, and successful if it furthers the living, interpreting thing. By applying biosemiotic theory to seemingly disparate studies of parasitic infections (Jaroslav Flegr), autonomic nervous systems (Stephen Porges), and social change (Charles Tilly) as well as the classical pragmatic notion that biology, psychology and sociology are disparate approaches to the singular, radically continuous, and perennial question of who (or what) am I (Dewey, James, Mead). I argue that the distinction (e.g.,) between voluntary and autonomic behavior is but a ghost of older dualisms, the pseudo-contradictions of matter v. mind, body v. soul, but also self v. not self. Moreover, all such pseudo-contradictions (individual v. social, sensation v. response, parasite v. host, and etc.) are resolved as scale thick, self-similar examples of semiotic transaction wherein degeneration or habituation on one scale of life allows for generative or novel interaction on another.     

“How Could I Live Here and Not Be a Member?”: Economic Versus Social Drivers of Participation in Namibian Conservation Programs

Economic goals form a critical component of community-based natural resource management (CBNRM) programs, but many studies question whether these initiatives actually deliver economic benefits to local communities. This presents a puzzle regarding why rural residents remain in CBNRM programs, and raises the possibility that non-economic incentives also influence participation. We address this question in a study of two Namibian communal conservancies, analyzing survey and interview data collected between 2009 and 2011. We find that economic incentives explain participation in one conservancy, whereas social motivations take precedence in the other. Our findings indicate that strong attachment to place and preferences for social cohesion can motivate people to comply with CBNRM even when economic incentives fail to materialize.     

“Just Get on with It”: Qualitative Insights of Coming to Terms with a Deteriorating Body for Older Women with Osteoarthritis

Objective

To qualify the psychosocial burden of osteoarthritis for older women and identify factors perceived to assist with psychological adjustment to the disease.

Methods

Women who indicated being diagnosed/treated for osteoarthritis in the previous three years in the fifth survey of the Australian Longitudinal Study on Women’s Health provided the sampling frame. Participants were randomly sampled until saturation was reached using a systematic process. Thematic content analysis was applied to the 19 semi-structured telephone interviews using a realist framework.

Results

The findings indicate that the emotional burden of osteoarthritis is considerable, and the process of psychological adjustment complex. Older women with osteoarthritis have psychological difficulties associated with increasing pain and functional impairment. Psychological adjustment over time was attributed primarily to cognitive and attitudinal factors (e.g. stoicism, making downward comparisons and possessing specific notions about the cause of arthritis). This was a dynamic ‘day to day’ process involving a constant struggle between grieving physical losses and increasing dependence amidst symptom management.

Conclusion

The findings of this study add to the current understanding of the complex processes involved in psychological adjustment over time. Targeted interventions focused on assisting women with arthritis redefine self-concepts outside the confines of caring responsibilities, coupled with public health education programs around understanding the destructive nature of arthritis are required. Understanding the destructive and (potentially) preventable nature of arthritis may facilitate early detection and increased uptake of appropriate treatment options for osteoarthritis that have the ability to modify disease trajectories.     

Cannibalism,Kuru, and Mad Cows: Prion Disease As a “Choose-Your-Own-Experiment” Case Study to Simulate Scientific Inquiry in Large Lectures

Despite significant efforts to reform undergraduate science education, students often perform worse on assessments of perceptions of science after introductory courses, demonstrating a need for new educational interventions to reverse this trend. To address this need, we created An Inexplicable Disease, an engaging, active-learning case study that is unusual because it aims to simulate scientific inquiry by allowing students to iteratively investigate the Kuru epidemic of 1957 in a choose-your-own-experiment format in large lectures. The case emphasizes the importance of specialization and communication in science and is broadly applicable to courses of any size and sub-discipline of the life sciences.