Views of what's wrong: diagnosis and patients' concepts of illness

'This has given me the peace of mind I needed': ethnographic insights into Barrett's oesophagus screening using the capsule sponge test

In 2021 and 2022, researchers carried out an implementation trial that considered how the capsule sponge test might be used to screen for Barrett's oesophagus using a mobile clinic in East Anglia. This paper offers insights from 15 months of ethnographic fieldwork studying the trial. It aims to highlight the value of the test in offering reassurance to worried patients, particularly to those with a family history of oesophageal adenocarcinoma. It also considers the variety of aims people held for the capsule sponge test, including the hope that it would address their symptoms of acid reflux, and the conflict that sometimes emerged as a result. The second half of the paper uses fieldwork carried out in virtual support groups for people with Barrett's oesophagus to explore experiences postdiagnosis, which sometimes were defined by fear of future cancers. It describes notable differences between the care offered to people with morphological risk conditions like Barrett's oesophagus and the care given to those with genetic risk conditions, including the provision of genetic counselling. More broadly, the paper highlights a tension between patient-centred and risk-centred medicine that is likely to grow as healthcare services continue to shift towards preventative approaches.

The challenges and necessity of situating 'illness narratives' in recovery and mental health treatment

In mental health services, recovery constitutes a guiding principle that is endorsed in professional medical guidelines and has become central to mental health policies across the world. However, for many clinicians, it can be a challenge to effectively embed recovery concepts into professionally directed treatment of disease without distortion, and ostensibly away from what matters to those who use the services. We discuss the evolving and multifaceted concept of 'recovery', including illness narratives to frame our discussion. We demonstrate how integration between a person-directed management of illness and a professionally directed treatment of disease can converge, resulting in positive outcomes for people with mental illness.

The role of moral explanations and structural inequalities in experiences of mental illness stigma in Northern Minas Gerais, Brazil

The process of stigmatization within different cultural contexts has long been viewed as essential in understanding the course and outcomes of mental illness. However, little research has examined which cultural constructs and categories are used to explain mental illness, and how they contribute to the way people with mental illness experience stigma and social exclusion, as well as how these beliefs affect healthcare practices. This study examines meanings ascribed to mental illness and experiences of stigma among four groups in urban settings of Minas Gerais, Brazil: persons with mental illness; their families; members of the lay public; and health professionals working at an alternative community-based psychosocial treatment service or a local university hospital. Qualitative methods, including semi-structured interviews and participant observation, were conducted with a purposive sample of 72 participants. Data were analyzed through content analysis. The findings suggest that stigma and discrimination are intrinsically rooted in a systemic process of social exclusion generated by meanings ascribed to mental illness and the structural vulnerabilities of the mental healthcare system. The findings further suggest that structural inequality is a powerful factor behind lay concepts of mental illness and that this is particularly harmful because it reinforces personal blame attributions instead of addressing the hidden structural forces that contribute to mental illness. The study highlights the subtle interrelations between cultural beliefs and structural vulnerabilities that should be addressed in mental health policy in order to diminish the effects of stigma on people with mental illnesses.

Definitions of Severity in Treatment Seeking Studies of Febrile Illness in Children in Low and Middle Income Countries: A Scoping Review

Objectives: Understanding treatment seeking for severe febrile illness (SFI) is methodologically challenging. In this scoping review, we investigate definitions of severe febrile illness in treatment seeking studies on children under 5 years of age in low and middle income countries. We analyze the association of SFI definitions with different concepts of treatment seeking and identify related research gaps. Methods: We searched Pubmed, Scopus and WHOLIS, and screened references of included publications for eligibility. Results: Definitions of SFI had either a biomedical perspective (predominantly in quantitative studies) or a caregiver perspective (predominantly in qualitative studies). In quantitative analyses of treatment seeking, severity was more often conceptualized as a determinant rather than an outcome of a treatment seeking process. The majority of quantitative analyses only included surviving children or did not explicitly mention dead children. Conclusion: Different research questions lead to diverse definitions and concepts of severity and treatment seeking outcomes, which limits the comparability of the available evidence. Systematic exclusion of dead children is likely to bias inferences on the association of treatment seeking and health outcomes of children with SFI in low and middle income countries.

Could it be osteoarthritis? How dog owners and veterinary surgeons describe identifying canine osteoarthritis in a general practice setting

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Owners describe a range of early behavioural indicators of canine osteoarthritis.

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Their beliefs and prior knowledge may impact when and how they seek advice.

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Vets in general practice describe a common “typical osteoarthritis” presentation.

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History, examination and trial treatment are used to diagnose osteoarthritis.

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Vets and owners may find osteoarthritis consultations frustrating and unrewarding.

Canine osteoarthritis is a common, painful condition that is typically managed in a general practice setting. Osteoarthritis may have significant negative impacts on the welfare of both dogs and their owners. Anticipated early clinical signs of canine osteoarthritis and the preferred route to its diagnosis are well described by veterinary subject experts in published literature. However, little is known about changes owners first recognise in a dog ultimately diagnosed with osteoarthritis, how they make decisions about when to present that dog to a general practitioner, or whether the described diagnostic pathways are followed by general practitioners. The aim of this research was to investigate how dog owners and veterinary surgeons describe identifying and diagnosing canine osteoarthritis.

Owners of osteoarthritic dogs were recruited for semi-structured interview, and veterinary surgeons working in general practice were invited to take part in practice-based focus groups. Transcripts from both datasets were thematically analysed using a contextualist epistemology with an ontology based on critical realism to construct convergent themes from latent and semantic codes. Thirty-two interviews were completed with 40 owners from 32 households who discussed 35 dogs with osteoarthritis, and 26 veterinary surgeons engaged in four practice-based focus groups.

Owners described identifying a wide range of acute and chronic, typically subtle and intermittent, behavioural and demeanour changes prior to their dogs’ osteoarthritis diagnosis. Few attributed these changes to canine osteoarthritis, and some waited many months before presenting their dog to a veterinary practice. Veterinary surgeons described a consistent ‘typical osteoarthritis’ presentation that they recognised through history taking and clinical examination. Their diagnostic work-up rarely followed that advocated by subject experts for reasons including lack of time and perceptions that it would not change the outcome. Many veterinary surgeons described frustration that some owners did not accept their recommendations to provide analgesia for affected dogs. Short consultation lengths, poor awareness of owner knowledge levels, and lack of recognition of the importance of owners’ prior knowledge, beliefs and assumptions may contribute to these consultations being perceived as challenging by some veterinary surgeons and owners.

This research demonstrates that veterinary surgeons and owners want dogs with clinical signs of osteoarthritis to be happy and comfortable, but that ineffective communication and lack of trust in the consulting room may be a barrier. Our data identifies many new avenues for future research and improved communication strategies that could facilitate earlier identification and treatment of canine osteoarthritis in general practice.

Causal Attributions in an Australian Aboriginal Family With Marfan Syndrome: A Qualitative Study

Causal attributions are important determinants of how health threats are processed and affect health-related behaviors. To date, there has been no research on causal attributions in genetic conditions in Aboriginal Australians. Forty members of a large Aboriginal Australian family with Marfan syndrome (MFS) were invited to participate in an ethically approved study exploring causal attributions, including perceived causes of phenotypic variability within the family. Eighteen individuals consented to conduct semi-structured qualitative interviews, which were recorded, transcribed verbatim and analyzed thematically. Most participants knew that MFS was genetic, but there were diverse theories about inheritance, including beliefs that it skipped generations, was affected by birth order and/or gender, and that it co-occurred with inheritance of blue eyes within this family. The mutation was thought to have been inherited from British settlers and initially triggered by disease or diet. Factors believed to modify disease severity included other genes and lifestyle factors, particularly alcohol and substance abuse and stress. Generally, this family did not endorse “blaming” chance or a higher power for phenotypic variability, though some felt that the spirits or a deity may have played a role. In conclusion, although participants knew MFS was a genetic condition, many speculated about the role of non-genetic causes in initiating the original mutation; and the gene-environment interaction was thought to affect severity. This study demonstrates a successful approach for exploring causal attributions in other genetic conditions in First Australians.

The midwife-woman relationship in a South Wales community: Experiences of midwives and migrant Pakistani women in early pregnancy

BACKGROUND

In 2015, 27.5% of births in England and Wales were to mothers born outside of the UK. Compared to their White British peers, minority ethnic and migrant women are at a significantly higher risk of maternal and perinatal mortality, along with lower maternity care satisfaction. Existing literature highlights the importance of midwife-woman relationships in care satisfaction and pregnancy outcomes; however, little research has explored midwife-woman relationships for migrant and minority ethnic women in the UK.

METHODS

A focused ethnography was conducted in South Wales, UK, including semi-structured interviews with 9 migrant Pakistani participants and 11 practising midwives, fieldwork in the local migrant Pakistani community and local maternity services, observations of antenatal appointments, and reviews of relevant media. Thematic data analysis was undertaken concurrently with data collection.

FINDINGS

The midwife-woman relationship was important for participants' experiences of care. Numerous social and ecological factors influenced this relationship, including family relationships, culture and religion, differing health-care systems, authoritative knowledge and communication of information. Marked differences were seen between midwives and women in the perceived importance of these factors.

CONCLUSIONS

Findings provide new theoretical insights into the complex factors contributing to the health-care expectations of pregnant migrant Pakistani women in the UK. These findings may be used to create meaningful dialogue between women and midwives, encourage women's involvement in decisions about their health care and facilitate future midwifery education and research. Conclusions are relevant to a broad international audience, as achieving better outcomes for migrant and ethnic minority communities is of global concern.

Salt Intake and Health Risk in Climate Change Vulnerable Coastal Bangladesh: What Role Do Beliefs and Practices Play?

Background

High salt consumption is an important risk factor of elevated blood pressure. In Bangladesh about 20 million people are at high risk of hypertension due to climate change induced saline intrusion in water. The objective of this study is to assess beliefs, perceptions, and practices associated with salt consumption in coastal Bangladesh.

Methods

The study was conducted in Chakaria, Bangladesh between April-June 2011. It was a cross sectional mixed method study. For the qualitative study 6 focus group discussions, 8 key informant interviews, 60 free listing exercises, 20 ranking exercises and 10 observations were conducted. 400 adults were randomly selected for quantitative survey. For analysis we used SPSS for quantitative data, and Anthropac and Nvivo for qualitative data.

Results

Salt was described as an essential component of food with strong cultural and religious roots. People described both health benefits and risks related to salt intake. The overall risk perception regarding excessive salt consumption was low and respondents believed that the cooking process can render the salt harmless. Respondents were aware that salt is added in many foods even if they do not taste salty but did not recognize that salt can occur naturally in both foods and water.

Conclusions

In the study community people had low awareness of the risks associated with excess salt consumption and salt reduction strategies were not high in their agenda. The easy access to and low cost of salt as well as unrecognised presence of salt in drinking water has created an environment conducive to excess salt consumption. It is important to design general messages related to salt reduction and test tailored strategies especially for those at high risk of hypertension.

Embodied Knowledge and Making Sense of Prenatal Diagnosis

Open-ended, qualitative interviews with women to whom amniocentesis was offered were analyzed to understand how women made sense of these tests. We found that women, whether tested or not, negotiated with biomedical information. They transformed it through identifiable processes, then wove it with their own instincts and beliefs and with their personal experiences, thereby creating "embodied" knowledge on which their decisions were based. Women who were and were not tested may have differed from each other when categorized on the basis of a final, binary choice, but they were more alike than unalike in reaching this point. The apparent importance of embodied knowledge suggests the critical role of the listening activities of the genetic counselor and of awareness of the validity and importance of women's complementary ways of knowing and doing in understanding the uses and meanings of prenatal genetic testing.

A qualitative study of changes in expectations over time among patients with chronic low back pain seeking four CAM therapies

BACKGROUND

The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy.

METHODS

We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time.

RESULTS

Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health.

CONCLUSIONS

The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.

Social capital among migrating doctors: the "bridge" over troubled water

PURPOSE

The purpose of this paper is to examine the concept of social capital among International Medical Graduates (IMGs). It will specifically examine bridging social capital and greater intercultural communication which provides IMGs access to the wider community and plays a key role in cross-cultural adaptation and acculturation.

DESIGN/METHODOLOGY/APPROACH

A review of the literature.

FINDINGS

An Australian wide shortage of doctors has led to an increased reliance on the recruitment of IMGs. As IMGs migrate, they may encounter different meanings of illness, models of care and a number of social challenges. Nevertheless, greater cross-cultural adaptation and acculturation occurs through bridging social capital, where intercultural communication, new social networks and identity aids integration. This process produces more opportunities for economic capital growth and upward mobility than bonding social capital.

PRACTICAL IMPLICATIONS

Concerns regarding immigration, appropriate support and on-going examination processes have been expressed by IMGs in a number of studies and policy papers. However, there is very little insight into what contributes cross-cultural adaptation of IMGs.

ORIGINALITY/VALUE

As IMGs migrate to not only a new country, but also a new health system and workplace they arrive with different cultural meanings of illness and models of care. These differences may be in contrast to the dominant western medical model, but often bring positive contributions to patient care in the new environment. In addition, improving bridging social capital provides IMGs access to the wider community and has been demonstrated to play a key role in cross-cultural adaptation and ultimately acculturation.

Modes of hoping: understanding hope and expectation in the context of a clinical trial of complementary and alternative medicine for chronic pain

This article explores the role of hope in participants' assessments of their expectations, experiences and treatment outcomes. Data analysis focused on semi-structured, open-ended interviews with 44 participants, interviewed 3-5 times each over the course of a study evaluating Traditional Chinese Medicine (TCM) for temporomandibular disorders (TMD), a form of chronic orofacial pain. Transcripts were coded and analyzed using qualitative and ethnographic methods. A "Modes of Hoping" (Webb, 2007)(1) framework informed our analysis. Five modes of hoping emerged from participant narratives: Realistic Hope, Wishful Hope, Utopian Hope, Technoscience Hope, and Transcendent Hope. Using this framework, hope is demonstrated as exerting a profound influence over how participants assess and report their expectations. This suggests that researchers interested in measuring expectations and understanding their role in treatment outcomes should consider hope as exercising a multi-faceted and dynamic influence on participants' reporting of expectations and their experience and evaluation of treatment.

Developing a dynamic model of treatment perceptions

A description of factors influencing perceptions of nonpharmacological treatment was derived inductively from interviews with people receiving chiropractic treatment for back pain, using grounded theory analysis. A theoretical model linking these factors was constructed, and was tested using interview data from a longitudinal study of people undertaking exercise therapy for dizziness. The model highlights the potential for reciprocal interactions between abstract beliefs relevant to illness and treatment and concrete experiences of therapy, and for interactions between perceptions of symptom change and of therapist competence. Therapist communication may modify abstract illness/treatment models and symptom perceptions, thus mediating effects of concordance on adherence and placebo effects.

Aspectos da identidade na experiência da deficiência física: um olhar socioantropológico

O artigo analisa a experiência da deficiência física enfocando a identidade das pessoas, discutindo-a pelas categorias "ser e sentir-se deficiente" e "estigma", balizadas pelo autoconceito como construção sociocultural, atualizadas cotidianamente e inscritas em uma trajetória singular. Trata-se de pesquisa qualitativa de cunho socioantropológico fundamentada na fenomenologia. Foram entrevistados oito homens e cinco mulheres com deficiência física adquirida, guiando-se por roteiro semiestruturado, cujos dados foram submetidos à análise temática. Ser e sentir-se deficiente comporta uma ambiguidade diante do conceito reducionista que orienta o sistema legitimador dessa condição, confrontado com um significado mais englobante expresso no desempenho cotidiano. Reafirma-se a identidade como autoconceito (re)construído nas interações subjetivas e intersubjetivas, não descolada de uma biografia histórica, cultural e socialmente contextualizada.

Interpersonal Issues in Expressing Lay Knowledge

This article examines lay knowledge about causes of infertility. We use discursive psychology to analyse semi-structured interviews with purposively sampled Malawians with a fertility problem. We observe that respondents deny knowledge of causes, sometimes emphatically, but this co-occurs with descriptions of potential causes. We show that these respondents thereby address problematic interpersonal issues: namely that one is not entitled to medical knowledge and that negative inferences that may be drawn about someone who knows particular causes of infertility. These findings shed new light on previous observations, and have implications for the study of lay knowledge.

Pre-emptive resistance: patients' participation in diagnostic sense-making activities

In medical clinic visits, patients do more than convey information about their symptoms and problems so doctors can diagnose and treat them. Patients may also show how they have made sense of their health problems and may press doctors to interpret their problems in certain ways. Using conversation analysis, we analyse a practice patients use early in the medical visit to show that relatively benign or commonplace interpretations of their symptoms are implausible. In this practice, which we term pre-emptive resistance, patients raise candidate explanations for their symptoms and then report circumstances that undermine these explanations. By raising candidate explanations on their own and providing evidence against them, patients call for doctors to restrict the range of diagnostic hypotheses they might otherwise consider. However, the practice does not compel doctors to transparently indicate whether they will do so. Patients also display their ability to recognise and weigh the evidence for common, easily remedied causes of their symptoms. By presenting evidence against them, they show doctors the relevance of more serious diagnostic interpretations without pressing for them outright.

Patients' beliefs about the causes of systemic lupus erythematosus

OBJECTIVE

Beliefs about the causes of SLE have rarely been investigated. The purpose of this study was to explore these beliefs.

METHODS

Face-to-face interviews were carried out with a total of 33 women with SLE, fulfilling the ACR criteria, with a median age of 40 (range 15-65) years. Data were analysed using interpretative phenomenological analysis.

RESULTS

Women attributed SLE to many causes, some of them being not congruent with biomedical models. The most frequent beliefs about the causes of SLE related to autoimmunity, psychological and familial causes, heredity, magico-religious causes (especially in first- and second-generation migrants) and infectious causes. Autoimmunity was often seen as a self-destructive process.

CONCLUSIONS

Being diagnosed with SLE prompted 'Why me?' and 'Why now?' questioning among these women, who attempted to reconstruct coherence in their life histories. For clinicians, analysis of the beliefs about the causes clarifies what is at stake for the patient. The objective is to allow patients to produce narrative to describe their chronic illness experience in order to facilitate a long-term treatment alliance. Further studies are required to understand relationships between beliefs about causes, psychological distress and SLE morbidity.

Patient delay in cancer studies: a discussion of methods and measures

Background

There is no validated way of measuring the prevalence and duration of patient delay, and we do not know how people perceive and define the time intervals they are asked to report in patient delay studies. This lack of a validated measure hampers research in patient delay and is counterproductive to efforts directed at securing early diagnosis of cancer.

Discussion

The main argument of the present paper is that current studies on patient delay do not sufficiently consider existing theories on symptom interpretation. It is illustrated that the interpretation of bodily sensations as symptoms related to a specific cancer diagnosis is embedded within a social and cultural context. We therefore cannot assume that respondents define delay periods in identical ways.

Summary

In order to improve the validity of patient delay studies, it is suggested that research be strengthened on three counts: More research should be devoted to symptom interpretation processes, more research should seek to operationalise patient delay, and, importantly, more research is needed to develop valid instruments for measuring patient delay.

Hospitalization for type 2 diabetes: the effects of the suspension of reality on patients' subsequent management of their condition

Hospitalization still plays a major part in the management of uncontrolled type 2 diabetes and its complications. In this article, we assess the effects of self-management education on the individual practices of 42 patients after discharge from specialized diabetes units on the French island of Reunion. Hospitalization offers respite and temporarily suspends the realities of daily life. When patients leave the unit where they have acquired new knowledge and practices, the extent to which the latter can be maintained depends on the practice in question, the individual's circumstances, and his or her social relationships and support systems. In the longer term, therefore, the effects of self-management education interventions can be weak. The study findings reveal the complexities surrounding the acquisition of habits that maintain health and prevent illness. The article makes a significant contribution to the debate on patient support and the role of inpatient educational units.

Análise socioantropológica da vivência do diabetes: um estudo de caso

Analisou-se a construção da experiência com o diabetes, enfatizando as explicações sobre o conceito, a descoberta, as causas e as formas de gerenciar essa enfermidade. Partiu-se da perspectiva de um portador de diabetes (tipo 2, não insulino dependente), considerando sua trajetória de vida, a experiência e o curso da doença e os significados e sentidos atribuídos a ela. Propôs-se um estudo de caso com coleta dos dados pela técnica do relato oral. Na vivência do diabetes o adoecido se apóia em representações sociais, na própria experiência e de outros para atribuir significado à situação e gerenciar a doença. Assim, as prescrições são ajustadas em meio às demandas diárias não-médicas, às idéias e aos significados de saúde, doença, diabetes; e o seu tratamento, aos sinais, às sensações, aos usos do corpo e aos aspectos significativos e prioritários da vida, viabilizando o sentir-se física e moralmente bem.

Education and self-management for people newly diagnosed with type 2 diabetes: a qualitative study of patients' views

OBJECTIVES

We explored the perceptions, views and experiences of diabetes education in people with type 2 diabetes who were participating in a UK randomized controlled trial of methods of education. The intervention arm of the trial was based on DESMOND, a structured programme of group education sessions aimed at enabling self-management of diabetes, while the standard arm was usual care from general practices.

METHODS

Individual semi-structured interviews were conducted with 36 adult patients, of whom 19 had attended DESMOND education sessions and 17 had been randomized to receive usual care. Data analysis was based on the constant comparative method.

RESULTS

Four principal orientations towards diabetes and its management were identified: 'resisters', 'identity resisters, consequence accepters', 'identity accepters, consequence resisters' and 'accepters'. Participants offered varying accounts of the degree of personal responsibility that needed to be assumed in response to the diagnosis. Preferences for different styles of education were also expressed, with many reporting that they enjoyed and benefited from group education, although some reported ambivalence or disappointment with their experiences of education. It was difficult to identify striking thematic differences between accounts of people on different arms of the trial, although there was some very tentative evidence that those who attended DESMOND were more accepting of a changed identity and its implications for their management of diabetes.

DISCUSSION

No one single approach to education is likely to suit all people newly diagnosed with diabetes, although structured group education may suit many. This paper identifies varying orientations and preferences of people with diabetes towards forms of both education and self-management, which should be taken into account when planning approaches to education.

Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation

OBJECTIVE

To identify the basis of the communication problems that characterise consultations about medically unexplained symptoms (MUS) and to identify implications for clinical education.

METHOD

Recent research into the details of clinical communication about MUS was reviewed narratively and critically, and broader research literature was scrutinised from the perspective of a practitioner who wishes to provide patients with explanations for such symptoms.

RESULTS

Consultations about MUS often involve contest between patients' authority, resting on their knowledge of their symptoms, and practitioners' authority, based on the normal findings of tests and investigations. The outcome of consultations can therefore depend on the strategies that each party uses to press their authority, rather than on clinical need.

CONCLUSION

Contest is a product of patients and practitioners occupying separate conceptual 'ground'. Avoiding contest requires the practitioner to find common conceptual ground within which each party can understand and discuss the symptoms. Finding common ground by collusion with explanations that patients suggest can damage clinical relationships. Instead the practitioner needs to fashion explanation that is acceptable to both parties from available medical and lay material.

PRACTICE IMPLICATIONS

Although practitioners commonly fashion such explanations, this aspect of their professional role seems not to be greatly valued amongst practitioners or in medical curricula. Clinical education programmes could include curricula in symptom explanation, drawing from research in medicine, psychology and anthropology.

Multiple sclerosis patients talking with healthcare providers about emotions

The purpose of this study was to consider multiple sclerosis (MS) patients' experiences of talking with healthcare professionals about emotions and their emotional well-being both at the time of diagnosis and while they are living with the illness. Relationships between talking about emotions and positive outcomes were examined. The 145 respondents completed a paper-and-pencil survey, an Internet survey, or a telephone interview. Forty-four percent of respondents indicated that a healthcare provider had discussed their emotional well-being at the time of their diagnosis. Fifty-six percent of respondents reported that their healthcare professional had talked with them about their fears, sadness, and anger related to living with their illness. For those respondents who wanted to talk with their healthcare professional, doing so appeared to be associated with several positive outcomes. The small number (N = 22) of respondents who did not want to talk with a healthcare professional about emotions were also doing well on several measures. Nurses can help MS patients deal with their uncertainty and emotional challenges by being willing to inquire about emotions and emotional well-being.

“I thought it was only ordinary fever!” cultural knowledge and the micropolitics of therapy seeking for childhood febrile illness in Tanzania

Economic considerations are often cited as important determinants of health-seeking behavior. This paper describes a situation in peri-urban Tanzania where user fees do not constitute the primary reason why mothers delay seeking prompt treatment at a public health facility for their young, febrile children. Mothers commonly believe that they are dealing with an ordinary fever and not malaria or any other serious illness complicated by fever. Hence, they engage in extended home-based treatment. Drawing upon an ethnographic study, this paper illustrates how cultural knowledge about disease symptomatology, cultural meanings associated with febrile illness, gender relations, and patterns of communication between health care providers and mothers significantly influence outcomes for childhood febrile illnesses. It is argued that an overemphasis on the correlation between user fees and treatment delays with regard to childhood illnesses tends to divert attention from other significant cultural factors and existing structural constraints that influence the dynamics of health care seeking and health outcomes. At a time when calls to implement artemisinine-based combination therapy as one of the front-line strategies in Tanzania are increasingly frequent, there is a need to pay closer attention to the contextual factors and socio-cultural dynamics that influence patterns of treatment-seeking for childhood malaria.

The potentially somatizing effect of clinical consultation

Many patients who present physical symptoms that their doctors cannot explain by physical disease have persisting symptoms and impairment. An influential view has been that such symptoms are the somatization of emotional distress, but there has also been concern that medical practice contributes to shaping these presentations. Analysis of patients' accounts indicate that they approach these consultations with a sense of being the expert on the nature and reality of their symptoms and, in primary care at least, they seek convincing explanations, engagement, and support. They often describe doctors as doubting that their symptoms are real and as not taking their symptoms seriously. Observational research has demonstrated that patients presenting idiopathic symptoms in primary care generally provide cues to their need for explanation or to psychosocial difficulties. Their doctors tend to provide simple reassurance rather than detailed explanations, and often disregard psychosocial cues. Patients seem to intensify their presentation in consequence, elaborating and extending their accounts of their symptoms, perhaps in the effort to engage their doctors and demonstrate the reality of their symptoms. When doctors propose physical investigation and treatment in response to such escalating presentation, they thereby inadvertently somatize patients' psychological presentation. Consultations, therefore, have elements of contest, whereby patients seek engagement from doctors who seek to disengage. Although provision of a medical label, such as a functional diagnosis, can legitimize patients' complaints and avoid contest, this is at the risk of indicating that medicine can take responsibility for managing the symptoms. More collaborative relationships rely on doctors recognizing patients' authority in knowing about their symptoms, and providing tangible explanations that make sense to the patient and allow them to tolerate or manage the symptoms. Researchers need to study how doctors can best achieve these aims within routine consultations.

Complementary medicine use by Australian women with gynaecological cancer

AIMS AND OBJECTIVES

Social and cultural factors are identified that impact on complementary therapy use among Australia-born and immigrant women diagnosed with gynaecological cancer.

METHODS

A qualitative study design including in-depth interviews with women diagnosed with gynaecological cancer (N=53) and participant observation was conducted.

RESULTS

Approximately one-third of women utilized complementary and alternative medicine, with this being determined by current health concerns and health beliefs related to the efficacy of different modalities. Four types of complementary therapy users emerged: consequential, therapeutic, informed and exploratory.

CONCLUSION

There was a relatively low uptake of complementary treatments. Choice was influenced by women's socio-demographic background, clinical and personal history, lack of personal experiences of gynaecological cancer among study participants' kin and friends, and lack of popular alternative literature on such cancer.

Roles, power and subjective choice

This paper examines the history underpinning the development of patient involvement in the decision-making process and the emergence of choice in the management of their illness. From the beginnings of the National Health Service (NHS) in United Kingdom, power, and therefore decisions, were in the hands of a well-organised and structured medical profession. With the dominance of a biomedical model of health care 'patient power' was subsumed by that of 'experts' in various emerging fields. Over the past 10 years however, in response to top down and bottom up decisions, evidence and a changing culture, a process of partnership is emerging. Such a philosophy enhances the value given and attached to all who participate. A new generation of patients have been brought up under the umbrella of the NHS, they have access to complex and detailed information and they have legally embedded power to participate in decisions that affect them. The culture of medicine is changing but if this new agenda is to have real meaning and make progress it must be embraced by all sections of society.

Enacting Appreciations: Beyond the Patient Perspective

The "patient perspective" serves as an analytical tool to present patients as knowing subjects in research, rather than as objects known by medicine. This paper analyses problems encountered with the concept of the patient perspective as applied to long-term mental health care. One problem is that "having a perspective" requires a perception of oneself as an individual and the ability to represent one's individual situation in language; this excludes from research patients who do not express themselves verbally. Another problem is that the idea of "talk" as a representation of the world ignores the fact that talk is also performative in the world: it requires, at least, the ability to deal with an interview situation. To think up alternative ways of including patients as subjects in research, I develop an approach that takes this performativity as a starting point. Analysing practical situations and activities, I argue that patients enact appreciations, making known what they like or dislike by verbal or non-verbal means in a given material environment, in situations that are co-produced by others. Thus, subjectivity is linked to situations and interactions, rather than just to individual characteristics; to "patient positions;" rather than "patient perspectives".

Aging and eating in the rural, southern United States: beliefs about salt and its effect on health

This paper draws upon qualitative research conducted among older adults in the rural, southern United States in which they articulated their beliefs and experiences with nutrition and foods, and lay models of the connection of diet with chronic disease. Salt emerged as a focus of contention. The goals of the paper are to (1) present the culturally constructed meaning of salt, (2) contrast the cultural meaning with biomedical views, and (3) discuss how these findings can be applied to health education and better doctor-patient communication. Data were collected in two rural communities characterized by high rates of poverty and a high proportion of minority residents. A total of 116 African American, Native American and white adults aged 60 years and older participated in 55 in-depth interviews or seven focus groups. A systematic analysis of text showed that salt was a highly contested component of food. While valued for its role in traditional foods and cuisine, it also held negative connotations because of biomedical links to chronic diseases prevalent in the population. We suggest that attempts to control salt intake are made difficult by the changes in taste perceptions that accompany aging. Respondents' articulation of salt's role in health and disease shows cross-over among different chronic diseases and a lay interpretation of blood as the medium through which salt affects disease. These older adults' narratives demonstrate their attempts to reconcile the important role of traditional foods in their identity as Southerners with their attempts to meet medical recommendations for healthy eating.

Lay perceptions of type 2 diabetes in Scotland: bringing health services back in

The growing prevalence of type 2 diabetes is placing Scottish health services under considerable strain. Consequently, diabetes services are undergoing a major process of reorganisation, including the devolvement of routine diabetes care/diabetic review from secondary to primary healthcare settings. This qualitative study was devised to explore newly diagnosed type 2 diabetes patients' perceptions of their disease and the health services they receive at a time when this restructuring of services is taking place. The sample comprised 40 patients resident in Lothian, Scotland, who had diverse experiences of services, some receiving GP-based care only, others having varying contact with hospital diabetes clinics. In-depth interviews were undertaken with patients, three times at six monthly intervals over 1 year, enabling their experiences to be tracked at critical junctures during the post-diagnostic period. Disease perceptions and health service delivery were found to be mutually informing and effecting. Not only did (different types of) health service delivery influence the ways in which patients thought about and self-managed their disease, over time patients' disease perceptions also informed their expectations of, and preferences for, diabetes services. We thus argue that there is a need for a reconceptualisation within the medical social sciences to take into account the context of healthcare and the economic/policy factors that inform health service delivery when looking at patients' disease perceptions. We also discuss the logistical and ethical challenges of drawing upon patients' perspectives, preferences and views in the design and delivery of future health services.

Illness representations of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic illness that usually follows a fluctuating course and, therefore, can be difficult to diagnose. Consequently, individuals with SLE often hold beliefs about the nature and course of the illness that are at odds with medical opinion. Clearly, a shared understanding of the illness would be beneficial to illness management. In this study, the authors used semistructured interviews and interpretative phenomenological analysis to explore the content of the illness representations held by 36 individuals diagnosed with SLE. They also identified the ways in which these illness representations were generated initially and attempted to determine whether changes occurred over time in these illness representations, as predicted by the self-regulatory model.

Information on video format can help patients with localised prostate cancer to be partners in decision making

A video was produced to inform men diagnosed with localised prostate cancer of the different management options for their disease. It was tested for increased knowledge and understanding on a healthy population of similar age (n=10), who were assessed before and after watching the video (20 interviews). The video was then shown to 12 men who had been diagnosed with prostate cancer but had not started any treatment for their disease (24 interviews). Interviews among the healthy cohort revealed not only the lack of knowledge of anatomy and physiology but also the way in which these men used past experiences to help explain and remember complex medical procedures. The patients focused on the treatments and outcomes, remembering less of the technicalities. All men interviewed vividly remembered the patients participating in the video; they drew inferences and developed affinity towards specific individuals. Both groups felt that video provided information in a user friendly way. Although remembering few anatomical terms all participants described a visual image that led to a perception of understanding rather than a definitive increase in knowledge. Patients, however, felt they had a clearer understanding of the disease and its treatment, and therefore better able to be active informed partners in the decision-making process.

Illness causal attributions: an exploratory study of their structure and associations with other illness cognitions and perceptions of control

Two studies were conducted to investigate the cognitive organization and psychological meaning of illness causes. Using a direct similarity judgment method (Study 1), illness causes were found cognitively organized in a hierarchical configuration that could meaningfully be represented as a tree with three main branches--environmental, behavioral, and hidden causes--that further divided into subcategories. This classification of illness causes was associated with other components of the illness schema, namely, the consequences and control/cure dimensions, but not with timeline perceptions (Study 2). Perceptions of control were significantly associated with the cognitive organization of illness causal attributions. Personal relevancy was found as a moderator of illness causal attributions, influencing the relationships between attributions and other illness cognitions.

Health perceptions of Mexican American women

This article describes the health perceptions of a sample of moderately to highly acculturated Mexican American women. Using an ethnographic design, the author interviewed 13 women to determine their health perceptions. The interviews were guided by the domains of health described in the World Health Organization (WHO) definition of health. Three broad categories of health perceptions were identified: the physical body, the emotional component, and finding balance. With the addition of a spiritual component, the WHO definition was a useful tool for uncovering health perceptions. The process of in-depth ethnographic interviewing provided a contextual view of health in which the complexity of intrafamilial relationships was revealed, as were the importance of spirituality as a coping mechanism and the perception of health as an integrated, holistic experience.

Coping with tooth pain: a qualitative study of lay management strategies and professional consultation

This research analyzes transcripts of semi-structured interviews with patients presenting with tooth pain at a rural dental clinic in North Florida. The primary objectives are to identify the strategies patients use to manage their pain and to elucidate the decision-making process leading to the clinic visit. Although respondents understood that their condition was not self-limiting, only about one-half contacted the clinic within several days of the onset of their pain. Most tried one or more lay management strategies.

Barriers to the effectiveness of any intervention in OA

One of the main barriers to the effectiveness of interventions in osteoarthritis (OA) is adherence to treatment interventions and advice. Estimates suggest that adherence to any intervention in OA is between 50 and 95% but many of these estimates are derived from clinical trials and the real levels in clinical practice may be much lower. The factors influencing adherence are complex and multifactorial and, although information is available from other diseases, little is known about the relative contribution of these factors in adherence to treatment in OA. Few interventions to improve adherence have been evaluated in OA, and such studies would be limited by the lack of an accurate method for assessing adherence.

An analytical framework for contrasting patient and provider views of the process of chronic disease management

Medical anthropologists involved in clinical research are often asked to help explain patients' "noncompliance" with treatment recommendations. The clinical literature on "noncompliance" tends to problematize only the patient's perspective, treating the provider's perspective as an uncontroversial point of departure. Explicating the articulation between provider and patient assumptions, expectations, and perceptions in managing chronic illness is an area well suited to the unique perspective of medical anthropologists. In this article we present an analytical framework for contrasting patient and provider goals, strategies, and evaluation criteria in chronic illness management, using examples from research on type 2 diabetes care in South Texas. This approach goes beyond contrasting patient and provider concepts and explanations of the illness itself and examines their contrasting views within the dynamic process of long-term care. This approach may prove especially useful for research aimed at a clinical audience, since it maintains a clinically relevant focus while giving serious consideration to the patient's perspective.

Surgery in the absence of pathology the relationship of patients' presentation to gynecologists' decisions for hysterectomy

OBJECTIVE

To test predictions from a theory about patients' influence over doctors' treatment decisions when physical symptoms are presented in the absence of physical pathology.

METHOD

We audiotaped 88 gynecological consultations of consecutive patients who presented menstrual symptoms without pathology. Each consultation was coded according to a scheme, developed from previous qualitative research, which identified specific strategies of patients and gynecologists. The occurrence of each strategy was compared between consultations in which hysterectomy was decided upon (N=15) and those leading to conservative treatment.

RESULTS

Consultations were more likely to lead to hysterectomy if patients deployed specific strategies, including reporting social effects of symptoms, catastrophization, requesting surgery and citing clinical or lay authority in support. Each strategy could account statistically for gynecologists' perceptions that decisions for hysterectomy reflected patients', rather than gynecologists', influence.

CONCLUSION

The findings are consistent with the theory that, in the absence of physical pathology, patients deploy specific strategies that influence gynecologists to offer surgery.

Patients who present physical symptoms in the absence of physical pathology: a challenge to existing models of doctor-patient interaction

Many patients seek physical treatment for physical symptoms in the absence of physical pathology and incur symptomatic interventions that are ineffective, costly and iatrogenic. It is therefore important to understand how decisions to provide physical intervention can arise in consultations in the absence of physical pathology. Existing models of doctor-patient communication are ill-suited to understanding these consultations. A series of studies has provided the components of an alternative approach that is based on understanding consultation from the patients' perspective. Specifically, these studies have delineated: sources of patients' perception of their authority over doctors; what patients seek by consulting their doctors; and ways that patients use their authority to influence doctors to provide what they seek. Patients' authority reflects primarily their own sensory and infallible knowledge of symptoms. Their influence derives from descriptions of subjective symptoms and from additional strategies including descriptions of the psychosocial effects of symptoms, catastrophising and requesting treatment. This analysis suggests directions for future research and medical training.

Ethnic variations in mental health attitudes and service use among low-income African American, Latina, and European American young women

This study examines the predictors of mental health service use among patients in an ethnically diverse public-care women's clinic. While waiting for their clinic appointments, 187 Latina, African American, and White women were interviewed about their attitudes towards mental illness and mental health services. White women were much more likely to have made a mental health visit in the past than the ethnic minority women. Having a substance use problem, use of mental health services by family or friends, and beliefs about causes of mental illness were all predictors of making a mental health visit.

Illness representations: mapping the experience of lupus

Lupus, a chronic illness that mainly affects women, presents numerous challenges to health professionals due to the unpredictable nature of the disease course. To provide appropriate educational interventions for those living with lupus, health educators must develop methods best suited to individuals' current mental representations of their illness. A cognitive mapping strategy was used in this study to ascertain the patients' own perceptions of living with lupus. The participants (N = 20) identified 192 unduplicated concepts in their maps, which were ultimately collapsed into 12 major categories. The results of this study indicate that, although diagnosed with the same illness, the women presented with different mental representations of their illness. Consequently, cognitive mapping could serve as a useful tool to initiate tailored educational interventions for those living with lupus.

Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis

OBJECTIVES

To describe, from the perspective of patients, distinguishing features of doctors' attempts to explain the symptoms of somatisation disorders.

DESIGN

Qualitative analysis of verbatim records of interviews in which patients recounted doctors' explanations of their symptoms.

SETTING

Patients with persistent somatising symptoms referred from general practices in Liverpool and St Helens and Knowsley were interviewed before entry into a treatment programme.

SUBJECTS

228 of 324 patients referred were interviewed. Initial interviews were used to develop the process and technique, and the final analysis was based on a subsample of 68 records, randomly chosen from the transcripts of 188 subjects who were interviewed subsequently.

RESULTS

Doctors' explanations were often at odds with the patients' own thinking. Analysis showed that medical explanations could be grouped into one of three categories, defined by the patients' perceptions. Most explanations were experienced as rejecting the reality of the symptoms. An intermediate category comprised explanations that were viewed as colluding, in which the doctor acquiesced with the patients' own biomedical theories. However, a few explanations were perceived by patients as tangible, exculpating, and involving. These explanations were experienced by patients as satisfying and empowering.

CONCLUSIONS

Patients with somatisation disorders feel satisfied and empowered by medical explanations that are tangible, exculpating, and involving. Empowering explanations could improve these patients' wellbeing and help to reduce the high demands they make on health services.

Moral reasoning and the meaning of cancer: causal explanations of oncologists and patients in southern Mexico

Moral themes were a striking feature of the causal explanations for female cancers discussed by oncologists and patients in an ethnographic study of hospital-based cancer care in southern Mexico. These explanations integrate general biomedical explanations with everyday expectations and experiences, giving meaning to otherwise arbitrary events. Analysis of case examples shows that causal models incorporate local constructs about what constitutes a virtuous life, especially in terms of class-and gender-based values. Although patients and physicians draw on similar concepts of moral order, they apply these constructs in distinct ways. Because physicians' explanations are necessarily framed in terms of object, their causal stories employ generalized presumptions about how categories of persons behave (e.g., women, the lower class). In contrast, patients' explanations are framed in terms of subject; they are based on the specific details of their personal history. The article examines the distinct perspectives of physicians and patients, and provides an illustration of how biomedical culture articulates with the local moral constructs of a particular community.

Porque me tocó a mi? Mexican American diabetes patients' causal stories and their relationship to treatment behaviors

This paper reports findings from an ethnographic study of self-care behaviors and illness concepts among Mexican-American non-insulin dependent diabetes mellitus (NIDDM) patients. Open-ended interviews were conducted with 49 NIDDM patients from two public hospital outpatient clinics in South Texas. They are self-identified Mexican-Americans who have had NIDDM for at least 1 yr, and have no major impairment due to NIDDM. Interviews focused on their concepts and experiences in managing their illness and their self-care behaviors. Clinical assessment of their glucose control was also extracted from their medical records. The texts of patient interviews were content analyzed through building and refining thematic matrixes focusing on their causal explanations and treatment behaviors. We found patients' causal explanations of their illness often are driven by an effort to connect the illness in a direct and specific way to their personal history and their past experience with treatments. While most cite biomedically accepted causes such as heredity and diet, they elaborate these concepts into personally relevant constructs by citing Provoking Factors, such as behaviors or events. Their causal models are thus both specific to their personal history and consistent with their experiences with treatment success or failure. Based on these findings, we raise a critique of the Locus of Control Model of treatment behavior prevalent in the diabetes education literature. Our analysis suggests that a sense that one's own behavior is important to the disease onset may reflect patients' evaluation of their experience with treatment outcomes, rather than determining their level of activity in treatment.

Patients with medically unexplained symptoms: sources of patients' authority and implications for demands on medical care

Lay and medical beliefs are not separate systems. The beliefs of somatizing patients, in particular, incorporate medical understanding and it has been argued that this increases the power that such patients exert in seeking treatment from doctors. To understand the nature and use of this power requires investigation of (i) how patients use medical ideas and language to explain their symptoms and (ii) how this process influences patients' expectations and evaluations of their doctors. We interviewed 68 patients, in whom no physical cause had been found for persistent physical symptoms. Their accounts of symptoms and of their experience of doctors were subjected to qualitative thematic analysis. As expected, patients used medical terms to explain their symptoms. However, these depicted explanatory themes which have long been familiar in traditional lay models: disease as a malign entity and imbalance between bodily forces. Patients' sense of authority over doctors derived, not from facility with medical language and ideas but from contrasting their own sensory, and therefore infallible, experience of symptoms with doctors' indirect and fallible knowledge. By providing explanations that questioned the reality of symptoms, doctors were perceived as incompetent and inexpert. Patients used their authority, not to seek treatment, but to secure naming of, and collaboration against, the disorder. Although these patients saw the doctors' role as limited and inexpert by comparison with their own, our analysis suggests ways in which doctors might more effectively engage with persistent somatizing patients.

Illness behavior in rheumatoid arthritis

OBJECTIVE

To explore prediagnostic illness behavior in rheumatoid arthritis (RA).

METHOD

In this descriptive study, interview and medical records data from 50 female patients were analyzed using quantitative and qualitative techniques.

RESULTS

Findings revealed a high incidence of symptom normalization, self-treatment, symptom comparison, and prolonged time to diagnosis with multiple misdiagnoses and physicians consulted. Most subjects reported invalidation of initial symptoms, multifaceted emotional distress, and relief upon accurate diagnosis. Significant associations were found between (a) illness-related symptom attributions and fewer physicians consulted (P < 0.05) and less invalidation (P < 0.05); (b) life stress events and fewer physicians consulted (P < 0.05) and shorter time to diagnosis (P < 0.05); (c) remissions and time to diagnosis (P < 0.05), number of physicians consulted (P < 0.001), and number of misdiagnoses (P < 0.001).

CONCLUSION

Illness behavior in RA is prolonged, convoluted, and accompanied by personal and social stress. Invalidation of reported symptoms and relief upon definitive diagnosis are prominent features of the process.