Barriers to Malaria Control among Marginalized Tribal Communities: A Qualitative Study

Background

Malaria infection accounts for over one million deaths worldwide annually. India has the highest number of malaria deaths outside Africa, with half among Indian tribal communities. Our study sought to identify barriers to malaria control within tribal populations in malaria-endemic Gadchiroli district, Maharashtra.

Methods and Findings

This qualitative study was conducted via focus groups and interviews with 84 participants, and included tribal villagers, traditional healers, community health workers (CHWs), medical officers, and district officials. Questions assessed knowledge about malaria, behavior during early stages of infection, and experiences with prevention among tribal villagers and traditional healers. CHWs, medical officers, and district officials were asked about barriers to treating and preventing malaria among tribal populations. Data were inductively analyzed and assembled into broader explanation linking barriers to geographical, cultural and social factors. Findings indicate lack of knowledge regarding malaria symptoms and transmission. Fever cases initially present to traditional healers or informal providers who have little knowledge of malaria or high-risk groups such as children and pregnant women. Tribal adherence with antimalarial medications is poor. Malaria prevention is inadequate, with low-density and inconsistent use of insecticide-treated nets (ITNs). Malaria educational materials are culturally inappropriate, relying on dominant language literacy. Remote villages and lack of transport complicate surveillance by CHWs. Costs of treating malaria outside the village are high.

Conclusions

Geographic, cultural, and social factors create barriers to malaria control among tribal communities in India. Efforts to decrease malaria burden among these populations must consider such realities. Our results suggest improving community-level knowledge about malaria using culturally-appropriate health education materials; making traditional healers partners in malaria control; promoting within-village rapid diagnosis and treatment; increasing ITN distribution and promoting their use as potential strategies to decrease infection rates in these communities. These insights may be used to shape malaria control programs among marginalized populations.     

Identifying Factors to Improve Oral Cancer Screening Uptake: A Qualitative Study

Aims

To engage with high risk groups to identify knowledge and awareness of oral cancer signs and symptoms and the factors likely to contribute to improved screening uptake.

Methods

Focus group discussions were undertaken with 18 males; 40+ years of age; smokers and/or drinkers (15+ cigarettes per day and/or 15+ units of alcohol per week), irregular dental attenders living in economically deprived areas of Teesside.

Results

There was a striking reported lack of knowledge and awareness of oral cancer and its signs and symptoms among the participants. When oral/mouth cancer leaflets produced by Cancer Research UK were presented to the participants, they claimed that they would seek help on noticing such a condition. There was a preference to seek help from their general practitioner rather than their dentist due to perceptions that a dentist is ‘inaccessible’ on a physical and psychological level, costly, a ‘tooth specialist’ not a ‘mouth specialist’, and also not able to prescribe medication and make referrals to specialists. Interestingly, none of the 18 participants who were offered a free oral cancer examination at a dental practice took up this offer.

Conclusions

The uptake of oral cancer screening may be improved by increasing knowledge of the existence and signs and symptoms of oral cancer. Other factors that may increase uptake are increased awareness of the role of dentists in diagnosing oral cancer, promotion of oral cancer screening by health professionals during routine health checks, and the use of a “health” screening setting as opposed to a “dental” setting for such checks.     

Socio-Psychological Factors Driving Adult Vaccination: A Qualitative Study

BackgroundWhile immunization is one of the most effective and successful public health interventions, there are still up to 30,000 deaths in major developed economies each year due to vaccine-preventable diseases, almost all in adults. In the UK, despite comparatively high vaccination rates among ≧65 s (73%) and, to a lesser extent, at-risk ≤65 s (52%) in 2013/2014, over 10,000 excess deaths were reported the previous influenza season. Adult tetanus vaccines are not routinely recommended in the UK, but may be overly administered. Social influences and risk-perceptions of diseases and vaccines are known to affect vaccine uptake. We aimed to explore the socio-psychological factors that drive adult vaccination in the UK, specifically influenza and tetanus, and to evaluate whether these factors are comparable between vaccines.Methods20 in-depth, face-to-face interviews were conducted with members of the UK public who represented a range of socio-demographic characteristics associated with vaccination uptake. We employed qualitative interviewing approaches to reach a comprehensive understanding of the factors influencing adult vaccination decisions. Thematic analysis was used to analyze the data.ResultsParticipants were classified according to their vaccination status as regular, intermittent and non-vaccinators for influenza, and preventative, injury-led, mixed (both preventative and injury-led) and as non-vaccinators for tetanus. We present our finding around five overarching themes: 1) perceived health and health behaviors; 2) knowledge; 3) vaccination influences; 4) disease appraisal; and 5) vaccination appraisal.ConclusionThe uptake of influenza and tetanus vaccines was largely driven by participants'' risk perception of these diseases. The tetanus vaccine is perceived as safe and sufficiently tested, whereas the changing composition of the influenza vaccine is a cause of uncertainty and distrust. To maximize the public health impact of adult vaccines, policy should be better translated into high vaccination rates through evidence-based implementation approaches.     

Multiple Interacting Factors Influence Adherence,and Outcomes Associated with Surgical Safety Checklists: A Qualitative Study

Objectives

The surgical safety checklist (SSC) is meant to enhance patient safety but studies of its impact conflict. This study explored factors that influenced SSC adherence to suggest how its impact could be optimized.

Methods

Participants were recruited purposively by profession, region, hospital type and time using the SSC. They were asked to describe how the SSC was adopted, associated challenges, perceived impact, and suggestions for improving its use. Grounded theory and thematic analysis were used to collect and analyse data. Findings were interpreted using an implementation fidelity conceptual framework.

Results

Fifty-one participants were interviewed (29 nurses, 13 surgeons, 9 anaesthetists; 18 small, 14 large and 19 teaching hospitals; 8 regions; 31 had used the SC for ≤12 months, 20 for 13+ months). The SSC was inconsistently reviewed, and often inaccurately documented as complete. Adherence was influenced by multiple issues. Extensive modification to accommodate existing practice patterns eliminated essential interaction at key time points to discuss patient management. Staff were often absent or not paying attention. They did not feel it was relevant to their work given limited evidence of its effectiveness, and because they were not engaged in its implementation. Organizations provided little support for implementation, training, monitoring and feedback, which are needed to overcome these, and other individual and team factors that challenged SSC adherence. Responses were similar across participants with different characteristics.

Conclusions

Multiple processes and factors influenced SSC adherence. This may explain why, in studies evaluating SSC impact, outcomes were variable. Recommendations included continuing education, time for pilot-testing, and engaging all staff in SSC review. Others may use the implementation fidelity framework to plan SSC implementation or evaluate SSC adherence. Further research is needed to establish which SSC components can be modified without compromising its effectiveness.     

Critical Environmental Factors for Transportation Cycling in Children: A Qualitative Study Using Bike-Along Interviews

Background

Environmental factors are found to influence transport-related physical activity, but have rarely been studied in relation with cycling for transport to various destinations in 10–12 yr old children. The current qualitative study used ‘bike-along interviews’ with children and parents to allow discussion of detailed environmental factors that may influence children''s cycling for transport, while cycling in the participant''s neighborhood.

Methods

Purposeful convenience sampling was used to recruit 35 children and one of their parents residing in (semi-) urban areas. Bike-along interviews were conducted to and from a randomly chosen destination (e.g. library) within a 15 minutes'' cycle trip in the participant''s neighborhood. Participants wore a GoPro camera to objectively assess environmental elements, which were subsequently discussed with participants. Content analysis and arising themes were derived using a grounded theory approach.

Results

The discussed environmental factors were categorized under traffic, urban design, cycling facilities, road design, facilities at destination, aesthetics, topography, weather, social control, stranger danger and familiar environment. Across these categories many environmental factors were (in)directly linked to road safety. This was illustrated by detailed discussions of the children''s visibility, familiarity with specific traffic situations, and degree of separation, width and legibility of cycle facilities.

Conclusion

Road safety is of major concern in this 10–12 yr old study population. Bike-along interviews were able to identify new, detailed and context-specific physical environmental factors which could inform policy makers to promote children''s cycling for transport. However, future studies should investigate whether hypothetical changes to such micro environmental features influence perceptions of safety and if this in turn could lead to changes in children''s cycling for transport.     

Why People Do,or Do Not,Immediately Contact Emergency Medical Services following the Onset of Acute Stroke: Qualitative Interview Study

Objectives

To identify the reasons why individuals contact, or delay contacting, emergency medical services in response to stroke symptoms.

Design

Qualitative interview study with a purposive sample of stroke patients and witnesses, selected according to method of accessing medical care and the time taken to do so. Data were analysed using the Framework approach.

Setting

Area covered by three acute stroke units in the north east of England.

Participants

Nineteen stroke patients and 26 witnesses who had called for help following the onset of stroke symptoms.

Results

Factors influencing who called emergency medical services and when they called included stroke severity, how people made sense of symptoms and their level of motivation to seek help. Fear of the consequences of stroke, including future dependence or disruption to family life, previous negative experience of hospitals, or involving a friend or relations in the decision to access medical services, all resulted in delayed admission. Lack of knowledge of stroke symptoms was also an important determinant. Perceptions of the remit of medical services were a major cause of delays in admission, with many people believing the most appropriate action was to telephone their GP. Variations in the response of primary care teams to acute stroke symptoms were also evident.

Conclusions

The factors influencing help-seeking decisions are complex. There remains a need to improve recognition by patients, witnesses and health care staff of the need to treat stroke as a medical emergency by calling emergency medical services, as well as increasing knowledge of symptoms of stroke among patients and potential witnesses. Fear, denial and reticence to impose on others hinders the process of seeking help and will need addressing specifically with appropriate interventions. Variability in how primary care services respond to stroke needs further investigation to inform interventions to promote best practice.

Trial Registration

UK Clinical Research Network UKCRN 6590     

Access to Tuberculosis Services for Individuals with Disability in Rural Malawi,a Qualitative Study

Tuberculosis occurs in all populations, but with higher prevalence in poor contexts. Vulnerable groups, including individuals with disability, run a particular risk due to poorer access to information and health services. Studying access to tuberculosis services for vulnerable groups in poor contexts may provide useful insight into the quality of such services in low-income contexts. This article aims to present a contextual understanding of access to tuberculosis services for people with disabilities in one district in southern Malawi. A qualitative method with semi-structured interviews and site observations was applied. In all, 89 participants were interviewed: 47 persons with disability, 11 parents/guardians of youths with disability, and the remaining 31 comprising eight health workers, four community rehabilitation assistants and volunteers, and 19 leaders in the community.Our main findings are that lack of information and knowledge, and considerable confusion related to tuberculosis, its cause and how to protect oneself, are major barrier to accessing services. Disease awareness and personal risk perception are key factors in this regard. Further findings concerns the pathways to tuberculosis related health services, in particular having a test and completing the treatment. The combination of lack of knowledge and barriers in accessing tests implies substantial availability and access problems.It is of importance to understand the combined impact of individual, social, contextual, and systems barriers to fully address the complexity of accessing tuberculosis services for vulnerable groups in poor populations. Lack of disability specific strategies in the local health services may be part of the reason why individuals with disability to not access such services.     

A Qualitative Study of Environmental Factors Important for Physical Activity in Rural Adults

Purpose

Despite increasing evidence that the physical environment impacts on physical activity among urban-dwellers, little attention has been devoted to understanding this relationship in rural populations. Work in this area is further hindered by a lack of environmental measures specifically designed for rural settings. This qualitative study aimed to explore the salience of urban physical activity environment constructs among rural adults.

Methods

In 2011, 49 rural men and women from three distinct areas (coastal, animal-based farming, forestry/plant-based farming) of rural Tasmania, Australia, were purposively recruited to participate in semi-structured interviews. Interviews explored features of the built and social environment commonly examined in studies of urban adults, including functional characteristics (eg, lighting, footpaths, roads/verges), road and personal safety, availability and accessibility of places to be active, destinations, and aesthetics. Interviews were recorded, transcribed verbatim and analysed using a content-thematic approach using QSR NVivo software.

Findings

While some urban environmental constructs were salient to these rural adults, such as availability of and accessibility to places to be active, some constructs were operationalised differently, such as road safety (where large trucks and winding roads rather than traffic density was of concern), or were not considered relevant (eg, personal safety related to crime, availability of walkable destinations, aesthetics).

Conclusions

The measurement of the physical environment in rural populations may require reconsideration and/or modification to ensure salience and appropriate quantification of associations with physical activity in future studies.     

Poultry Slaughtering Practices in Rural Communities of Bangladesh and Risk of Avian Influenza Transmission: A Qualitative Study

Slaughtering sick poultry is a risk factor for human infection with highly pathogenic avian influenza and is a common practice in Bangladesh. This paper describes human exposures to poultry during slaughtering process and the customs and rituals influencing these practices in two Bangladeshi rural communities. In 2009, we conducted 30 observations to observe slaughtering practices and 110 in-depth and short interviews and 36 group discussions to explore reasons behind those practices. The villagers reported slaughtering 103 poultry, including 20 sick poultry during 2 months. During different stages of slaughtering, humans, the environment, healthy poultry, and other animals were exposed to poultry blood and body parts. Women performed most of the slaughtering tasks, including evisceration. Defeathering required the most time and involved several persons. During festivals, ceremonies, and rituals, many people gathered and participated in the slaughtering of poultry. Exposure to poultry slaughtering created numerous opportunities for potential avian influenza transmission. Strategies that can be further tested to determine if they reduce the risk of transmission include skinning the carcasses of sick poultry, using hot water for defeathering and cleaning, using a bucket to contain slaughtering blood and carcass, burying the offal and encouraging handwashing.     

Spatial Access to Emergency Services in Low- and Middle-Income Countries: A GIS-Based Analysis

Injury is a leading cause of the global disease burden, accounting for 10 percent of all deaths worldwide. Despite 90 percent of these deaths occurring in low and middle-income countries (LMICs), the majority of trauma research and infrastructure development has taken place in high-income settings. Furthermore, although accessible services are of central importance to a mature trauma system, there remains a paucity of literature describing the spatial accessibility of emergency services in LMICs. Using data from the Service Provision Assessment component of the Demographic and Health Surveys of Namibia and Haiti we defined the capabilities of healthcare facilities in each country in terms of their preparedness to provide emergency services. A Geographic Information System-based network analysis method was used to define 5- 10- and 50-kilometer catchment areas for all facilities capable of providing 24-hour care, higher-level resuscitative services or tertiary care. The proportion of a country’s population with access to each level of service was obtained by amalgamating the catchment areas with a population layer. A significant proportion of the population of both countries had poor spatial access to lower level services with 25% of the population of Haiti and 51% of the population of Namibia living further than 50 kilometers from a facility capable of providing 24-hour care. Spatial access to tertiary care was considerably lower with 51% of Haitians and 72% of Namibians having no access to these higher-level services within 50 kilometers. These results demonstrate a significant disparity in potential spatial access to emergency services in two LMICs compared to analogous estimates from high-income settings, and suggest that strengthening the capabilities of existing facilities may improve the equity of emergency services in these countries. Routine collection of georeferenced patient and facility data in LMICs will be important to understanding how spatial access to services influences outcomes.     

Hospital Emergency Services for Children and Adolescents: A One-Year Review at the Vancouver General Hospital

The records of visits of children and adolescents to the emergency department of the Vancouver General Hospital were reviewed during the period July 1, 1965, to June 30, 1966, and the diagnostic and disposal data recorded. One-quarter of all visits were made by children and adolescents. Three-quarters of the visits were made for surgical conditions. There were more males than females in both surgical and medical groups, and the peaks in attendance were of those in the early preschool and late adolescent age groups. Three-quarters of the patients were referred to the family doctor and approximately one-sixth were admitted to the hospital. These findings suggested that while prompt medical attention was usually indicated, the majority of problems were not urgent and that the emergency department was becoming a substitute for the office of the family physician.     

Making and Maintaining Lifestyle Changes with the Support of a Lay Health Advisor: Longitudinal Qualitative Study of Health Trainer Services in Northern England

Objective

To explore and document the experiences of those receiving support from a lay health trainer, in order to inform the optimisation and evaluation of such interventions.

Design

Longitudinal qualitative study with up to four serial interviews conducted over 12 months. Interviews were transcribed and analysed using the constant comparative approach associated with grounded theory.

Participants

13 health trainers, 5 managers and 26 clients.

Setting

Three health trainer services targeting disadvantaged communities in northern England.

Results

The final dataset comprised 116 interviews (88 with clients and 28 with staff). Discussions with health trainers and managers revealed a high degree of heterogeneity between the local services in terms of their primary aims and activities. However, these were found to converge over time. There was agreement that health trainer interventions are generally ‘person-centred’ in terms of being tailored to the needs of individual clients. This led to a range of self-reported outcomes, including behaviour changes, physical health improvements and increased social activity. Factors impacting on the maintenance of lifestyle changes included the cost and timing of health-promoting activities, ill-health or low mood. Participants perceived a need for ongoing access to low cost facilities to ensure that any lifestyle changes can be maintained in the longer term.

Conclusions

Health trainers may be successful in terms of supporting people from socio-economically disadvantaged communities to make positive lifestyle changes, as well as achieving other health-related outcomes. This is not a ‘one-size-fits-all’ approach; commissioners and providers should select the intervention models that best meet the needs of their local populations. By delivering holistic interventions that address multiple lifestyle risks and incorporate relapse prevention strategies, health trainers could potentially have a significant impact on health inequalities. However, rigorous, formal outcome and economic evaluation of the range of health trainer delivery models is needed.     

Factors Likely to Affect Community Acceptance of a Malaria Vaccine in Two Districts of Ghana: A Qualitative Study

Malaria is a leading cause of morbidity and mortality among children in Ghana. As part of the effort to inform local and national decision-making in preparation for possible malaria vaccine introduction, this qualitative study explored community-level factors that could affect vaccine acceptance in Ghana and provides recommendations for a health communications strategy. The study was conducted in two purposively selected districts: the Ashanti and Upper East Regions. A total of 25 focus group discussions, 107 in-depth interviews, and 21 semi-structured observations at Child Welfare Clinics were conducted. Malaria was acknowledged to be one of the most common health problems among children. While mosquitoes were linked to the cause and bed nets were considered to be the main preventive method, participants acknowledged that no single measure prevented malaria. The communities highly valued vaccines and cited vaccination as the main motivation for taking children to Child Welfare Clinics. Nevertheless, knowledge of specific vaccines and what they do was limited. While communities accepted the idea of minor vaccine side effects, other side effects perceived to be more serious could deter families from taking children for vaccination, especially during vaccination campaigns. Attendance at Child Welfare Clinics after age nine months was limited. Observations at clinics revealed that while two different opportunities for counseling were offered, little attention was given to addressing mothers’ specific concerns and to answering questions related to child immunization. Positive community attitudes toward vaccines and the understanding that malaria prevention requires a comprehensive approach would support the introduction of a malaria vaccine. These attitudes are bolstered by a well-established child welfare program and the availability in Ghana of active, flexible structures for conveying health information to communities. At the same time, it would be important to improve the quality of Child Welfare Clinic services, particularly in relation to communication around vaccination.     

Barriers to Implementing the DSM-5 Cultural Formulation Interview: A Qualitative Study

The Outline for Cultural Formulation (OCF) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) marked an attempt to apply anthropological concepts within psychiatry. The OCF has been criticized for not providing guidelines to clinicians. The DSM-5 Cultural Issues Subgroup has since converted the OCF into the Cultural Formulation Interview (CFI) for use by any clinician with any patient in any clinical setting. This paper presents perceived barriers to CFI implementation in clinical practice reported by patients (n = 32) and clinicians (n = 7) at the New York site within the DSM-5 international field trial. We used an implementation fidelity paradigm to code debriefing interviews after each CFI session through deductive content analysis. The most frequent patient threats were lack of differentiation from other treatments, lack of buy-in, ambiguity of design, over-standardization of the CFI, and severity of illness. The most frequent clinician threats were lack of conceptual relevance between intervention and problem, drift from the format, repetition, severity of patient illness, and lack of clinician buy-in. The Subgroup has revised the CFI based on these barriers for final publication in DSM-5. Our findings expand knowledge on the cultural formulation by reporting the CFI’s reception among patients and clinicians.     

A Metabolomic Approach to Study Major Metabolite Changes during Acclimation to Limiting CO2 in Chlamydomonas reinhardtii

Using a gas chromatography-mass spectrometry-time of flight technique, we determined major metabolite changes during induction of the carbon-concentrating mechanism in the unicellular green alga Chlamydomonas reinhardtii. In total, 128 metabolites with significant differences between high- and low-CO₂-grown cells were detected, of which 82 were wholly or partially identified, including amino acids, lipids, and carbohydrates. In a 24-h time course experiment, we show that the amino acids serine and phenylalanine increase transiently while aspartate and glutamate decrease after transfer to low CO₂. The biggest differences were typically observed 3 h after transfer to low-CO₂ conditions. Therefore, we made a careful metabolomic examination at the 3-h time point, comparing low-CO₂ treatment to high-CO₂ control. Five metabolites involved in photorespiration, 11 amino acids, and one lipid were increased, while six amino acids and, interestingly, 21 lipids were significantly lower. Our conclusion is that the metabolic pattern during early induction of the carbon-concentrating mechanism fit a model where photorespiration is increasing.Most microalgae express a carbon-concentrating mechanism (CCM; Raven et al., 2005). The green alga Chlamydomonas reinhardtii is one of the species with a CCM (Giordano et al., 2005). The CCM in C. reinhardtii is typically induced when the concentration of CO₂ in the air bubbled through the cultures is decreased to around 0.5% or lower (Vance and Spalding, 2005). Within the first few hours after starting the induction, numerous genes are either up- or down-regulated (Miura et al., 2004; Yamano et al., 2008; Yamano and Fukuzawa, 2009). However, the change in gene expression is only manifested as rather limited detectable changes in the abundance of proteins (Manuel and Moroney, 1988; Spalding and Jeffrey, 1989). Even though the response to decreased concentrations of inorganic carbon (C_i) is fast (Eriksson et al., 1998), the algal cells go through a transient phase before the CCM is fully operational.Many genes coding for enzymes of the photorespiratory pathway are up-regulated (Marek and Spalding, 1991; Miura et al., 2002, 2004) within 20 min and show a transient expression pattern (Tural and Moroney, 2005; Yamano et al., 2008). A decline in starch content is also detectable within 30 min after transfer to low CO₂ (Kuchitsu et al., 1988). This decline in starch is followed, after about 2 h, by a net synthesis of starch (Thyssen et al., 2001) that is mainly deposited around the pyrenoid, rather than as the starch grains distributed in the stroma normally found in high-CO₂-grown cells. When the CCM is fully induced, the alga can concentrate C_i inside the cell/chloroplast against a free-energy gradient. Accumulation of C_i increases the CO₂-oxygen ratio at the site of Rubisco (Giordano et al., 2005), with a corresponding increase in photosynthesis, a decrease in photorespiration, and a greater capacity for net organic carbon production at low external C_i (Giordano et al., 2003).Induction of the CCM is thus known to affect genes of many different pathways, and especially the photorespiratory pathway has been studied extensively (Moroney et al., 1986; Tural and Moroney, 2005). The aim of this work was to screen for metabolic changes in order to find key metabolites that could trigger the expression of genes that regulate the CCM. We have extended the analyses by using metabolomics to detect changes in major metabolites, particularly in the beginning of the induction period but also in preliminary experiments, over a 24-h time period. The resulting metabolic changes have enabled us to propose a working model for the coordinated regulation of cellular metabolism during the induction of the CCM in C. reinhardtii.     

A Metagenomic Framework for the Study of Airborne Microbial Communities

Understanding the microbial content of the air has important scientific, health, and economic implications. While studies have primarily characterized the taxonomic content of air samples by sequencing the 16S or 18S ribosomal RNA gene, direct analysis of the genomic content of airborne microorganisms has not been possible due to the extremely low density of biological material in airborne environments. We developed sampling and amplification methods to enable adequate DNA recovery to allow metagenomic profiling of air samples collected from indoor and outdoor environments. Air samples were collected from a large urban building, a medical center, a house, and a pier. Analyses of metagenomic data generated from these samples reveal airborne communities with a high degree of diversity and different genera abundance profiles. The identities of many of the taxonomic groups and protein families also allows for the identification of the likely sources of the sampled airborne bacteria.     

Chronological Changes in Japanese Physicians' Attitude and Behavior Concerning Relationships with Pharmaceutical Representatives: A Qualitative Study

Background

Recent qualitative studies indicated that physicians interact with pharmaceutical representatives depending on the relative weight of the benefits to the risks and are also influenced by a variety of experiences and circumstances. However, these studies do not provide enough information about if, when, how and why their attitudes and behaviors change over time.

Methods and Findings

A qualitative study using semi-structured face-to-face individual interviews was conducted on 9 Japanese physicians who attended a symposium on conflicts of interest held in Tokyo. Interviews were designed to explore chronological changes in individual physicians'' attitude and behavior concerning relationships with pharmaceutical representatives and factors affecting such changes. Their early interaction with pharmaceutical representatives was passive as physicians were not explicitly aware of the meaning of such interaction. They began to think on their own about how to interact with pharmaceutical representatives as they progressed in their careers. Their attitude toward pharmaceutical representatives changed over time. Factors affecting attitudinal change included work environment (local regulations and job position), role models, views of patients and the public, acquisition of skills in information seeking and evidence-based medicine, and learning about the concepts of professionalism and conflict of interest. However, the change in attitude was not necessarily followed by behavioral change, apparently due to rationalization and conformity to social norms.

Conclusions

Physicians'' attitudes toward relationships with pharmaceutical representatives changed over time and factors affecting such changes were various. Paying attention to these factors and creating new social norms may be both necessary to produce change in behavior consistent with change in attitude.