Postmodern medicine

The Intersection of Health Literacy and Public Health: A Machine Learning-Enhanced Bibliometric Investigation

In recent decades, health literacy has garnered increasing attention alongside a variety of public health topics. This study aims to explore trends in this area through a bibliometric analysis. A Random Forest Model was utilized to identify keywords and other metadata that predict average citations in the field. To supplement this machine learning analysis, we have also implemented a bibliometric review of the corpus. Our findings reveal significant positive coefficients for the keywords "COVID-19" and "Male", underscoring the influence of the pandemic and potential gender-related factors in the literature. On the other hand, the keyword "Female" showed a negative coefficient, hinting at possible disparities that warrant further investigation. Additionally, evolving themes such as COVID-19, mental health, and social media were discovered. A significant change was observed in the main publishing journals, while the major contributing authors remained the same. The results hint at the influence of the COVID-19 pandemic and a significant association between gender-related keywords on citation likelihood, as well as changing publication strategies, despite the fact that the main researchers remain those who have been studying health literacy since its creation.

The Social Bifurcation of Reality: Symmetrical Construction of Knowledge in Science-Trusting and Science-Distrusting Discourses

This article proposes a conceptual framework to study the social bifurcation of reality in polarized science-trusting and science-distrusting lay worldviews, by analyzing and integrating five concepts: science work, number work, emotion work, time work, and boundary work. Despite the epistemological asymmetry between accounts relying on mainstream science and science-distrusting or denialist ones, there are symmetrical social processes contributing to the construction of lay discourses. Through conceptual analysis, we synthesize an alternative to the deficit model of contrarian discourses, replacing the model of social actors as "defective scientists" with a focus on their culturally competent agency. The proposed framework is useful for observing the parallel construction of polarized realities in interaction and their ongoing articulation through hinge objects, such as vaccines, seatbelts, guns, or sanitary masks in the Covid-19 context. We illustrate the framework through a comparative approach, presenting arguments and memes from contemporary online media in two controversies: namely, vaccine-trusting versus vaccine-distrusting views and Covid-convinced versus Covid-suspicious discourses.

Vaccine hesitancy in Western and Eastern Europe: The significance of contextual influences

Using the example of Eastern and Western Europe, the paper points out the importance of contextual influences on decisions and behaviour regarding vaccines and vaccination. Contextual determinants have been identified as important in theorizing the concept of vaccine hesitancy that allows for a comprehensive understanding of the reasons why the public questions vaccines. Therefore, the paper first presents the theoretical elaboration of the aforementioned concept, and then discusses the contextual influences on vaccine hesitancy within the European region in order to showcase the differences that exist in this respect between Western and Eastern Europe, as well as between certain minority communities and the majority population in some Western European countries. In all cases, vaccine hesitancy appears to be a matter of trust which has been further eroded by social, political and economic experiences characteristic for the post-socialist context in Eastern Europe and the conditions in which some minority communities live in Western Europe. The theoretical framework of the concept of vaccine hesitancy is presented according to the report of the SAGE Working Group on Vaccine Hesitancy, while the presentation of contextual determinants is based on the results of quantitative and qualitative research in different European countries and reviews of studies that focus on these influences.

Vaccine hesitancy and implications on childhood immunisation in Malaysia

Purpose

The World Health Organization identified vaccine hesitancy as one of the ten threats to global health in 2019. The purpose of this paper is to evaluate the implications and factors affecting parental decision on childhood immunisation in Malaysia.

Design/methodology/approach

This paper reviews literature on vaccine hesitancy and evaluation of factors affecting parental decision on childhood immunisation in Malaysia.

Findings

Vaccine hesitancy is a growing public health concern in Malaysia with factors such as influence of Internet and social media, personal choice and individual right, conspiracy theory, religious reasons and alternative medicine as among the influencing dynamics. An urban, educated demography operating within a postmodern medical paradigm compounds the diminishing value of vaccines.

Originality/value

This paper provides a comprehensive examination of vaccine hesitancy in Malaysia. Critical appraisal on personal choice over societal responsibility within an Asian/Muslim collectivist society has not been discussed in previous studies. The acceptance of homeopathy as an Islamic medicine alternative is peculiar to multi-ethnic, multi-cultural Malaysia.

Here we go again: the reemergence of anti-vaccine activism on the Internet

Abstract: This essay discusses the resurgence of anti-vaccine activism in recent years, based on relevant literature and the author’s own experiences. After presenting possible reasons for the reemergence of such movements and their consequences, the author analyses the role of Internet-mediated communication in amplifying this discourse and making it less amenable to criticism, presenting some of the main arguments deployed by the anti-vaccine agents in their discussions. The text concludes with a draft of possible responses to this increasingly worrying phenomenon.

Determinants of vaccine hesitancy in Switzerland: study protocol of a mixed-methods national research programme

INTRODUCTION

Vaccine hesitancy is a complex public health issue referring to concerns about the safety, efficacy or need for vaccination. Relatively little is known about vaccine hesitancy in Switzerland. This ongoing study (2017-2021) focuses on biomedical and complementary and alternative medicine (CAM) providers and their patients since healthcare professionals play important roles in vaccination decision-making. This national research programme seeks to assess the sociocultural determinants of vaccine hesitancy regarding childhood and human papillomavirus vaccines in Switzerland. We aim to provide a detailed characterisation of vaccine hesitancy, including CAM and biomedical perspectives, patient-provider interactions, and sociocultural factors, to establish the mediating effects of vaccine hesitancy on underimmunisation, and to design an intervention to improve vaccination communication and counselling among physicians, parents and adolescents.

METHODS AND ANALYSIS

Our transdisciplinary team employs a sequential exploratory mixed-methods study design. We have established a network of more than 150 medical providers across Switzerland, including more than 40 CAM practitioners. For the qualitative component, we conduct interviews with parents, youth, and biomedical and CAM providers and observations of vaccination consultations and school vaccination information sessions. For the quantitative component, a sample of 1350 parents of young children and 722 young adults (15-26 years) and their medical providers respond to questionnaires. We measure vaccine hesitancy with the Parent Attitudes about Childhood Vaccines 15-item survey and review vaccination certificates to assess vaccination status. We administer additional questions based on findings from qualitative research, addressing communication with medical providers, vaccine information sources and perceptions of risk control vis-à-vis vaccine-preventable diseases. The questionnaires capture sociodemographics, political views, religion and spirituality, and moral foundations.

ETHICS AND DISSEMINATION

The study was approved by the local ethics committee. The results will be published in peer-reviewed journals and disseminated to healthcare professionals, researchers and the public via conferences and public presentations.

Teaching evidence-based medicine application: transformative concepts of information mastery that foster evidence-informed decision-making

Information mastery is an approach to applying the methods of evidence-based medicine to everyday practice. The aim of this research is to describe concepts identified by clinicians attending a 3-day course on applied evidence-based medicine that led to 'transformative learning', in which they experienced a deep, structural shift in the basic premises of thought, feelings and actions in their approach to making medical decisions. We used a qualitative approach to capture the lived experience of 12 current and 9 prior attendees of the 'information mastery' course through individual interviews, focus groups and observation. Data were thematically analysed and themes were reported. We found that current and previous attendees who seemed to undergo transformative learning identified eight concepts that constitute an information mastery approach to medical decision-making, which we grouped into two general themes. Some participants attending this course underwent transformative learning, resulting in an alternative decision-making process no longer relying on the anecdotes or guidance of others (what 'ought to work') and instead on incorporating patient-oriented outcomes based on the best evidence (what 'does work').

Systematic De-escalation of Successful Triple Antiretroviral Therapy to Dual Therapy with Dolutegravir plus Emtricitabine or Lamivudine in Swiss HIV-positive Persons

BACKGROUND

Studies increasingly suggest that the efficacy of certain dual antiretroviral therapy (ART) combinations is equal to triple ART. Increasing concerns among HIV-positive patients and physicians in Switzerland include ART cost and long-term ART safety and toxicity, i.e. taking only as many ART agents as necessary. The aims of this retrospective analysis are to report on the de-escalation of our entire clinic population of eligible patients with well-controlled HIV-infection to dolutegravir-containing dual ART.

METHODS

Starting in March 2015, we systematically considered the de-escalation of eligible patients to either dolutegravir/emtricitabine or dolutegravir/lamivudine, by discontinuing tenofovir disoproxil fumarate or abacavir. We report on the virological efficacy, tolerability and patient satisfaction ≥ 48 weeks after de-escalation.

FINDINGS

Of 106 HIV-positive patients followed in our clinic, 70 patients were de-escalated. Three returned to triple ART (insomnia after dolutegravir start, n = 2; new wish for single tablet regimen, n = 1). All de-escalated patients and all who continued triple ART had suppressed HIV viremia at last follow-up and were satisfied with their ART regimen, except for one patient who had virological failure after ART discontinuation in the setting of major depression. The most common reasons to not de-escalate included hepatitis B co-infection (n = 6), physician's concern about ART adherence (n = 6), patient reluctance to switch from a single tablet to a 2-tablet regimen (n = 7), patient satisfied with current ART (n = 5) and others (n = 12).

INTERPRETATION

ART de-escalation to dolutegravir/FTC or dolutegravir/3TC is possible in the majority of patients virologically suppressed on triple ART, and may effectively address patient and physician concerns about long-term safety and cost of ART.

Psychiatry in the future

Psychiatry is a branch of medicine, and medicine has its roots in scientific empiricism. Scientific modernism, a product of the Enlightenment, has come under considerable fire from critics, often labelled as postmodern (Muir Gray, 1999; Bracken & Thomas, 2001; Laugharne, 2002). These criticisms include a portrayal of science as a ‘grand narrative’ that reduces reality to a material, measurable world, which follows rational rules, and excludes the non-measurable and non-material. The idea of the objective observer is questioned, because all observers have some interest in what is being observed. Also, multiple views of reality are seen as necessary to understand different perspectives, and the idea that scientific knowledge should ‘trump’ other forms of experience is criticised. This has been described by Bracken in the following way.

["Deciding wisely together" - an initiative of the Association of the Scientific Medical Societies in Germany: Mission, methodology and application]

The question of how to improve healthcare quality and the need for patient empowerment and shared decision-making has been the subject of political and scientific debate for years. In addition to various quality initiatives, "top lists" summarizing selected recommendations to increase awareness of overuse, spread by means of public campaigns, has become popular on the international level - known as the "Choosing Wisely" initiative. However, the trustworthiness of "top lists", their impact on patient-relevant outcomes, their role in and integration into the context of the various pre-existing approaches to improve healthcare quality and the effects of neglecting under- and misuse are not clear. On the other hand, "top lists" may provide new opportunities to improve awareness and dissemination of carefully selected recommendations based on high-quality guidelines. Therefore, the Association of Scientific Medical Societies in Germany (AWMF) has established an ad hoc commission to design a system-specific initiative. The commission has the task to clarify goals, methods of development and concepts for implementation and evaluation, to address concerns and to build upon specific existing resources - e. g., the established quality management system for guidelines in Germany. The key goals defined by the commission include the systematization of the dialogue between healthcare practitioners and patients and the promotion of ethically founded decision-making as an answer to an increasing economic orientation of the healthcare system. To ensure the methodological quality of specific recommendations, the commission has developed a manual. To the best of our knowledge, this manual is the first detailed method paper aiming to guide developers of "Choosing Wisely" recommendations. More than 20 German medical scientific societies have already addressed the subject of "top lists".

Recreating Communities to Support Active Living: A New Role for Social Marketing

The lack of routine physical activity has become an all too pervasive health threat in the United States. Social marketing can be used directly to promote increased physical activity among people who have access to active living options (e.g., safe and convenient sidewalks or bike paths). A second, albeit indirect, use of social marketing to promote physical activity — and the focus of this article — involves promoting behaviors that influence the built environment for the purpose of increasing people's access to active living options. This use of social marketing involves changing the behavior of consumers, developers, distribution channels (e.g., real estate agents) and policy makers. The approach offers public health and other organizations a disciplined, consumer-focused means of mobilizing their available resources in a manner that maximizes the odds of creating active living communities. These means include understanding the competition, understanding target markets, creating mutually beneficial exchanges, segmenting markets and targeting them based on anticipated return. This article identifies specific opportunities for applying the social marketing approach to create active living communities, and identifies opportunities at the state and national level that will enhance the effectiveness of local efforts.

Vaccination persuasion online: a qualitative study of two provaccine and two vaccine-skeptical websites

BACKGROUND

Current concerns about vaccination resistance often cite the Internet as a source of vaccine controversy. Most academic studies of vaccine resistance online use quantitative methods to describe misinformation on vaccine-skeptical websites. Findings from these studies are useful for categorizing the generic features of these websites, but they do not provide insights into why these websites successfully persuade their viewers. To date, there have been few attempts to understand, qualitatively, the persuasive features of provaccine or vaccine-skeptical websites.

OBJECTIVE

The purpose of this research was to examine the persuasive features of provaccine and vaccine-skeptical websites. The qualitative analysis was conducted to generate hypotheses concerning what features of these websites are persuasive to people seeking information about vaccination and vaccine-related practices.

METHODS

This study employed a fully qualitative case study methodology that used the anthropological method of thick description to detail and carefully review the rhetorical features of 1 provaccine government website, 1 provaccine hospital website, 1 vaccine-skeptical information website focused on general vaccine safety, and 1 vaccine-skeptical website focused on a specific vaccine. The data gathered were organized into 5 domains: website ownership, visual and textual content, user experience, hyperlinking, and social interactivity.

RESULTS

The study found that the 2 provaccine websites analyzed functioned as encyclopedias of vaccine information. Both of the websites had relatively small digital ecologies because they only linked to government websites or websites that endorsed vaccination and evidence-based medicine. Neither of these websites offered visitors interactive features or made extensive use of the affordances of Web 2.0. The study also found that the 2 vaccine-skeptical websites had larger digital ecologies because they linked to a variety of vaccine-related websites, including government websites. They leveraged the affordances of Web 2.0 with their interactive features and digital media.

CONCLUSIONS

By employing a rhetorical framework, this study found that the provaccine websites analyzed concentrate on the accurate transmission of evidence-based scientific research about vaccines and government-endorsed vaccination-related practices, whereas the vaccine-skeptical websites focus on creating communities of people affected by vaccines and vaccine-related practices. From this personal framework, these websites then challenge the information presented in scientific literature and government documents. At the same time, the vaccine-skeptical websites in this study are repositories of vaccine information and vaccination-related resources. Future studies on vaccination and the Internet should take into consideration the rhetorical features of provaccine and vaccine-skeptical websites and further investigate the influence of Web 2.0 community-building features on people seeking information about vaccine-related practices.

An AIDS-denialist online community on a Russian social networking service: patterns of interactions with newcomers and rhetorical strategies of persuasion

BACKGROUND

The rise of social media proved to be a fertile ground for the expansion of the acquired immune deficiency syndrome (AIDS)-denialist movement (in the form of online communities). While there is substantial literature devoted to disproving AIDS-denialist views, there is a lack of studies exploring AIDS-denialists online communities that interact with an external environment.

OBJECTIVE

We explored three research areas: (1) reasons for newcomers to come to an AIDS-denialist community, (2) the patterns of interactions of the community with the newcomers, and (3) rhetorical strategies that denialists use for persuasion in the veracity of their views.

METHODS

We studied the largest AIDS-denialist community on one of the most popular social networking services in Russia. We used netnography as a method for collecting data for qualitative analysis and observed the community for 9 months (at least 2-3 times a week). While doing netnography, we periodically downloaded community discussions. In total, we downloaded 4821 posts and comments for analysis. Grounded theory approach was used for data analysis.

RESULTS

Most users came to the community for the following reasons: their stories did not fit the unitary picture of AIDS disease progression translated by popular medical discourse, health problems, concern about HIV-positive tests, and desire to dissuade community members from false AIDS beliefs. On the basis of strength in AIDS-denialist beliefs, we constructed a typology of the newcomers consisting of three ideal-typical groups: (1) convinced: those who already had become denialists before coming to the group, (2) doubters: those who were undecided about the truth of either human immunodeficiency virus (HIV) science theory or AIDS-denialist theory, and (3) orthodox: those who openly held HIV science views. Reception of a newcomer mainly depended on the newcomer's belief status. Reception was very warm for the convinced, cold or slightly hostile for the doubters, and extremely hostile or derisive for the orthodox. We identified seven main rhetorical strategies of persuasion used by the denialists on the "undecided".

CONCLUSIONS

Contrary to the widespread public health depiction of AIDS denialists as totally irrational, our study suggests that some of those who become AIDS denialists have sufficiently reasonable grounds to suspect that "something is wrong" with scientific theory, because their personal experience contradicts the unitary picture of AIDS disease progression. Odd and inexplicable practices of some AIDS centers only fuel these people's suspicions. We can conclude that public health practitioners' practices may play a role in generating AIDS-denialist sentiments. In interactions with the newcomers, the experienced community members highlighted the importance of personal autonomy and freedom of choice in decision making consistent with the consumerist ideology of health care. The study findings suggest that health care workers should change a one-size-fits-all mode of counseling for a more complex and patient-tailored approach, allowing for diversity of disease progression scenarios and scientific uncertainty.

Trust, choice and power in mental health care: experiences of patients with psychosis

BACKGROUND

Trust, choice and power are critical issues in clinical practice, public policies and a post-modern understanding of mental health care. We aimed to investigate the experiences and attitudes of patients with psychosis in relation to trust, choice and power.

METHOD

We conducted 20 in-depth interviews with patients with psychotic disorders in care of NHS services. The interviews were subjected to thematic analysis.

DISCUSSION

Patients discussed aspects of their care in terms of dimensions that enhance or undermine trust, choice and power. Two interpretive themes emerged from this data. First, patients perceive the need for a shifting balance of power, according to the severity of their illness and their own experience of care, but feel that threats of coercion and neglect disable them. Second, they appreciate the expertise of clinicians, but particularly value 'the personal touch' that goes beyond this expertise, including personal disclosure about their own lives, common acts of kindness and conversation outside clinical matters. Patients view trust as a two-way process with responsibility shared between patient and clinician.

CONCLUSIONS

The active involvement of patients with psychosis in their individual care may be strengthened, particularly when they are not acutely ill and have more experience of their illness. While patients value expertise and respect in interactions with clinicians, they also appreciate a 'personal touch', which may go beyond current notions of professionalism.

Anti-vaccine activists, Web 2.0, and the postmodern paradigm--an overview of tactics and tropes used online by the anti-vaccination movement

Websites opposing vaccination are prevalent on the Internet. Web 2.0, defined by interaction and user-generated content, has become ubiquitous. Furthermore, a new postmodern paradigm of healthcare has emerged, where power has shifted from doctors to patients, the legitimacy of science is questioned, and expertise is redefined. Together this has created an environment where anti-vaccine activists are able to effectively spread their messages. Evidence shows that individuals turn to the Internet for vaccination advice, and suggests such sources can impact vaccination decisions - therefore it is likely that anti-vaccine websites can influence whether people vaccinate themselves or their children. This overview examines the types of rhetoric individuals may encounter online in order to better understand why the anti-vaccination movement can be convincing, despite lacking scientific support for their claims. Tactics and tropes commonly used to argue against vaccination are described. This includes actions such as skewing science, shifting hypotheses, censoring dissent, and attacking critics; also discussed are frequently made claims such as not being "anti-vaccine" but "pro-safe vaccines", that vaccines are toxic or unnatural, and more. Recognizing disingenuous claims made by the anti-vaccination movement is essential in order to critically evaluate the information and misinformation encountered online.

A postmodern Pandora's box: anti-vaccination misinformation on the Internet

The Internet plays a large role in disseminating anti-vaccination information. This paper builds upon previous research by analyzing the arguments proffered on anti-vaccination websites, determining the extent of misinformation present, and examining discourses used to support vaccine objections. Arguments around the themes of safety and effectiveness, alternative medicine, civil liberties, conspiracy theories, and morality were found on the majority of websites analyzed; misinformation was also prevalent. The most commonly proposed method of combating this misinformation is through better education, although this has proven ineffective. Education does not consider the discourses supporting vaccine rejection, such as those involving alternative explanatory models of health, interpretations of parental responsibility, and distrust of expertise. Anti-vaccination protestors make postmodern arguments that reject biomedical and scientific "facts" in favour of their own interpretations. Pro-vaccination advocates who focus on correcting misinformation reduce the controversy to merely an "educational" problem; rather, these postmodern discourses must be acknowledged in order to begin a dialogue.

Negotiating the diagnostic uncertainty of contested illnesses: physician practices and paradigms

In the absence of scientific consensus about contested illnesses such as Chronic Fatigue Syndrome (CFS), Multiple Chemical Sensitivities (MCS), and Gulf War Syndrome (GWS), physicians must make sense of competing accounts and develop practices for patient evaluation. A survey of 800 United States physicians examined physician propensity to diagnose CFS, MCS, and GWS, and the factors shaping clinical decision making. Results indicate that a substantial portion of physicians, including nonexperts, are diagnosing CFS, MCS, and GWS. Diagnosing physicians manage the uncertainty associated with these illnesses by using strategies that enhance bounded rationality and aid in thinking beyond current disease models. Strategies include consulting ancillary information sources, conducting analytically informed testing, and considering physiological explanations of causation. By relying on these practices and paradigms, physicians fit CFS, MCS, and GWS into an explanatory system that makes them credible and understandable to them, their patients, and the medical community. Findings suggest that physicians employ rational decision making for diagnosing contested illnesses, creating a blueprint of how illnesses lacking conclusive pathogenic and etiological explanations can be diagnosed. Findings also suggest that patients with contested illnesses might benefit from working with physicians who use these diagnostic strategies, since they help manage the complexity and ambiguity of the contested illness diagnostic process and aid in diagnosis. In addition, findings provide a window into how emerging illnesses get diagnosed in the absence of medical and scientific consensus, and suggest that diagnosing physicians advance the legitimacy of controversial illnesses by constructing the means for their diagnosis.

Anthrax vaccination in a military population before the war in Iraq: side effects and informed choice

BACKGROUND

To assess any health consequences of the anthrax vaccination programme in UK Armed Forces deployed to Iraq.

METHODS

Data were collected from two samples simultaneously. The first was 5302 randomly selected UK service personnel. The second was 607 service personnel involved in a longitudinal study, where pre-vaccination health had previously been collected. Both samples were offered the anthrax vaccination before they deployed to Iraq in 2003 and subsequently following their service in Iraq. Participants completed a detailed questionnaire, including a range of health outcomes, receipt of the anthrax vaccination and quality of choice.

RESULTS

Seventy-two percent of the combined sample had the anthrax vaccination. Being a member of the Army, a commissioned officer or a reservist was associated with higher uptake. No differences in self-reported health were observed between those who did and did not receive the vaccination. For participants who accepted the vaccination, we found an association between making an uninformed choice and adverse health. After adjustment for baseline health in the longitudinal cohort these associations remained significant.

CONCLUSIONS

Anthrax vaccination used by the UK Armed Forces in preparation for the Iraq War has not resulted in adverse health outcomes. However, of those who did accept the vaccination, reported side effects were related to whether acceptance of vaccination was perceived to be informed. Improving the quality of choice may improve self-reported ill health.

Trust, choice and power in mental health: a literature review

Trust, choice and empowerment of patients are emerging as important issues in mental health care. This may be due to an increasingly consumerist attitude amongst patients and as a consequence of postmodern cultural changes in society. This study aimed to find evidence for the influence of trust, patient choice and patient empowerment in mental health care. A literature review was undertaken. Six searches of PubMed were made using the key terms trust, patient choice and power combined separately with psychiatry and mental health. The literature search found substantial research evidence in the areas of trust, choice and power including validated scales measuring these concepts and evidence that they are important to patients. Trust in general health clinicians was found to be high and continuity of care increases patients' trust in their clinician. However, only qualitative research has been found on trust in mental health settings and further quantitative studies are needed. Patient choice is important to patients and improves engagement with services, although studies on outcome show varying results. Empowerment has impacted more at an organisational level than on individual care. Innovative research methodologies are needed to expand on the present significant body of research, utilising qualitative and quantitative techniques.

Adolescent quality of life and satisfaction with care

PURPOSE

1) To describe adolescents' responses to a client satisfaction and family-centered care survey; 2) to examine the relationship between satisfaction with health care and health-related quality of life (HRQL) among these adolescents; and 3) to determine if adolescents and their parents differ in their satisfaction with services.

METHODS

We recruited 104 adolescents who attended the Alberta Children's Hospital pediatric neurology clinic. Each family completed the Client Satisfaction Questionnaire (CSQ), the Family Centered Care Survey (FCCS), the Measure of Processes of Care (MPOC) survey, the Give Youth a Voice (GYV) survey, and the Pediatric Quality of Life Inventory (PedsQL).

RESULTS

Of 116 eligible families, 104 (90%) completed the study. The majority (83%) of adolescents were satisfied with services provided. Adolescents who were very satisfied on the CSQ and the FCCS had higher PedsQL psychosocial scores (p = .009 and .013, respectively). Multivariate analysis revealed that adolescents' psychosocial HRQL was the most significant predictor of their satisfaction with care (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01 to 1.06). There was a difference between parents' and adolescents' responses to the FCCS (p = .02), with adolescents being less satisfied overall.

CONCLUSIONS

Given that adolescents and parents differ in their satisfaction with health care, it is helpful to have direct input from adolescents on health services surveys. The positive relationship between adolescents' psychosocial HRQL and satisfaction with care highlights the potential impact of emotional health on subjective rating of services. Further studies should determine if improvement in adolescents' mental health is associated with greater satisfaction with health care and/or increased adherence with medical treatments.

The burden of musculoskeletal disease--a global perspective

Musculoskeletal diseases are one of the major causes of disability around the world and have been a significant reason for the development of the Bone and Joint Decade. Rheumatoid arthritis, osteoarthritis and back pain are important causes of disability-adjusted-life years in both the developed and developing world. COPCORD studies in over 17 countries around the world have identified back and knee pain as common in the community and are likely to increase with the ageing population. Musculoskeletal conditions are an enormous cost to the community in economic terms, and these figures emphasise how governments need to invest in the future and look at ways of reducing the burden of musculoskeletal diseases by encouraging exercise and obesity prevention campaigns.

Toward a socioethical approach to behavior change

Infection control professionals have traditionally relied on didacticism to promote behavior change among health care workers, but this approach yields disappointing results in a postmodern era of social fragmentation and intellectual ambiguity. We define a socioethical approach to behavior change and propose its implementation in 4 movements: from individualism to community, from rationality to rhetoric, from productivity to praxis, and from monologue to dialogue.

Consent, confidentiality, and the Data Protection Act

Overly strict interpretation of the law is hampering epidemiological research. Here, one research team shows why regulators and organisations holding data should adjust their approach

Foundation Trusts: economics in the 'postmodern hospital'

Foundation Trust Hospitals are community-controlled health care providers which have increased autonomy about how they produce outcomes for the British National Health Service. Although there is a literature on hospital economics it is unclear how these innovative providers will behave, if they have to compete for scarce resources with other hospitals. This paper reviews some of the earlier theories, such as the neoclassical theory of the firm, and discusses their relevance along with 'newer' economic theories such as the transaction costs and evolutionary theory of the firm, plus organizational and human resources theory, to the performance of Foundation Trusts. Much contemporary health care provision is shaped along modernist lines, using scientific endeavour to maximize the impact on health outcomes and technical and social efficiency. However, there is an increasingly postmodern standpoint--critical of modernity--being taken by both patients and hospital staff, to deconstruct processes in the organizations that serve them. Foundation Trusts are postmodern hospitals insomuch as they (to attract scarce resources in a competitive environment), need to marshal the diverse theories of the firm together in order to provide a mass-customized, quality experience, transparently and at least cost--whilst maintaining a stable organizational culture for staff.

Children with unexplained chronic pain: do pediatricians agree regarding the diagnostic approach and presumed primary cause?

OBJECTIVE

To investigate the opinions of general pediatricians regarding children with unexplained chronic pain (UCP), with respect to the presumed cause of the pain and the optimal diagnostic approach for these children.

DESIGN

Diagnostic follow-up study.

SETTING

Outpatient clinic of a university children's hospital.

PARTICIPANTS

A total of 134 consecutive patients, 8 to 18 years of age, referred for pain of > or =3-month duration without a satisfactory explanation at presentation.

METHODS

A full copy of the patient records from routine medical practice and data from standardized psychiatric assessments, standardized questionnaires, and standardized follow-up assessments were provided to 17 pediatricians assigned to 3 panels.

MAIN OUTCOME MEASURES

Agreement regarding the presumed primary cause and diagnostic approach for children with UCP, with consensus being defined as > or =80% agreement among the pediatricians.

RESULTS

The mean age of the children (73% girls) was 11.8 years (SD: 2.6 years). Psychiatric (co)morbidity was present for 60% of the children. Consensus regarding the presumed primary cause was reached for 43% of the patients (58 of 134 patients), ie, 72% (42 of 58 patients) primarily dysfunctional, 17% (10 of 58 patients) primarily psychologic, and 10% (6 of 58 patients) primarily somatic. Consensus regarding the diagnostic approach was reached for 63% of the children (84 of 134 children), leaving more than one-third of the children (37%) without diagnostic consensus.

CONCLUSIONS

The relatively high rates of disagreement regarding the optimal diagnostic approach and presumed primary cause illustrate the difficulties of diagnostic evaluation and subsequent therapeutic strategy design for this patient group. Therefore, children with UCP might be at risk for suboptimal care.

No epidemiological evidence for infant vaccinations to cause allergic disease

CONTEXT

The prevalence of allergic diseases has increased considerably over the last decades. The hygiene hypothesis has emerged, linking reduced microbial exposure and infections early in life with the development of allergic diseases. Especially some of currently available non-replicating infant vaccines are unlikely to mimic a natural infection-mediated immune response that protects against the development of allergic diseases. Moreover, several studies suggested infant vaccinations to increase the risk of allergic diseases.

OBJECTIVE

To determine whether infant vaccinations increase the risk of developing allergic disease.

DATA SOURCES

We searched MEDLINE from 1966 to March 2003 and bibliography lists from retrieved articles, and consulted experts in the field to identify all articles relating vaccination to allergy.

STUDY SELECTION AND DATA EXTRACTION

We selected epidemiological studies with original data on the correlation between vaccination with diphtheria, pertussis, tetanus (DPT), measles, mumps, rubella (MMR) and Bacillus Calmette-Guérin (BCG) vaccine in infancy and the development of allergic diseases, and assessed their quality and validity.

DATA SYNTHESIS

Methodological design and quality varied considerably between the studies we reviewed. Many studies did not address possible confounders, such as the presence of lifestyle factors, leaving them prone to bias. The studies that offer the stronger evidence, including the only randomized controlled trial at issue published to date, indicate that the infant vaccinations we investigated do not increase the risk of developing allergic disease. Furthermore, BCG does not seem to reduce the risk of allergies.

CONCLUSIONS

The reviewed epidemiological evidence indicates that, although possibly not contributing to optimal stimulation of the immune system in infancy, current infant vaccines do not cause allergic diseases.

[Dependency levels and health care services' utilization in psychiatric hospitals in Aragon (Spain)]

OBJECTIVES

To determine the characteristics of patients living in psychiatric hospitals in Aragon, to assess their dependency levels, and to analyze health care services' utilization by these patients.

METHODS

We performed a cross-sectional study between July 1 and November 31. The questionnaire used was the Resident Assessment Instrument- Mental Health (RAI-MH). The sample consisted of 437 patients living in public psychiatric hospitals in Aragon. These hospitals provide care to chronically mentally ill patients and to patients undergoing rehabilitation. The Resource Utilization Group (RUG-I) system was used to classify patients by their dependency levels for activities of daily life (ADL).

RESULTS

Of the 437 patients, 259 (59.3%) were men with a mean age of 62.2 years. A total of 82.1% of the patients were classified as RUG-I group 1. Patients in groups 1 and 2 required more formal health care services. At least one visit by a psychiatrist was required by 25.3% of patients in group 1 and by 15.2% of those in group 2 compared with no visits by the other groups. Nursing interventions were more frequently required by patients in the more dependent groups. All of the of patients in groups 2 to 8 needed daily physical assistance for ADL vs. 26.3% of those in group 1. In the multivariate analysis, predictive variables were the hospital and type of unit.

CONCLUSIONS

There is wide variation in health care services' utilization by patients living in psychiatric hospitals, which is related to dependency levels. Many psychiatric patients do not need formal psychiatric care. Health care professionals should assess the real needs of patients to provide each of them with appropriate care.

Patient activism and the struggle for diagnosis: Gulf War illnesses and other medically unexplained physical symptoms in the US

We examine Gulf War illnesses--which include the fatigue, joint pain, dermatitis, headaches, memory loss, blurred vision, diarrhea, and other symptoms reported by Gulf War veterans--in relation to other medically unexplained physical symptoms such as multiple chemical sensitivity, chronic fatigue syndrome, and fibromyalgia. Our intent is to examine the diagnosis negotiations involved in these mysterious diseases, by showing the different forms of legitimacy involved in such interactions. Factors involved in diagnostic legitimacy are: diagnostic legitimacy in the medical community, lay acceptance of the diagnosis, uncertainty in looking for causes, and social mobilization. We conclude by noting that research may not be able to find any cause for these diseases/conditions; hence, it may be necessary to embrace medical uncertainty, and also to accept patient experience in order to facilitate diagnosis, treatment, and recovery process. Such a change can alter patients' expectations and taken-for-granted assumptions about medicine, and perhaps in turn reduce the frequency with which dissatisfied individuals form illness groups that mobilize to challenge what they see as an unresponsive medical system.

The impact of chronic illness: partnerships with other healthcare professionals

Healthcare workforce shortfalls require a rethinking of models for delivering care to people with chronic disease. Chronic disease needs to be managed by a multiskilled team of healthcare professionals with specialist input. Education at undergraduate, graduate and postgraduate levels needs to prepare healthcare professionals for this new paradigm. Some tasks currently seen only as part of a doctor's purview could be performed by other trained professionals to allow doctors to concentrate on more appropriate activities. We need to explore new collaborations to deliver multidisciplinary healthcare for chronic disease and evaluate these for patient outcomes and cost effectiveness.

Appraisal of doctors: problems with terminology and a philosophical tension

The term appraisal lacks useful definition. It is used to describe both the summative assessment which forms part of performance management, as well as an educational process sometimes referred to as formative assessment. In this analysis we trace the purpose of each of these components as applied to career grade doctors. In the first, authority for the process, and the motive for applying it, lies with management. Within a publicly funded health service the purpose of this is directed towards equality of health care, and to obtain the greatest performance available with the resources available. By contrast, appraisal which supports a doctor's self-directed learning is likely to address issues of quality. The two processes exist in tension with each other, and are mutually informative. We argue that in the appraisal of doctors the two processes and purposes should be made explicit.

If not evidence, then what? Or does medicine really need a base?

This essay analyses the concept of ' base' in relation to its use in evidence-based medicine (EBM). It evaluates the extent to which evidence provides a sufficient base for health care to rest and discusses whether medicine needs a base, and, if so, what are the other possible candidates. This paper will argue that EBM is linked epistemologically to the theory of foundationalism and shows how important criticisms of EBM emerge from anti-foundationalist epistemologies and interpretive frameworks. Drawing from recent writings in the philosophy of science, it is argued that there is a need to see multiple perspectives relevant to the practice and understanding of medicine.

Clinical evaluation: constructing a new model for post-normal medicine

The current paradigm in medicine is served by an explanatory model based on scientific positivism. We argue that there are inherent weaknesses in this model: its basis on reductionism, its reliance on linear thinking and its failure to incorporate human values invite a revision of our thinking about knowledge in medicine. We propose that a fresh explanatory model should be based on complexity theory, and argue that this better suits the new era of post-normal medicine, where analytical and predictive power are obtained by stepping back and looking at the relationships and overall context of a system rather than forcing reality into a preferred disciplinary framework. Better at times to be vaguely right, we argue, rather than precisely wrong.