Mental health program evaluation: where you start?
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Communication Barriers↗
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Cross-cultural differences in the care of patients with cancer. A review.
In order to assure optimal care of patients with chronic medical illnesses it is necessary to take into account the cultural factors that may influence health-related behaviors. By using cancer as a model, this paper discusses the major cultural issues that should be considered in order to increase cultural sensitivity in the medical setting: family function, sex roles, language, disclosure of disease-related information, pain, attitudes towards illness and health practices, immigration, region, autonomy versus dependency, and death and bereavement. Case histories illustrating the relevance of such socio-cultural factors in the cancer setting are reported.
Adult↗
The effects of culture on illness behavior and medical care. Asian and American differences.
This paper examines the effects of culture on illness behavior and medical care by contrasting the differences between American and Asian cultures. We examine the differences in definitions of self and patterns of self-other interaction between these two cultures and how these differences influence the interpretation of illness experience, illness behavior, and interactions among physicians, patients, and families. We propose that understanding the patients' self-concepts and patterns of self-other relationships, which are largely culturally determined, is essential for an objective understanding of the patients' experience of illness, and can profoundly affect the quality of the physician-patient relationship and medical care.
Adult↗
Suicide in the elderly. Recognizing the signs.
We wish to stress the importance of remaining alert to the possibility of both depression and suicidality in the geriatric population. There is also a need for flexibility in assessing the elderly who may present with atypical symptoms of depression and who may not express their distress directly. The interaction of risk factors may be instrumental in determining the risk for suicide in a particular patient. In our case, we have identified an impaired ability to communicate, intractable tinnitus, and feelings of helplessness.
Age Factors↗
Impediments to recruitment in the Canadian National Breast Screening Study: response and resolution.
Eighteen months after the 1980 initiation of the Canadian National Breast Screening Study (NBSS) (a multicenter randomized controlled trial that will involve 90,000 women), the Toronto center experience such severe problems with recruitment that the study as a whole was jeopardized. Impediments to recruitment arose in five areas. The design of the protocol was criticized by some physicians and participants, a problem that could only be met by justifying the design. A second problem was a lack of understanding of the concept of screening and mistaken assumptions about what participation in the NBSS entailed. Thirdly, recruitment problems occurred at a time when the media were focusing much attention on the hazards of low-level ionizing radiation. Fourthly, women were found to have a variety of personal reasons for delaying or avoiding entry into the study. Finally, factors characteristic of the Canadian milieu such as universal health coverage may have acted as a disincentive to entry. To improve physician understanding, NBSS personnel made presentations at medical rounds and scientific meetings; articles were written for medical journals. To win support from the lay public, talks were given to recreation or work-based groups. Appearances on radio and television talk shows were sought out. Mass mailings to university staff and professional associations did not produce large responses, nor did advertisements on television, radio, or in newspapers. The distribution of a check insert in a government mailing gave rise to hundreds of appointments across Canada. However, for generating an ongoing adequate level of recruitment, the best measure has been the mailing of personally addressed letters to eligible women followed by a telephone call. Data on response rates, cost and women's attitudes toward the study are reported. By early 1983, Toronto met its recruitment target of 12,000.
Adult↗
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Communication Barriers↗
A study of nurse-patient interaction in a high dependency unit.
Interaction between patients and nurses has for many years been recognised as a crucial part of the process of nursing. Whilst research has been performed into the interactions of individuals within intensive care units and in surgical wards, little work has been done on the intermediate of these two areas: the high-dependency unit. This research uses a grounded approach to qualitative research and introduces the beginnings of a model framework for interaction within the area.
Communication Barriers↗
Breast cancer: varied perceptions of social support in the illness experience.
Social support has been identified as an important factor in cancer. However, the stigma associated with cancer often leads to avoidance behavior and withdrawal of support. This investigation examines perceived social support in a population of 100 breast cancer patients, and anticipated social support among 100 disease-free individuals. Results demonstrate that healthy individuals report assignment of stigma and avoidance behavior directed towards cancer patients, yet they believe they themselves would have a dense network of support to call upon if stricken with cancer. Patients report nonmaterialization of expected support networks, and decreased adjustment due to this subjective experience. In addition, patients assert that the support extended to them is often inappropriate in nature, due to the mistaken assumption on the part of healthy individuals that the most salient concern of a mastectomized woman is the loss of her breast, rather than the fact that she has cancer.
Adult↗
Medical misinformation: communication between outport Newfoundland women and their physicians.
A middle-aged woman in a Newfoundland outport fishing village visits the doctor at a local medical clinic and complains of a case of bad nerves. Because he neither adequately understands the subtleties of the village concept of nerves nor the local etiquette of disease disclosure, the physician misinterprets the women's complaint and treats her for an ailment she does not have. The incident discourages the woman and other villagers from seeking medical care in the future. Any outport doctor should be familiar with the character of nerves as effectors of temperament, as conversation capital, and as female status enhancers and also with the role that 'women the worrier' plays in the local fishery. Features of village life which the physician, in this case study, fails to understand include: the complex patterns of social interaction behind the woman's decision to seek medical aid, the outporter's reluctance to ask for help or become obligated to others, and the local fear of persons in positions of authority. Most importantly the doctor is ignorant of the local view of the physician as a kind of moral adjudicator with the power to undermine the patient's reputation as a good woman in the community.
Communication↗
Cross-cultural communication between doctors and peasants in Bolivia.
Practitioners of modern medicine in Bolivia are often ignorant of traditional health practices among Andean peasants in the Department of Oruro. This ignorance makes them less effective agents for improving health. The author describes a method for teaching traditional concepts of health and disease to practitioners of modern medicine (doctors, nurses, and assistant nurses). He discusses workshops offered to these practitioners, where the participants were guided through a series of exercises which assisted them in deciding what aspects of the traditional system to change and what aspects to leave alone. He finally shows how Andean myths can be used as a method for teaching them how to cure disease. The objective is to educate modern medical practitioners in traditional beliefs and to use these beliefs for teaching peasants about modern medicine.
Bolivia↗
Confrontation and politeness strategies in physician-patient interactions.
The therapeutic success of physician-patient interactions depends in large part on how physicians interpret and respond to patients' implicit and explicit messages. Using a hypothetical vignette, in which a patient refuses to comply with a recommended therapeutic regimen, we found that first-year medical students with no classroom training in medical interviewing implicitly recognized that the situation called for face preserving or polite linguistic behavior. Ninety percent of them used culturally sanctioned politeness forms to repair the conversational breakdown depicted in the vignette. They responded to this clinical scenario, however, with linguistic behaviors borrowed from their everyday interactions, some of which were culturally appropriate, but not necessarily therapeutic. We suggest that students can learn to adapt their culturally appropriate behaviors and engage in therapeutic communication as physicians if they are given the necessary conceptual tools. We discuss how Brown and Levinson's theories of politeness and strategic language usage can (1) provide a framework for interpreting communication in general and physician-patient interaction in particular, (2) illuminate some of the problems inherent in doctor-patient encounters, and (3) be used prescriptively for teaching students and health professionals how to avoid some communication difficulties.
Communication↗
Community health workers in Bolivia: adapting to traditional roles in the Andean community.
Community health workers (CHW) constitute an outreach program where community members become involved in their health concerns and elect someone to be trained and administer primary health care. A major problem is that CHWs do not fit into leadership roles of either modern or traditional medicine. CHWs of Oruro, Bolivia, are discussed to examine the success of this program in which CHWs adapted to political, economic, and cultural patterns of Andean communities.
Bolivia↗
Living with a chronic illness: Chinese-Canadian and Euro-Canadian women with diabetes--exploring factors that influence management.
The study reported on here was designed to address how Euro-Canadian and Chinese-Canadian women living with diabetes experience and manage their illness in their day to day lives, and the factors that influence daily management (diet, exercise, medication and blood testing). It was hypothesized that women's patterns of diabetes management would be associated with (a) ethnicity and/or (b) fluency in English. It was also hypothesized that the extent to which women with diabetes (whether Chinese- or Euro-Canadian, fluent or not fluent in English) would carry out daily management in accordance with western health care practices would be associated with: (i) the extent to which desired professional care is experienced; (ii) the women's awareness of facts as endorsed by health professionals (biomedical knowledge); and (iii) her satisfaction with the support received from family and friends. A total of 196 women were interviewed to explore these hypotheses. While we do not yet know the magnitude or relative importance of each of the independent variables, the findings from this study suggest that the management of diabetes is a complex construct, comprised of several components, each being influenced by a number of factors. How a woman managed her illness was not reducible to her ethnicity. Instead, the contextual features of her life, coupled with her ability to access resources seemed to organize the ways in which she managed her illness. Diabetes management therefore becomes a multifaceted phenomenon, which has to be understood within the mediating circumstances of a woman's life.
Adaptation, Psychological↗
Dynamics of participation in a community health project.
Although the term 'participation' is widely used in discussing community development strategies, there has been relatively little said about the characteristics of 'participatory relationships', i.e. the interactions between community developers and those who stand to benefit from community development initiatives. There is seen to be a need for case studies which attempt to understand the relational and communicative processes involved in participatory development. The paper presents an analysis of the participatory dynamics of a community health development project. The principal source of data is interviews conducted with thirteen selected participants in the project. Analysis of interview data using a structured hermeneutic method led to a description of the meaning of participation for each of the participants interviewed. Further interpretation led to the identification of a number of modes of participation in the project as a whole. For each mode of participation descriptions were developed of how it was perceived by others not participating from that mode. An attempt was made to understand the dynamics of the project in terms of the relationship between the different modes of participation and in terms of the discrepancies between how participants saw themselves and how others saw them. Finally, these problems were discussed at a general theoretical level and suggestions were made about how such problems might be alleviated.
Communication Barriers↗
Doctor-patient interactions in oncology.
Studies which apply content analysis techniques to the cancer consultation are few. This descriptive study examines the structure and content of the bad news cancer consultations of 117 outpatients newly referred to the Medical Oncology Department of a large London teaching hospital. From previous communication research three main hypotheses are formed: (i) the cancer consultation is clinician-dominated rather than patient-centred; (ii) the level of psychosocial discussion between clinicians and patients is low and (iii) patient characteristics such as sex, age and prognostic category influence clinician behaviours. Each patient had two consultations with one of 5 oncologists. Both these were audiotaped with the patients' consent. The tapes were content coded using the Roter Interaction Analysis System. Results showed that clinicians tended to use closed rather than open questions. Patients asked few questions and were seldom given space to initiate discussion. Thus, the level of patient-centredness was low. Despite the fact that consultations concerned life threatening disease and often contained information regarding toxic treatment which is known to provoke psychological dysfunction, the number of questions relating to patients' psychological health were few. The amount of discussion concerning medical topics from both parties was 2.5 times greater than the amount of psychosocial discussion. Although there was a suggestion in the data that 3 clinicians showed variations in behaviour according to patient age and prognostic group, the number of patients for each doctor was small. Patients were well informed about their diagnosis, prognosis and treatment options, but their emotional well-being was rarely probed.
Adult↗
Medical professional dominance and client dissatisfaction. A study of doctor-patient interaction and reported dissatisfaction with medical care among female patients at four hospitals in Trinidad and Tobago.
The aims of the study were to evaluate the presence of 'medical professional dominance' displayed by physicians, and to assess the levels of satisfaction with care received, as reported by a simple random sample of 320 patients on obstetric and gynaecology wards at four hospitals in Trinidad and Tobago. Professional Dominance was defined entirely in relation to quality of doctor-patient interaction, while patient satisfaction levels were reported measures. Two methods were used in the study: participant observation techniques were employed to obtain data on doctor-patient interaction, and the survey interview method was used for assessing levels of satisfaction of patients with care received. The results showed disturbingly high levels of both medical professional dominance and patient dissatisfaction. The results of similar studies carried out in the U.S.A. and Britain were used to draw a causative relationship between medical professional dominance and patient dissatisfaction.
Adolescent↗
The meaning of 6.8: numeracy and normality in health information talks.
The ambiguities of risk which stem from its translation from epidemiological findings into clinical knowledge and practice and thus to lay experiences of health and illness is a clear dilemma. How are risks expressed statistically, or otherwise mathematically, to be interpreted and communicated within the discourse of medico-science, and how within the discourse of an individual's everyday life? An important tool in all risk discourses and in preventive practices such as health information is testing and test results. Test results--presented in mathematical terms as points on a scale, or as a number--are in fact fundamental to preventive practice. But what do we know about how people involved in these tests understand them and how the results are used in the construction of ideas about risk and normalcy? This article attempts to answer part of that question by drawing on an empirical study of the use of numbers as metaphors in talks between a nurse and her potential patients in a directed health survey.
Adult↗
Translating research findings into health policy.
Evidence of the influence of research on health policy is paradoxical. While there is scant evidence that research has had any impact on the direction or implementation of widespread health reforms, research on evidence-based medicine has dramatically increased, despite limited evidence that it has affected clinical practice. These developments have occurred in the context of a general decline in state intervention and provision and a post-modern questioning of researchers' authority. Models of the relationship between research and policy range from one where empirical research rationally informs decision-making, through research incrementally affecting policy, to an "enlightenment" or "infiltration" model, which may operate on a conceptual level. Health research that contributes to large-scale socio-political change may require more methodological pluralism and greater focus on key institutional structures. Case studies reviewed suggest that dissemination is enhanced if researchers involve managers and policy-makers in the development of the framework for and focus of research and if investigators assume a responsibility for seeing their research translated into policy. Public health research is more influential if topical, timely, well-funded and carried out by a collaborative team that includes academics. Evaluations are more influential if, in addition, they are commissioned by health authorities but based on local collection of data, and instruments and incentives to implement policy are available. In some areas, such as the recent policy focus on careers in the community, researchers were largely responsible for raising this policy issue, whereas in other areas, such as the relationship between unemployment and health, researchers are just one of the groups of experts making competing claims about causality. In conclusion, clear research findings are not always a passport to policy, but researchers can reframe the way health policy issues are seen, and collaboration with policy-makers initially can enhance implementation later.
Communication Barriers↗