Quality of care from the perspective of people obtaining abortion: a qualitative study in four countries

OBJECTIVE

This qualitative study aimed to identify person-centred domains that would contribute to the definition and measurement of abortion quality of care based on the perceptions, experiences and priorities of people seeking abortion.

METHODS

We conducted interviews with people seeking abortion aged 15-41 who obtained care in Argentina, Bangladesh, Ethiopia or Nigeria. Participants were recruited from hospitals, clinics, pharmacies, call centres and accompaniment models. We conducted thematic analysis and quantified key domains of quality identified by the participants.

RESULTS

We identified six themes that contributed to high-quality abortion care from the clients' perspective, with particular focus on interpersonal dynamics. These themes emerged as participants described their abortion experience, reflected on their interactions with providers and defined good and bad care. The six themes included (1) kindness and respect, (2) information exchange, (3) emotional support, (4) attentive care throughout the process, (5) privacy and confidentiality and (6) prepared for and able to cope with pain.

CONCLUSIONS

People seeking abortion across multiple country contexts and among various care models have confirmed the importance of interpersonal care in quality. These findings provide guidance on six priority areas which could be used to sharpen the definition of abortion quality, improve measurement, and design interventions to improve quality.

Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial

Importance

Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians.

Objective

To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation.

Design, Setting, and Participants

This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022.

Intervention

The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care.

Main Outcome and Measures

The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing.

Results

A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase.

Conclusions and Relevance

In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool.

Trial Registration

ClinicalTrials.gov Identifier: NCT04857060.

"I was afraid they will be judging me and even deny me the service": Experiences of denial and dissuasion during abortion care in Ethiopia

INTRODUCTION

Disrespect and abuse are components of poor quality abortion care. This analysis aimed to understand negative experiences of care from perspectives of abortion clients in public and private facilities in Ethiopia.

STUDY DESIGN

We conducted 23 in-depth interviews with people who obtained abortion care in Addis Ababa, Ethiopia as well as Aksum and Mekele in Tigray State, Ethiopia. The interviews were coded using a priori and emergent codes and we conducted thematic analysis to understand negative interactions with providers from participant's perspectives.

RESULTS

Participants experienced denial of abortion services along their pathway to care and attempts by providers to dissuade them prior to providing an abortion. Underlying both the denial and the dissuasion were reports of disrespect and condemnation from providers. Participants described how providers doubted or forced them to justify their reasons for having an abortion, stigmatized them for seeking multiple abortions or later abortions, and ascribed misinformation about abortion safety. Despite reports of denial, dissuasion, and disrespect, abortion clients generally felt that providers had their best interest at heart and were grateful for having access to an abortion.

CONCLUSIONS

Participants in Ethiopia experienced providers as gatekeepers to legal abortion services, facing disrespect and judgment at facilities where they sought care. Interventions aimed at increasing awareness of abortion laws such that clients understand their rights and values clarification interventions for providers could help reduce barriers to accessing care and improve the quality of abortion services.

Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital

INTRODUCTION

Despite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer's disease and related Dementias, regardless of age.

METHODS AND ANALYSIS

The Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included.

ETHICS AND DISSEMINATION

The Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT04857060; ClinicalTrials.gov.

Perspectives on high-quality interpersonal care among people obtaining abortions in Argentina

Introduction

Little is known about how people who have abortions describe high-quality interpersonal care in Argentina. This qualitative study aimed to understand preferences and priorities in their interactions with providers.

Study design

We conducted 24 in-depth interviews with people who obtained abortions at a comprehensive reproductive health clinic or with support from a feminist accompaniment group in Buenos Aires and Neuquén, Argentina. We iteratively coded transcripts using a thematic analysis approach based on interpersonal domains present in current quality of care frameworks.

Results

Participants described high-quality abortion care as feeling acompañamiento and contención from their providers – terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortion. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management.

Conclusions

People obtaining abortions in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people’s perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01401-1.

Little is known about how people who have abortions perceive the quality of the care they receive and what aspects of interpersonal interactions with providers matter to them. This qualitative study aimed to understand preferences of  people who had abortions at both a reproductive health clinic and with an accompaniment group in Argentina. We interviewed 24 people who obtained abortion care in Buenos Aires and Neuquén, Argentina. We asked them about their preferences for and experiences of abortion care. Then we analyzed the interviews, specifically assessing aspects of interpersonal care based on quality of care frameworks from the literature. Participants described high-quality abortion care as feeling acompañamiento and contención from their providers—terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortions. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management. In conclusion, people obtaining abortions in two distinct models of care in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people’s perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion.

"It's not a seven-headed beast": abortion experience among women that received support from helplines for medication abortion in restrictive settings

There are a growing number of abortion helplines where counselors provide person-centered medication abortion services in legally restrictive settings. Few researchers have explored the perceptions and experiences of the people who obtain support from these helplines. Between April and August 2017, we conducted 30 interviews with women who had a medication abortion with support from helpline counselors in Poland, Brazil, or Nigeria. Before seeking care with the helpline, women often heard negative stories about abortion and faced enacted stigma from the formal healthcare sector, or chose not to seek services from their doctors due to fear of stigmatizing treatment. Conversely, during their care with the helpline counselors, women received clear information in a timely manner, and were treated with kindness, compassion, respect, and without judgment. Many women gained knowledge and understanding of medication abortion, and some gained a sense of community among those who experienced abortion. Helpline models can provide high-quality, person-centered abortion care to people seeking abortions in legally restrictive contexts. Evidence from these service-delivery models could help improve service within the formal healthcare systems and expand access to high-quality, safe abortion by redefining what it means to provide care.

Construction of a simple thermoluminescence and optically stimulated luminescence reader for luminescence dosimetry research

This work describes the construction of a simple thermoluminescence (TL) and optically stimulated luminescence (OSL) reader using commercial components such as temperature and power controllers for thermal stimulation, as well as green laser diodes (532 nm) for optical stimulation. To evaluate the performance of the equipment, TL measurements were carried out on the built equipment and Risø TL/OSL reader using Al₂O₃:C chip dosimeters. Both measurements showed the same glow curve with two TL peaks, one with low intensity at 85 °C and the other with high intensity at 220 °C. OSL measurements in Al₂O₃:C chips showed a well-behaved exponential decay signal and linear behavior of OSL intensity for doses between 2 and 10 mGy with a rough calculation of minimum detection dose of ∼2 µGy.

Experiences of women who travel for abortion: A mixed methods systematic review

OBJECTIVE

To systematically review the literature on women's experiences traveling for abortion and assess how this concept has been explored and operationalized, with a focus on travel distance, cost, delays, and other barriers to receiving services.

BACKGROUND

Increasing limitations on abortion providers and access to care have increased the necessity of travel for abortion services around the world. No systematic examination of women's experiences traveling for abortion has been conducted; this mixed-methods review provides a summary of the qualitative and quantitative literature on this topic.

METHODS

A systematic search was conducted using PubMed, Embase, Web of Science, Popline, and Google Scholar in July 2016 and updated in March 2017 (PROSPERO registration # CRD42016046007). We included original research studies that described women's experiences traveling for abortion. Two reviewers independently performed article screening, data extraction and determination of final inclusion for analysis. Critical appraisal was conducted using CASP, STROBE, and MMAT checklists.

RESULTS

We included 59 publications: 46 quantitative studies, 12 qualitative studies, and 1 mixed-methods study. Most studies were published in the last five years, relied on data from the US, and discussed travel as a secondary outcome of interest. In quantitative studies, travel was primarily conceptualized and measured as road or straight-line distance to abortion provider, though some studies also incorporated measures of burdens related to travel, such as financial cost, childcare needs, and unwanted disclosure of their abortion status to others. Qualitative studies explored regional disparities in access to abortion care, with a focus on the burdens related to travel, the impact of travel on abortion method choice, and women's reasons for travel. Studies generally were of high quality, though many studies lacked information on participant recruitment or consideration of potential biases.

CONCLUSIONS

Standardized measurements of travel, including burdens associated with travel and more nuanced considerations of travel costs, should be implemented in order to facilitate comparison across studies. More research is needed to explore and accurately capture different dimensions of the burden of travel for abortion services on women's lives.

Puberty Experiences of Low-Income Girls in the United States: A Systematic Review of Qualitative Literature From 2000 to 2014

PURPOSE

Puberty is a critical period of development that lays the foundation for future sexual and reproductive health. It is essential to learn about the puberty experiences of low-income girls in the United States given their increased vulnerability to negative sexual and reproductive health outcomes. To understand the present-day puberty experiences of this population, we conducted a qualitative systematic review.

METHODS

We systematically searched the peer-reviewed literature published between 2000 and 2014 on the puberty experiences of low-income girls in the United States. Reviewers screened titles, abstracts, and the full texts of articles. Using standardized templates, reviewers assessed the methodologic quality and extracted data. Data were synthesized using thematic analysis. Confidence in each finding was assessed using Confidence in the Evidence from Reviews of Qualitative research.

RESULTS

Twenty qualitative articles were included. They described the experiences of mostly African-American, Caucasian, and Hispanic girls living primarily in urban areas of Northeastern United States. Five overarching themes emerged: content of girls' puberty experiences, quality of girls' puberty experiences, messages girls receive about puberty, other factors that shape girls' puberty experiences, and relationships that shape girls' experiences of puberty.

CONCLUSIONS

The limited existing evidence suggests that low-income girls in the United States are unprepared for puberty and have largely negative experiences of this transition.

Compounds derived from endophytes: a review of phytochemistry and pharmacology

OBJECTIVE

Endophytes, microorganisms that reside in the tissues of living plants, are a promising source of novel compounds with biological activity, or an alternative source of compounds originally isolated from higher plants. The intent of this review is to provide insights into their occurrence in nature, the products that they make, and how some of these organisms are beginning to show some potential for human use.

METHODS

Information for analysis of endophytic microorganisms was obtained from libraries and Internet scientific databases such as Scirus, Google Scholar, CAB-Abstracts, MedlinePlus, PubMed, SciFinder, Scopus and Web of Science.

RESULTS

Many of the compounds reported here were isolated exclusively from endophytes in culture, while other compounds had been previously reported as chemical constituents of higher plants. A survey of the literature shows endophytic microorganisms are mainly known for their alkaloids with cytotoxic, chemopreventive, anti-metastatic and antitumor properties used in the treatment of several types of cancer. The studies of these alkaloids highlight the existence of various potential leads for the development of novel anti-cancer agents. Modern pharmacology studies demonstrated that their crude extracts and active compounds possess wide pharmacological actions, especially for anti-microbial drug discovery, with neuroprotective, antioxidant, nematicidal, antiplasmodium, anti-inflammatory activities.

AIM OF THE REVIEW

This review summarizes the up-to-date and comprehensive information on compounds from endophytes fungi from 1995 to 2011 that relates to 313 compounds isolated from endophytic microorganisms, together with the botany, phytochemistry, pharmacology and toxicology, and discusses possible trends and the scope for future research of endophytes.

Pathogenicity of chicken anaemia virus (isolate 10343) for young and older chickens

One-day-old chicks, inoculated intramuscularly (i.m.) with the chicken anaemia virus (CAV) isolate 10343, showed depression of body weight gain and anaemia, particularly between days 14 and 21 post-inoculation (p.i.)- The weights of thymus and bursa were substantially reduced compared to controls at days 14 and 21 p.i. The histological lesions detected in thymus, bursa, spleen and liver were similar in frequency at days 14 and 21 p.i. Eosinophilic intranuclear inclusion bodies, lymphocyte depletion, and focal necrosis were detected in the thymus, spleen, bursa and liver of more than 50% of the inoculated chicks at days 14 and 21 p.i. Focal necrosis and vacuolar degeneration in the liver, as well as apoptosis in different organs were more evident at days 14 and 21 p.i. Ten-week-old broiler breeders, inoculated i.m. with isolate 10343 showed pathological changes that were less severe than the changes shown by 1-day-old chicks. No anaemia could be detected in this group. However, severe thymus atrophy, and histological lesions in bursa, spleen, and liver, were also evident at days 14 and 21 p.i. in some of the inoculated birds. Viral detection by immunofluorescence using a monoclonal antibody revealed a wide distribution of the CAV isolate. CAV antigen was detected until day 21 p.i. in thymus, spleen, bursa and liver. According to the severity of the lesions shown by 1-day-old chicks, the length of the period in which CAV antigen could be detected in tissues, and the fact that CAV isolate 10343 was capable of inducing disease in 10-week-old chickens, it seems that this CAV isolate may be particularly virulent.

Myofibroblast transdifferentiation in obliterative bronchiolitis: tgf-beta signaling through smad3-dependent and -independent pathways

We have shown that Smad3, an intracellular signal transducer for transforming growth factor-beta1 (TGF-beta1), is required to elicit the full histological manifestations of obliterative airway disease in a tracheal transplant model. This suggests that chronic allograft rejection results in TGF-beta1-induced Smad3 activation that leads to airway obliteration through fibroproliferation and increased matrix deposition. In other systems, these latter events are causally related to the transdifferentiation of fibroblasts into myofibroblasts, but their role in obliterative bronchiolitis (OB) after lung transplantation is unknown. We confirmed the presence of myofibroblasts inside affected airways associated with experimental OB using immunohistochemistry. Studying airway fibroblasts in vitro, we observed increased myofibroblast transdifferentiation in response to TGF-beta1, evidenced by increased alpha-smooth muscle actin mRNA and protein expression. In Smad3-null fibroblasts, TGF-beta1 induction of myofibroblast transdifferentiation was greatly diminished but not abolished, suggesting the presence of Smad3-independent pathways. Further studies revealed that small molecule inhibitors of p38 (SB203580) and MEK/ERK (U1026) further reduced the remaining effect of TGF-beta1 in Smad3-deficient fibroblasts. Together, these studies suggest that in chronic allograft rejection, TGF-beta1 stimulates myofibroblast transdifferentiation through Smad3-dependent and -independent signals, contributing to the excessive matrix deposition that characterizes obliterative bronchiolitis.

Peripheral-type benzodiazepines inhibit proliferation of astrocytes in culture

Peripheral-type benzodiazepine (BZD) receptors have been identified in brain and are predominantly localized to astrocytes. To determine their potential role in controlling astroglial proliferation, DNA synthesis, growth curves and mitotic index were investigated in primary astrocyte cultures which had been exposed to Ro5-4864 (a peripheral-type BZD ligand) and PK11195 (a peripheral-type BZD receptor antagonist). There was a dose-dependent inhibition of mitosis when two-week-old cells in culture were exposed to 50 nM, 500 nM, 1 microM and 10 microM Ro5-4864 for 24 h. Exposure of 5-, 8-, 12- and 15-day-old cultures to Ro5-4864 and PK11195 for 24 h did not affect growth rate and DNA synthesis; however, continuous exposure to 10 microM Ro5-4864 caused a persistent inhibition of cell growth and [3H]thymidine incorporation (P less than 0.05) while nanomolar concentrations did not cause any significant change. Concurrent administration of Ro5-4864 with PK11195 resulted in a partial reversal of Ro5-4864-induced inhibition in DNA synthesis and mitosis. These results indicate that peripheral-type BZDs are capable of inhibiting proliferation of astrocytes in culture.

Morbidity from acquired cytomegalovirus infection in a neonatal intensive care unit

In a prospective study of transfused neonates, 32 of 262 infants were viruric at greater than 20 days of life. Of 212 neonates whose early status was known, postnatally acquired infection was proven in 21, two of whom were seronegative at birth and were thought to have transfusion-acquired cytomegalovirus (CMV). Maternal transmission of CMV is important in this population as there was 91% seropositivity for CMV at birth among the 21 babies who acquired CMV compared with 55% positivity among 150 babies who did not shed CMV (P less than 0.01). Significantly increased morbidity (increased length of stay in hospital, increased use of antibiotics, and longer duration of antibiotic administration) was found in babies with acquired CMV compared with matched controls who did not become viruric. Significant morbidity and mortality was not restricted to the two seronegative babies with transfusion-acquired CMV. The cost of providing CMV antibody negative blood for this neonatal unit would be less than the cost of providing the extended hospital care needed by the two babies with transfusion-acquired CMV found during this 3 year study.

Posttransfusion hepatitis: a persistent problem

Between 1977-84 the reported frequency of clinically evident posttransfusion hepatitis has halved both nationally and in the Auckland region. This is mainly due to a decrease in the frequency of posttransfusion hepatitis B coincident with widespread introduction of sensitive screening tests for HBsAg. About half the cases of transfusion induced hepatitis are now classified as non A non B hepatitis. A further fall in the reported frequency of posttransfusion hepatitis occurred in 1985-86. Possible strategies to further reduce the low frequency of posttransfusion hepatitis in New Zealand are discussed. Although the problem of clinical posttransfusion hepatitis B or non B appears small, the need to report all such cases and to utilise blood and blood products with care is emphasised.

Hepatitis delta virus infection: a recently imported disease in New Zealand

In a study of 565 hepatitis B antigen (HBsAg) positive persons from the Auckland region, antibody to the hepatitis delta virus was detected in 38. The largest number were in Samoans (61%) although the infection was present in some other Pacific Islanders. Among HBsAg positive healthy blood donors, antenatal patients and acute hepatitis patients between 3.8 and 4.8% were anti-delta positive; while 28% of chronic hepatitis patients were positive suggesting an association between this disease and delta infection. Some positive results were also found in sera from intravenous drug addicts. By contrast, anti-delta was uncommon in New Zealand born Maoris or Europeans. Delta infection can be detected in some Pacific Islanders, some European immigrants as well as intravenous drug addicts and has the potential to spread in an epidemic form to HBsAg carriers in the general community. Widespread vaccination against hepatitis B is recommended to eventually reduce the number of HBsAg carriers in New Zealand.

Intradermal, low dose, short course hepatitis B vaccination

Seventy-five of 88 (85.2%) vaccinees seroconverted at three months after three 2 micrograms doses of a plasma-derived hepatitis B vaccine had been given intradermally one month apart. Vaccinees under 30 years of age had a significantly better seroconversion rate (88.8%) than older subjects (50%) as measured at three months. Forty-three of 47 (91%) vaccinees who were bled one year post vaccination had antibody levels in excess of 10 IU/1. This study indicates that short course, low dose, intradermal vaccination with plasma-derived hepatitis B vaccine may be a viable and cheap regimen for inducing immunity against hepatitis B in younger subjects.

Percutaneous fixation of supracondylar fractures of the humerus in children

Of 1,118 supracondylar fractures of the humerus in children treated over a six-year period, 189 are described with a follow-up of more than two years. These patients were treated with closed reduction and percutaneous fixation of the fragments with two wires. Eighty-five per cent of the final results were satisfactory.