The experience of emotional distress among women with scleroderma

Emotional distress is common among patients with chronic medical illnesses, but the nature of the distress is not well understood. Our objective was to understand patients' experiences of emotional distress by conducting in-depth interviews using the McGill Illness Narrative Interview with women affected by scleroderma (N = 16). We sought to determine how participants described their distress, what they believed caused it, and how they coped. We analyzed interview transcripts using thematic analysis. Many participants described distress associated with scleroderma, but the term depression was reserved for extraordinary, severe experiences. Instead, participants preferred more normal mood descriptors and often viewed their distress in keeping with the definition of "demoralization." Participants listed concrete symptoms and experiences that caused distress, and some added that stress could exacerbate scleroderma. Participants dealt with distress by not dwelling on their circumstances and working to maintain autonomy. Most preferred to not rely on psychologists and support groups.

Barriers, facilitators, and recommendations related to implementing the Baby-Friendly Initiative (BFI): an integrative review

Despite growing evidence for the positive impact of the Baby-Friendly Initiative (BFI) on breastfeeding outcomes, few studies have investigated the barriers and facilitators to the implementation of Baby-Friendly practices that can be used to improve uptake of the BFI at the local or country levels. This integrative review aimed to identify and synthesize information on the barriers, facilitators, and recommendations related to the BFI from the international, peer-reviewed literature. Thirteen databases were searched using the keywords Baby Friendly, Baby-Friendly Hospital Initiative, BFI, BFHI, Ten Steps, implementation, adoption, barriers, facilitators, and their combinations. A total of 45 English-language articles from 16 different countries met the inclusion criteria for the review. Data analysis was guided by Cooper's five stages of integrative research review. Using a multiple intervention program framework, findings were categorized into sociopolitical, organizational-level, and individual-level barriers and facilitators to implementing the BFI, as well as intra-, inter-, and extraorganizational recommendations for strengthening BFI implementation. A wide variety of obstacles and potential solutions to BFI implementation were identified. Findings suggest some priority issues to address when pursuing Baby-Friendly designation, including the endorsements of both local administrators and governmental policy makers, effective leadership of the practice change process, health care worker training, the marketing influence of formula companies, and integrating hospital and community health services. Framing the BFI as a complex, multilevel, evidence-based change process and using context-focused research implementation models to guide BFI implementation efforts may help identify effective strategies for promoting wider adoption of the BFI in health services.

Using the cultural formulation to resolve uncertainty in diagnoses of psychosis among ethnoculturally diverse patients

OBJECTIVE

The aim of the study was to assess the impact of systematic use of the DSM-IV-TR cultural formulation on diagnoses of psychotic disorders among patients of ethnic minority and immigrant backgrounds referred to a cultural consultation service (CCS) in Canada.

METHODS

The study entailed a review of medical records and case conference transcripts of 323 patients seen in a ten-year period at the CCS to determine factors associated with change in the diagnosis of psychotic disorders by the CCS. Logistic regression analysis was used to identify variables associated with changes in diagnosis.

RESULTS

A total of 34 (49%) of the 70 cases with an intake (referral) diagnosis of a psychotic disorder were rediagnosed as nonpsychotic disorders, whereas only 12 (5%) of the 253 cases with an intake diagnosis of a nonpsychotic disorder were rediagnosed as a psychotic disorder (p<.001). Major depression, posttraumatic stress disorder (PTSD), adjustment disorder, and bipolar affective disorder were the common disorders diagnosed with use of the cultural formulation. Rediagnosis of a psychotic disorder as a nonpsychotic disorder was significantly associated with being a recent arrival in Canada (odds ratio [OR]=6.05, 95% confidence interval [CI]=1.56-23.46, p=.009), being nonblack (OR=3.72, CI=1.03-13.41, p=.045), and being referred to the CCS by nonmedical routes (such as social work or occupational therapy) (OR=3.23, CI=1.03-10.13, p=.044).

CONCLUSIONS

Misdiagnosis of psychotic disorders occurred with patients of all ethnocultural backgrounds. PTSD and adjustment disorder were misidentified as psychosis among immigrants and refugees from South Asia. Studies are needed that compare clinical outcomes of use of cultural consultation with outcomes from use of other cultural competence models.

Embodying 'health citizenship' in health knowledge to fight health inequalities

This paper wishes to contribute to the debate around citizen participation in health system decision-making that has been present internationally for the last 30 years. I argue that if we aim to change health inequalities, health professionals and planners need to understand the illness and health service experience of citizens. The concept of 'health citizenship' introduced here refers to health knowledge that integrates the lay knowledge of patients and that this integration is translated into health actions such as clinical communication and the planning of health care, programs, and policy. We illustrate our argument with the two cases: health literacy and the promotion of breastfeeding in a Canadian population living in context of poverty. This paper then concludes by addressing the leadership role, Brazilian graduate nursing schools can play in promoting 'health citizenship' and by doing so, contribute to fight health inequalities.

Shared decision-making in palliative care: a systematic mixed studies review using narrative synthesis

The aim of this study is to synthesize knowledge about the process of shared decision-making (SDM) in palliative care. Medline, EMBASE, CINAHL, PsychInfo, Web of Science were searched with core concepts: shared decisions, patient participation in decision-making, and palliative care. Titles and abstracts were screened according to inclusion criteria (original research, adult patients, Western contexts, decision-making, palliative treatment or setting), yielding 37 articles for analysis. A narrative synthesis was created using the methods of thematic analysis, conceptual mapping, and critical reflection on the synthesis process. Results demonstrate that while a majority of patients want to participate in treatment decisions to some extent, most do not achieve their preferred levels of involvement because decisions are delayed and alternative treatment options are seldom discussed. The literature regarding the process of SDM itself remains scarce in palliative care. Further research is needed in order to better understand the longitudinal, interactive, and interdisciplinary process of decision-making in palliative care.

Patients diagnosed with nonepileptic seizures: their perspectives and experiences

The objective of this qualitative study was to examine how patients with nonepileptic seizures (NES) make sense of their illness experience in light of the many obstacles they may face when seeking treatment. We conducted semistructured interviews with five patients with NES to explore their illness perspectives and different modes of reasoning in regard to their illness and treatment experiences. The data were examined using thematic content analysis. The participants who implicitly incorporated epilepsy as an illness prototype demonstrated less effective treatment expectations and imposed greater life constraints on themselves than the participant who used anxiety attacks. The participants who defined an explanatory model with a psychosocial basis for illness onset were receptive and demanding of psychotherapeutic intervention. Emergent themes included accounts of adverse and positively perceived life events coinciding with illness onset, head injury, presence of caregivers during events, comorbid illness, and previously witnessing epilepsy in others.

Spiritual reconfigurations of self after a myocardial infarction: Influence of culture and place

This study explored illness narratives following a myocardial infarction (MI) in French Canadians. Qualitative interviews were completed using the McGill Illness Narrative Interview with 51 patients following a first MI. Content analysis of interviews suggested that the heart was perceived as a receptacle that contained an accumulation of life's ordeals, negative emotions and family traumas. This resulted in perceived heart strain, which was considered a direct cause of the MI. References to spirituality were central to the patients' narratives and were identified as instrumental in post-MI recovery. Results illustrate how place and culture interact to shape illness experience and recovery trajectories after a life-threatening health event.

Therapeutic processes and perceived helpfulness of dang-ki (Chinese shamanism) from the symbolic healing perspective

This study focuses on the therapeutic process and perceived helpfulness of dang-ki, a form of Chinese shamanistic healing, in Singapore. It aims to understand the healing symbols employed in dang-ki, whether or not patients find them helpful and whether their perceived helpfulness can be explained by the symbolic healing model (Dow, Am Anthropol 88(1):56-69, 1986; Levi-Strauss, Structural anthropology. Basic Books, New York, 1963). Although many researchers have applied this model to explain the efficacy of shamanistic healings, they did not directly provide empirical support. Furthermore, the therapeutic process of a shared clinical reality as proposed by the model may be achievable in small-scale traditional societies that are culturally more homogeneous than in contemporary societies that are culturally more diversified due to globalization and immigration. Patients may hold multidimensional health belief systems, as biomedicine and alternative healing systems coexist. Thus, it would be interesting to see the relevance and applicability of the symbolic healing model to shamanistic healing in contemporary societies. In this study, ethnographic interviews were conducted with 21 patients over three stages: immediately before and after the healing and approximately 1 month later. The dang-ki healing symbols were identified by observing the healing sessions with video recording. Results show that dang-kis normally applied more than one method to treat a given problem. These methods included words, talismans and physical manipulations. Overall, 11 patients perceived their consultations as helpful, 4 perceived their consultations as helpful but were unable to follow all recommendations, 5 were not sure of the outcome because they had yet to see any concrete results and only 1 patient considered his consultation unhelpful. Although the symbolic healing model provides a useful framework to understand perceived helpfulness, processes such as enactment of a common meaning system and symbolic transformation are complex and dynamic, and may be carried over several healing sessions.

Breastfeeding practices after Kangaroo Mother Method in Rio de Janeiro: the necessity for he alth education and nursing intervention at homea

IThe "teaching-leaning" is part of the Brazilian Kangaroo Mother Method with the objective of increasing skills of mother's breastfeeding infants with special health needs. Nevertheless, we do not know if this knowledge was embodied in the family inner circle, so we aimed at identifying and analyzing how this medical knowledge was incorporated in the context of infants' homes. Participatory research was developed at home with eleven groups of mother, family members and neighbors. Local knowledge of neighbors' and family members' replaced the medical knowledge and changed infant feeding practices. Health education should be implemented beyond hospital and include family members.

Cost-effectiveness of insulin detemir compared to NPH insulin for type 1 and type 2 diabetes mellitus in the Canadian payer setting: modeling analysis

OBJECTIVE

This study was conducted to quantify the long-term cost-effectiveness of insulin detemir (Levemir) versus intermediate-acting neutral protamine Hagedorn (NPH) insulin for the treatment of type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in Canada, and to assess the sensitivity of results to dis-utilities for hypoglycemic events. dagger Levemir is a trade name of Novo Nordisk, Princeton, NJ, USA RESEARCH DESIGN AND METHODS: The web-based IMS-CORE diabetes model has a menu-driven interface programmed in hypertext markup language (HTML). It was used to project lifetime (60 years for T1DM and 35 years for T2DM) clinical and economic outcomes for patients on detemir vs. NPH. Cohort characteristics, utilities, and costs were derived from published literature. For T1DM, clinical trial data for HbA(1c) improvement (detemir -0.94% +/- 1.07; NPH -0.82% +/- 1.01) from baseline, and rates of hypoglycemic events (major events: 0.20 vs. 0.80 per patient-year for detemir vs. NPH, respectively) were modeled. For T2DM, observational study data for HbA(1c) improvement (detemir -0.18%) from baseline, and reductions in hypoglycemic events (major events: 0.0995 vs. 1.33 per patient-year for detemir vs. NPH, respectively) were modeled. Base-case hypoglycemia dis-utilities were -0.0118 for major and -0.0035 for minor events. Sensitivity analyses were conducted on discount rate and hypoglycemia dis-utility.

OUTCOME MEASURES

Outcomes included costs of treatment/management and costs (and incidence) of diabetes-related complications. Incremental cost-effectiveness ratios (ICERs) were calculated from differences in total costs and quality-adjusted life-years (QALYs).

RESULTS

Average total costs for T1DM were $CAN 83 622 +/- 4585 for detemir and $CAN 72 016 +/- 4593 for NPH. QALYs increased by 0.475 years with detemir, with an ICER of $CAN 24 389/QALY. Average direct costs for T2DM were $CAN 74 919 +/- 6391 (detemir) and $CAN 69 230 +/- 6840 (NPH). QALYs increased by 0.305 years. The ICER was $CAN 18 677. Although detemir was associated with slightly lower costs for most complications, results were driven by the differences in rates and costs for hypoglycemic events, and their assumed dis-utility. Study limitations include the use of single trials for clinical assumptions and the lack of analyses for patient risk sub-groups.

CONCLUSIONS

Findings provide evidence for the cost-effectiveness of detemir vs. NPH in treating T1 and T2DM in Canada, and support the key role of assumptions regarding the impact of hypoglycemic events. Additional work is needed to determine the extent to which results are robust for different sub-groups of patients and for variation in assumptions around HbA(1c) improvements and hypoglycemic event rates.

Reconfiguring insufficient breast milk as a sociosomatic problem: mothers of premature babies using the kangaroo method in Brazil

This study focuses on Brazilian mothers who gave birth to premature babies who were discharged from hospital using the Kangaroo Mother Care Method. While mothers left the hospital breastfeeding exclusively, once back at home, they abandoned exclusive breastfeeding because of insufficient breast milk (IBM). In this project we explored how IBM was interpreted by mothers within their social context. Participatory research using the Creative Sensitive Method was done in the homes of mothers with family members and neighbours. We described the conflicting social discourse that influenced the mothers' perception of IBM and explored their sources of distress. At the hospital and Kangaroo ward, mothers considered that clinicians recognized they were experiencing IBM and thus supported them to overcome this problem. Back at home and in their community, other sources of stress generated anxiety such as: the lack of outpatient clinical support, and conflicting local norms to care and feed premature babies. These difficulties combined with economic constraints and discontinuity in models of health care led mothers to lose confidence in their breastfeeding capacity. Mothers, thus, rapidly replaced exclusive breastfeeding by mixed feeding or formula feeding. Our analysis suggests that IBM in our sample was the result of a socio-somatic process. Recommendations are proposed to help overcome IBM and corresponding contextual barriers to exclusive breastfeeding.

Enhancing generalizability: moving from an intimate to a political voice

Weak external validity of qualitative data has been a subject of debate outside and within the field of qualitative health research. Though some narratives have the power to reveal universal existential issues and inform theoretical development, each story remains unique and cannot be generalized. If the goal of qualitative researchers is to have narrative knowledge effect social change, we are faced with a pervasive problem. Our main objective with this article is methodological; that is, to argue and illustrate that a sequential-consensual qualitative design can yield data with adequate external validity to influence clinicians and public health programming. We seek to contribute to the debate on the generalizability of qualitative research in the health field and provide a methodological template for this type of qualitative design so researchers can apply it to future projects to transfer and translate popular knowledge in a way that can influence social change.

Evaluation of Multiwavelength Culture Fluorescence for Monitoring the Aroma Compound 4-Hydroxy-2(or 5)-ethyl-5(or 2)-methyl-3(2H)-furanone (HEMF) Production

Fluorescence spectra of a 4-hydroxy-2(or 5)-ethyl-5(or 2)-methyl-3(2H)-furanone (HEMF) fermentation culture broth were combined with measurable process variables for off-line and on-line process monitoring. Culture broth fluorescence in UV and visible ranges was acquired by a fiber optic LCD array spectrometer. Process dynamics was followed on-line using a fiber optic probe attached to an external recirculation loop of the bioreactor. Partial least squares and stepwise regression methods were used to correlate measurable process parameters with the components of the fluorescence spectra. Both methods provided adequate approximation of yeast density, HEMF, glucose, and ethanol concentrations from fluorescence spectra. HEMF production was observed during the oxido-reductive growth phase when there was a lack of measurable oxygen in the culture broth and an excess of glucose. The addition of glucose resulted in the rapid production of HEMF and other metabolite intermediates such as ethanol, acetate, and glycerol.

Traumatic amputation: a case of Laotian indignation and injustice

Culture is an essential variable of diagnosis and treatment. A cultural perspective draws attention to the social context within which symptoms arise, are given meaning, and are managed. Ethno-cultural work on illness narratives suggests that most people can provide culturally-based explanations for their symptoms. While these explanations are inconsistent with biomedical theory, they relieve patient distress by allowing the patient to create meaning for symptoms. Exploring the characteristics, context, and antecedents of the symptoms enables the patient to convey them to the clinician who may have a divergent explanation of sickness. This case study uses the Outline for Cultural Formulation of the DSM-IV created for clinicians to elicit a narrative account of the illness experience from the patient. Our study examines how the patient, a Laotian used social indignation ("Kwam khem keuang") as an explanatory model for his ailment. He was diagnosed with post-traumatic stress disorder after having undergone a traumatic amputation. In the process of explaining his illness through a cultural idiom, the patient was able to reveal both personal and collective meaning of repressed anger and frustration, expressing them in a context that was acceptable to him. This cultural idiom allowed the patient to reflect upon the structure of the health care system and the specific context in which symptoms and their possible origins are recounted and explored. It also clarified to the treating clinicians some categories of experience and causal explanations that did not fit easily with western biomedical and psychiatric understanding. The case study illustrates how a cultural approach to illness from the patient's perspective offers a reflexive stance on the clinician-patient interaction that allows for better patient care.

Training researchers in cultural psychiatry: the McGill-CIHR Strategic Training Program

OBJECTIVES

The authors aim to summarize the pedagogical approaches and curriculum used in the training of researchers in cultural psychiatry at the Division of Social and Transcultural Psychiatry at McGill University.

METHOD

We reviewed available published and unpublished reports on the history and development of the McGill cultural psychiatry programs to identify the main orientations (conceptual and methodological), teaching methods, curriculum and course content. Student evaluations of teaching were reviewed. Follow-up data on research and other academic activities and employment of trainees who graduated from the program was obtained by e-mail questionnaire.

RESULTS

The McGill program includes a Master of Science program, an intensive summer school, annual Advanced Study Institutes, and the McGill-CIHR Strategic Training Program in Culture and Mental Health Services Research. The interdisciplinary training setting emphasizes the cultural history and embedding of psychiatric knowledge and practice; the social construction of ethnicity, race, and cultural identity; the impact of globalization, migration, and ideologies of citizenship on individual identity and the configuration of cultural communities; and the integration of quantitative and qualitative ethnographic methods in basic and evaluative research.

CONCLUSION

This critical transdisciplinary approach provides researchers with conceptual tools to address the impact of the changing meanings of culture and ethnicity difference in the contemporary world on mental health services.

The McGill Illness Narrative Interview (MINI): an interview schedule to elicit meanings and modes of reasoning related to illness experience

This article summarizes the rationale, development and application of the McGill Illness Narrative Interview (MINI), a theoretically driven, semistructured, qualitative interview protocol designed to elicit illness narratives in health research. The MINI is sequentially structured with three main sections that obtain: (1) A basic temporal narrative of symptom and illness experience, organized in terms of the contiguity of events; (2) salient prototypes related to current health problems, based on previous experience of the interviewee, family members or friends, and mass media or other popular representations; and (3) any explanatory models, including labels, causal attributions, expectations for treatment, course and outcome. Supplementary sections of the MINI explore help seeking and pathways to care, treatment experience, adherence and impact of the illness on identity, self-perception and relationships with others. Narratives produced by the MINI can be used with a wide variety of interpretive strategies drawn from medical anthropology, sociology and discursive psychology.

A multicentre, retrospective study of resource utilization and costs associated with glaucoma management in France and Sweden

PURPOSE

To assess resource utilization and costs associated with glaucoma management in France and Sweden.

METHODS

A total of 267 patient records (121 in France, 146 in Sweden) with diagnoses of primary open-angle glaucoma (POAG) and ocular hypertension (OH), treated medically, were reviewed for a 2-year period (beginning during 1997-99) for relevant clinical and resource utilization data. Economic data were applied to estimate treatment costs.

RESULTS

The annual cost of treating glaucoma was estimated at SEK5305 (531 euro )/patient in Sweden and 390 euro/patient in France. In both countries, medication costs comprised about half of the total costs. Surgical procedures and hospitalizations represented greater proportions of total cost in France (7.0% and 9.6%, respectively) than in Sweden (3.7% and 0.6%, respectively).

CONCLUSION

Medication costs represent a high proportion of total treatment costs. These findings highlight the relative importance of medical therapy and of assessing the cost-effectiveness of medications in glaucoma.

Understanding immigrants' reluctance to use mental health services: a qualitative study from Montreal

OBJECTIVE

Studies suggest that non-European immigrants to Canada tend to under use mental health services, compared with Canadian-born people. Social, cultural, religious, linguistic, geographic, and economic variables may contribute to this underuse. This paper explores the reasons for underuse of conventional mental health services in a community sample of immigrants with identified emotional and somatic symptoms.

METHOD

Fifteen West Indian immigrants in Montreal with somatic symptoms and (or) emotional distress, not currently using mental health services, participated in a face-to-face in-depth interview exploring health care use. Interviews were analyzed thematically to discern common factors explaining reluctance to use services.

RESULTS

Across participants' narratives, we identified 3 significant factors explaining their reluctance to use mental health services. First, there was a perceived overwillingness of doctors to rely on pharmaceutical medications as interventions. Second, participants perceived a dismissive attitude and lack of time from physicians in previous encounters that deterred their use of current health service. Third, many participants reported a belief in the curative power of nonmedical interventions, most notably God and to a lesser extent, traditional folk medicine.

CONCLUSION

The above factors may highlight important areas for intervention to reduce disparities in immigrant use of mental health care. We present our framework as a model, grounded in empirical data, that further research can explore.

Breastfeeding and the cultural configuration of social space among Vietnamese immigrant woman

This study aimed to identify cultural factors involved in the abandonment of breastfeeding amongst Vietnamese immigrant women in Canada. Qualitative interviews were conducted with 19 mothers, exploring their perinatal experience from Vietnam to Canada. The results suggest that the decision to bottle-feed was not related to acculturation to local practices as has been claimed in previous studies but to conflicts between Vietnamese cultural practices and the configuration of the new social space in Canada. Living in Canada did not allow specific family members to conduct postnatal traditional rituals thus jeopardizing mothers' perceived health and the quality of their milk. Culturally appropriate strategies to promote breastfeeding among migrants must consider the social and spatial organization of cultural practices.

Explaining medically unexplained symptoms

Patients with medically unexplained symptoms comprise from 15% to 30% of all primary care consultations. Physicians often assume that psychological factors account for these symptoms, but current theories of psychogenic causation, somatization, and somatic amplification cannot fully account for common unexplained symptoms. Psychophysiological and sociophysiological models provide plausible medical explanations for most common somatic symptoms. Psychological explanations are often not communicated effectively, do not address patient concerns, and may lead patients to reject treatment or referral because of potential stigma. Across cultures, many systems of medicine provide sociosomatic explanations linking problems in family and community with bodily distress. Most patients, therefore, have culturally based explanations available for their symptoms. When the bodily nature and cultural meaning of their suffering is validated, most patients will acknowledge that stress, social conditions, and emotions have an effect on their physical condition. This provides an entree to applying the symptom-focused strategies of behavioural medicine to address the psychosocial factors that contribute to chronicity and disability.