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PubMed2002

Women who sell sex in a Ugandan trading town: life histories, survival strategies and risk.

Little is known about the background of commercial sex workers in Africa. This study investigated how women in a trading town on the trans-Africa highway in southwest Uganda become involved in commercial sex work, which factors contribute to their economic success or lack of success, and what effect life trajectories and economic success have on negotiating power and risk behaviour. Over the course of two years detailed life histories of 34 women were collected through recording open, in-depth interviews, the collection of sexual and income and expenditure diaries, visits to the women's native villages, and participant observation. The women share similar disadvantaged backgrounds and this has played a role in their move into commercial sex. They have divergent experiences, however, in their utilisation of opportunities and in the level of success they achieve. They have developed different life styles and a variety of ways of dealing with sexual relationships. Three groups of women were identified: (1) women who work in the back-street bars, have no capital of their own and are almost entirely dependent on selling sex for their livelihood; (2) waitresses in the bars along the main road who engage in a more institutionalised kind of commercial sex, often mediated by middlemen and (3) the more successful entrepreneurs who earn money from their own bars as well as from commercial sex. The three groups had different risk profiles. Due partly to their financial independence from men, women in the latter group have taken control of sexual relationships and can negotiate good sexual deals for themselves, both financially and in terms of safe sex. The poorer women were more vulnerable and less able to negotiate safer sex. A disadvantaged background and restricted access to economic resources are the major reasons for women gravitating to commercial sex work. Various aspects of personality play a role in utilising income from commercial sex to set up an economic basis that then makes the selling of sex unnecessary. This has implications for interventions, and part of the longer-term solution should lie in improving the economic position of women vis-à-vis men.

Acquired Immunodeficiency Syndrome↗

PubMed1998

An international comparative study of total hip arthroplasty cost and practice patterns.

The cost of total hip arthroplasty (THA) was assessed on a worldwide basis, with specific information obtained regarding implant type, cost, manufacturer, fixation method, as well as other clinical related practices. One hundred and ten orthopaedic surgeons representing 30 countries and 6 continents responded to the questionnaire. The average number of THAs per year per surgeon was 75 (range, 2-300). Surgeons reported using all cemented components in 35% of THAs at an average cost of $1,536 (U.S. dollars). Uncemented components were used in 31% at an average cost of $2,674, and hybrid reconstructions in 34% at an average cost of $2,114. Almost half (44%) of the respondents stated that the hospital negotiated the type and price of the implants. Most surgeons (80%) indicated they were under pressure to decrease the cost of THA and 68% were under pressure to reduce the length of patients' hospital stay. When asked for recommended ways to reduce costs, 30% stated that negotiating a reduced implant price from the supplier was the most important measure. On a worldwide basis, there is tremendous variation in the cost and availability of implants. The reported cost for identical implants from a single manufacturer can vary as much as 700%. The comments of those responding are similar to the findings of surgeons here in the United States regarding cost containment and the role of reducing the length of hospital stay as well as negotiating reduced prosthesis and supply costs. The orthopaedic surgeon's practice pattern is a major determinant of total costs.

Arthroplasty, Replacement, Hip↗

PubMed1998

Skills training for pregnancy and AIDS prevention in Anglo and Latino youth.

PURPOSE: This study tested social skills training (SST), didactic training (DT), and no training (NT) on adolescents' social skills for resisting peer pressure to engage in acquired immunodeficiency syndrome (AIDS) and pregnancy risk behavior. METHODS: A total of 307 Latino and Anglo youth ages 13-18 years were assigned at random to receive 18 h of SST, 18 h of DT, or NT. RESULTS: Significantly (p < 0.05) greater increases in assertiveness followed SST compared to DT or NT for three trained skills: condom negotiation, asking a friend about their sex/drug history, and discussing a friend's risk of AIDS. Untrained negotiation skills (e.g., purchasing a condom) did not increase significantly. SST did not result in increased assertiveness for refusal skills. DT increased knowledge of AIDS significantly more than SST; both DT and SST increased knowledge significantly more than NT. CONCLUSIONS: Social skills training can increase assertiveness for certain negotiation skills that may decrease risk of AIDS for Latino, Anglo, and male and female adolescents. Both DT and SST can increase knowledge of AIDS prevention. Differences between experimental groups were supported by differences between trained and untrained skills within the SST condition, adding to discriminant validity.

Acquired Immunodeficiency Syndrome↗

PubMed1999

Partner condom use among adolescent girls with sexually transmitted diseases.

PURPOSE: To explore associations of self-reported condom use with sexual risk knowledge and behaviors, perceptions of peer condom use, and communication with sexual partners about condom use among adolescent girls with sexually transmitted diseases (STDs). METHODS: Adolescent girls with cervicitis or pelvic inflammatory disease (PID) completed a 62-item self-administered questionnaire on sexual risk knowledge and behaviors, condom use, perceptions of peer condom use, and condom use negotiation with partners. Associations with frequency of condom use and condom use at last sexual intercourse were analyzed. RESULTS: A total of 24 girls were enrolled: 13 with cervicitis and 11 with PID; 22 had complete data for analysis. Compared with girls who reported low frequency of condom use, girls who reported condom use all or most of the time were younger (16.7 vs. 19.5 years; p = .008), were less likely to have a prior history of STD (67% vs. 0%; p = .03), and were more likely to think that all or most of their friends use condoms (72% vs. 0%; p = .02). Compared with girls who had not used a condom with last sexual intercourse, girls who had used a condom were younger (16.2 vs. 17.9 years; p = .04), had fewer lifetime partners (2.7 vs. 8.4; p = .03) and had higher mean scores in condom use negotiation (29.1 vs. 24.4; p = .02), and were more likely to think that all or most of their friends used condoms (100% vs. 31%; p = .001). Knowledge about condoms and STD prevention was high (mean 14.3 +/- 2.3 of 16) but was not associated with condom use. CONCLUSIONS: STD interventions for partner condom use among high-risk adolescent girls must recognize the decrease in condom use with increasing age and focus on maintaining safer sex behaviors, building condom use negotiation skills, and promoting the perception of condom use by friends.

Adolescent↗

PubMedDate not supplied

Decisions regarding resuscitation of the extremely premature infant and models of best interest.

Differences concerning the care of an extremely premature infant may stem from alternative points of view on how to determine the infant's best interest. These alternatives are illustrated by differences between recently published statements by the American Academy of Pediatrics (AAP) Committee on Fetus and Newborn (COFN) and the Committee on Bioethics (COB). The statements agree that a goal of neonatal medicine is to minimize both under- and overtreatment of the extremely premature infant, and advocate that the decision-making process ought to be based on the concept of the premature infant's best interest. However, the two AAP Committees appear to diverge in how they operationalize the concept of an infant's best interest. The COFN adopts a process consistent with an "expertise" model of best interest, while the COB process is consistent with a "negotiated" model. In the "expertise" model, medical re-evaluation of the infant's status, the best outcome data available, and the treating physician's best medical judgment determine best interest. This model limits parental and societal input, and can lead a physician to act paternalistically. In the "negotiated" model, best interest is determined by outcome data and physician assessment, as well as the moral value of an outcome. This model maximizes parental input, accepts physicians as moral agents, and respects social influence in a decision. It is important to clarify one's model of best interest to help understand the differences of opinion regarding decisions based on best interest. The negotiated model of best interest is a more ethically appropriate model to approach decision making.

Decision Making↗

PubMed1977

The mental health center and the women's liberation group: an intergroup encounter.

When two separate and independent organizations must work together to accomplish a mutual task, difficulties often arise which remain poorly understood. The analysis of intergroup phenomena involves an exploration of interaction within and between groups; such relationships include problems arising from differences in tasks, structure, and culture of the two groups, definition of the intergroup task, choice of group representatives, and the possibilities and problems of dual group membership for the negotiators. While the literatures on group process and organization development contain some work on intergroup phenomena (e.g., Aldrich, 1971; Baker and O'Brien, 1971; Klein et al., 1971; Mills, 1975; Walton, 1972), much conceptual work remains to be done. We will focus upon one type of intergroup relationship--that between a traditional human service organization and a social movement group--in which dual membership is a particular problem, and in which conflict may be neutralized by the form of the negotiations. A case example of an interaction between a mental health center and a women's liberation group will provide one example of such negotiations. The analysis is presented within the framework of the open system model of Miller and Rice (1967) and Rice's general model of intergroup relations (1965, 1969).

Community Mental Health Services↗

PubMed2001

Making midwives: postmodern conditions and midwifery training in Saint Lucia.

Drawing on material from fieldwork conducted on the island of Saint Lucia, I examine how Saint Lucian nurse-midwives and student midwives negotiate multiple ways of understanding and evaluating their practices and roles in light of contradictory and powerful cultural, historical, and political forces. I argue that, although Saint Lucian nurse-midwives may not qualify as "postmodern" according to the criteria proposed by Davis-Floyd and Davis (1996), they are nonetheless struggling with postmodern conditions as they negotiate between competing healing ideologies. I illustrate the significance of these negotiations through analyzing: (1) the ways nurse-midwives understand and articulate the healing ideologies at play in Saint Lucia, (2) historical and ideological aspects of the Saint Lucian nurse-midwifery training program, and (3) a classroom discussion during which student reported on "bush-midwives."

Attitude of Health Personnel↗

PubMed2002

Relationship power, condom use and HIV risk among women in the USA.

Women's ability to negotiate safer sexual practices, particularly condom use, is a vital component of HIV/STD prevention strategies. Gender-based power imbalances may constrain women's negotiation ability, yet few empirical studies have tested the hypothesis that sexual relationship power constitutes a key factor in condom use negotiation. In this investigation, a new measure - the Sexual Relationship Power Scale (SRPS) - was applied. Data were collected from 388, mostly Latina, women at an urban community health centre in Massachusetts. Women with high levels of relationship power were five times as likely as women with low levels to report consistent condom use, after controlling for sociodemographic and psychosocial variables (p < 0.05). Population attributable risk estimates indicate that 52% of the lack of consistent condom use among women can be attributed to low sexual relationship power. The strong association between the Sexual Relationship Power Scale and consistent condom use supports the hypothesis that relationship power plays a key role in safer sex decision making. These findings underscore the importance of including the issue of relationship power in the design and implementation of programmes that promote sexual and reproductive health, as well as research investigating condom use and HIV risk.

Adolescent↗

PubMed2002

The medical futility debate: patient choice, physician obligation, and end-of-life care.

Physicians' use of the "medical futility" concept to override the treatment demands of patients or their family/surrogates is difficult to justify in principle. At the same time, patient demands for obviously futile treatments can conflict with physicians' professional obligation to do no harm to their patients. There is no clear general principle available to resolve this conflict between patient self-determination and physician autonomy; extended negotiation between patient or family/surrogates and physicians provides the only prospect for satisfactory resolution. Though such negotiation will not invariably succeed in reaching agreement, the legal system should ensure that each side has some practical measure of independent authority and power to exert against the other in order to maximize the likelihood that the negotiating process will be seriously engaged.

Brain Death↗

PubMed1995

Collaborating with re-engineering consultants: maintaining resources for the future.

The negotiations of a pharmacy department with a consulting firm hired to help cut the institution's staff are described. In July 1994 Duke University Medical Center announced its intention to reduce the number of full-time equivalents (FTEs) from 6500 to 5000 and hired a consulting firm. The pharmacy department was scheduled to be studied for 16 weeks. The entire pharmacy staff was educated about the initiative and about what management expected of the staff during the process. Each assistant director of pharmacy was asked to lead the "operations improvement process," as the re-engineering plan was called, in his or her area of responsibility. The assistant directors were to describe key work activities and their time requirements and develop instruments for measuring work activities. Data were collected on supplemental resource requirements for paid time off and educational and meeting time. Resource requirements for clinical pharmacy specialists and other selected staff members were determined separately. The data were collected for one fiscal month, and the assistant directors then began negotiating human-resource requirements with the consultants. The director finalized the negotiations and presented the results to the hospital's leaders and the consulting firm's executives. It was proposed to reduce total pharmacy FTEs by only 5%, and the department actually gained 1 pharmacist FTE. Far greater reductions were proposed for most other departments (the entire medical center lost more than 800 FTEs). The pharmacy department at Duke dealt successfully with a re-engineering initiative. Strategies that contributed to the success included teamwork, active participation by the entire staff, empowering a core group to help lead in the process, and substantiating the value of the pharmacy's services to the medical center and its patients.

Consultants↗

PubMed2007

Ethnic segregation in Kosovo's post-war health care system.

BACKGROUND: Seven years after the end of war in Kosovo, Final Status Negotiations have begun to determine the long-term political future of the province. This article provides an overview of the present situation regarding ethnic groups and their relations in Kosovo's health care system that might be helpful in preparing for the array of potential ramifications and repercussions that could arise at the conclusion of the negotiations. METHODS: A review of the literature (including grey) was performed, and 16 interviews and two focus groups with key informants were conducted in Kosovo during October and November 2004. In addition, six informal discussions were held in-person or by telephone in London. Information collected in 2004 was re-confirmed and partially updated in October and November 2005, when three additional interviews were conducted in Kosovo. RESULTS: Ongoing ethnic tensions in Kosovo, mainly between the Albanian and Serb populations, perpetuate a rigidly segregated health care system. Some other minority communities, such as the Roma, Ashkali and Egyptians, are afflicted by the double burden of getting caught up in the middle of these ethnic disputes and at the same time suffering from poverty and discrimination. CONCLUSION: While efforts have been put forward to promote peace-building within Kosovo's post-war health sector, very little progress has been achieved in fostering ethnic integration, reconciliation, cooperation or even co-existence. This failure reflects Kosovo's broader unresolved inter-ethnic problems. Final Status Negotiations are one of the last opportunities for the international community to address the problems of ethnic segregation in the province.

Delivery of Health Care↗

PubMed2000

Taking prisoners: Havelock Ellis, Sigmund Freud, and the construction of homosexuality, 1897-1951.

This paper addresses the efforts of both Havelock Ellis and Sigmund Freud to posit a theory of homosexuality, and especially considers their efforts to (re-)negotiate each other's theories. Its central premise derives from the sociology of scientific knowledge: that it is not what is written, but the way that what is written is treated by ensuing experts, that makes knowledge. In the case study used in this paper, Ellis and Freud struggle to posit what they consider to be the proper model for understanding homosexual desire. They utilize aspects of each other's word, but are careful not to appear to be following each other too closely. Such a struggle to establish different schools of thought is exemplified by the informal negotiations engaged in when a student, Joseph Wortis, made contact with both Freud and Ellis. Again following sociology of scientific knowledge precepts, these informal negotiations (contained in published and archival letters) are used to show how knowledge claims are constructed, deconstructed any reconstructed by the actors who have stakes in the outcome of what is to be regarded as knowledge in the relevant communities.

History, 19th Century↗

PubMed1995

Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda.

OBJECTIVE: To describe sexual interaction and HIV-related communication in Rwandan couples and to examine their relationship to HIV testing and condom use. STUDY DESIGN: Cross-sectional survey of a longitudinal cohort. METHODS: In 1988, women recruited for an epidemiological study of HIV, and interested male partners, received confidential HIV testing and counseling. Two years after enrollment, 876 women reporting one steady partner in the past year completed a questionnaire addressing sexual and HIV-related communication, sexual motivation and violence in the partnership. RESULTS: Men control sexual decision making, and coercive sex and violence between partners is not uncommon. HIV-positive women were more likely to report coercive sex and less likely to have discussed their test results with their partner. Women with HIV-positive partners were more likely to report being physically abused. Condom use was more common if the man had been previously tested, and if women reported discussing or negotiating condom use. HIV-negative women with untested or seronegative partners were the least likely to use condoms or to discuss or attempt to negotiate condom use. CONCLUSIONS: Participation of the male partner is crucial for successful HIV risk reduction in couples. HIV testing and counseling of couples has beneficial long term effects on condom use and HIV-related communication. Couple communication is associated with condom use, but only when the discussion is specific (sexually transmitted disease risks and using condoms). Seronegative women with untested partners are at increased risk for HIV as they are the least likely to discuss or attempt to negotiate condom use.

Coercion↗

PubMed2001

Conflict resolution at the end of life.

OBJECTIVE: Limited empirical research has examined how decisions are made when the preferences of terminally ill patients conflict with physicians' recommendations. This study sought to investigate physicians' strategies for resolving conflicts with dying patients. DESIGN: Cross-sectional, qualitative interviews. SUBJECTS: Subjects were 158 physicians caring for at least one terminally ill patient. SETTING: University medical center. MEASUREMENTS AND MAIN RESULTS: We analyzed physicians' responses to the open-ended interview questions, "How do you handle a situation when a patient wants a treatment that you believe does not provide any benefit?" and "How do you handle a situation when a patient does not want a treatment you think would be beneficial?" For patient requests of nonbeneficial treatments, physicians reported the following as important: negotiating with and educating patients (71%), deferring to patient requests for benign or uncomplicated treatments (34%), convincing patients to forgo treatments (33%), refusing patient requests for nonbeneficial treatment (22%), using family influence (16%), not offering futile treatments (13%), and referring to other physicians for disputed care (9%). Potential harm (23%) and cost of treatment (18%) were reasons cited for withholding treatments. In response to patient refusals of beneficial treatments, physicians report the following as important: negotiating with patients (59%), convincing patients to receive treatment (41%), assessing patient competence (32%), using family influence (27%), and referring to other physicians (21%). CONCLUSIONS: Physicians vary in the communication and negotiation strategies they use when their medical judgment conflicts with dying patients' preferences. Medical ethicists could play a greater role in teaching ethically important communication skills. Physicians providing care at the end of life report strategies for respecting patients that reflect graduated degrees of accommodation tailored to the costliness and riskiness of requests; they are most accepting of patient requests for benign, technically easy, inexpensive, and medically effective treatments.

Adult↗

PubMed2000

Frequency of second mesiobuccal canals in maxillary molars as determined by use of an operating microscope: a clinical study.

Operating microscopes have recently been introduced to facilitate treatment of surgical and nonsurgical endodontic cases. The aim of this study was to determine in an in vivo clinical study if the use of an operating microscope would increase the number of second mesiobuccal canals located and obturated in maxillary first and second molars. Two hundred maxillary first and second molars treated with the aid of a microscope were evaluated. The number of second mesiobuccal canals that could be negotiated and obturated within 4 mm of the apex was recorded. Thirty percent of all maxillary molars had a negotiable second mesiobuccal canal. Evaluated separately, 33.1% of the maxillary first molars and 24.3% of the second molars had a negotiable second mesiobuccal canal. Results indicated that use of a surgical microscope did not increase the number of second mesiobuccal canals located, compared with those reports where access preparations were modified and the microscope was not used.

Dental Pulp Cavity↗

PubMed1976

The potential of the teaching hospital for the development of prepaid group practices.

This paper deals with the development of a hospital based prepaid group practice at Long Island Jewish-Hillside Medical Center. The paper provides an historical perspective of the factors leading to the decision to develop such a Medical Group practice, the difficulties encountered in obtaining conceptual approval from the Medical Center's Board of Trustees and its medical staff, the negotiations between the Medical Center and Blue Cross-Blue Shield of Greater New York as the insurance company which agreed to market the program and to subsidize it in its developmental stage, factors relating to the contractual negotiations between the Medical Center and Blue Cross, the key elements of the negotiated contract from the standpoint of the prepaid group, and the nature of the subsidies provided to ensure a healthy fiscal beginning. The paper highlights the methods used in achieving the desired goals and the development of the Group, sets forth the resistance which other, similar hospitals might anticipate in undertaking such a venture of their own, and highlights the nature and the degree of commitment necessary to bring such a program into being.

Blue Cross Blue Shield Insurance Plans↗

PubMed1996

Physician factors affecting patient willingness to comply with exercise recommendations.

OBJECTIVE: To evaluate how physician factors such as weight, exercise habits, and humanistic traits could influence patient willingness to comply with exercise recommendations. DESIGN: Survey questionnaire. SETTING: University-based Family Medicine Clinic. PATIENTS: 411 consecutive established patients of the Family Medicine Clinic. MAIN OUTCOME MEASURES: Selected Physician characteristics that patients believed would increase their willingness to comply with exercise recommendations. Results were compared with patient demographics to determine possible effects of physician characteristics on patients acceptance of exercise recommendations. RESULTS: Patients with higher education levels could be positively influenced by a physician being of appropriate weight, a regular exerciser, and a nonsmoker, and enlisting use of other experts, negotiating an exercise program, providing exercise counseling, and being their primary provider. Patients with higher income levels could be positively related to a physician's being of appropriate weight, and a nonsmoker, negotiating an exercise program, and enlisting use of other experts. Female patients could be positively influenced by physicians being well groomed, well dressed, accessible, and good listeners. Patients who regularly exercise could be positively influenced by a physician's appropriate weight and exercise regimen. CONCLUSIONS: Physicians may have a positive impact on patient willingness to comply by prescribing exercise and providing education and detailed guidance for all candidates. The study also showed that physicians' negotiating exercise programs and being good "exercise" role models is very important.

Adolescent↗

PubMed2004

The process of hospital discharge for medical patients: a model.

BACKGROUND: The 1990 NHS Community Care Act established a requirement for hospital discharge policies and procedures in the United Kingdom to be developed in collaboration with local government authorities in order to ensure supported discharge for those in need. AIMS: The aim of the study reported in this paper was to track decisions about hospital discharge in relation to outcomes for a sample of medical patients and their carers, identified as at risk of experiencing unsuccessful discharge processes. METHODS: Themed unstructured interviews were conducted in three different hospitals with 30 patients identified as at risk of unsuccessful discharge and their carers pre- and postdischarge. Hospital, community and social care staff involved in the care of the patient were also interviewed. FINDINGS: Patients and carers were constantly negotiating their social roles, seeking to juggle appropriate identities and limited resources to maintain their own and each others' dignity and quality of life. When the negotiation process was destabilized (for example, by exacerbation of chronic disease, withdrawal of some resource, or the experience of additional stressors - not necessarily health-related), then either or both parties sought a way out. In all the cases examined the result was admission to hospital - usually, but not always, mediated by community professionals. CONCLUSIONS: The effective discharge of patients from hospital needs to move from a functional focus on symptom management to a negotiation of quality of life that seeks to promote health for all parties involved.

Adult↗