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PubMed2005

Exploring the social and cultural context of sexual health for young people in Mongolia: implications for health promotion.

Recent political, economic, and cultural changes in Mongolia make its large proportion of young people vulnerable to HIV infection. While there had been only two clinical cases of HIV in Mongolia by the year 2000, the incidence of sexually transmitted infections (STIs) is on the rise, especially among people aged 15-24. Little is known about the social and cultural context in which the sexual knowledge, attitudes, and behaviour of Mongolian young people are created and negotiated. This context must be better understood in order to promote safer sex practices. This study employed qualitative research methods to explore and describe the social and cultural context in which sexual behaviour is negotiated among secondary school students in Ulaanbaatar, Mongolia. Students and teachers from two schools in Ulaanbaatar and health professionals were selected by purposeful sampling to participate in six semi-structured focus group interviews in autumn 2000. Thematic content analysis was conducted on the focus group transcripts. Seven themes were extracted including embarrassment, lack of knowledge, concepts of sex, perceptions of condoms, gender roles, peer norms, and the influence of drinking on sexual activity. Results presented are the first description of the social and cultural context of sexual health and highlight the combined impact of these themes on safer sex practices in Mongolia. These findings are not generalizable, but their agreement with the Mongolian and the international literature indicates that they may be transferable. Implications for STI and HIV/AIDS prevention efforts and further research in Mongolia are discussed.

Adolescent↗
PubMed2004

"What's wrong with me?": cervical cancer in Venezuela--living in the borderlands of health, disease, and illness.

Social scientists concerned with studying the social and cultural meaning of illness problematize the relationship between disease and illness, noting that illness can exist without disease-abnormal physical changes in the body. What has received less attention is the existence of disease-made visible through technological advances-in the absence of illness. Cervical cancer (or the more ambiguous cervical abnormalities) is an example of a disease that is largely symptomless in its early stages and can occur in the absence of illness. In this paper I explore how women seek to understand and negotiate cervical cancer in the context of their everyday lives, as they are confronted with seemingly disparate and contradictory physical and psychological states of well-being, sickness, and disease. This experience is what I call living on the borderlands of health, disease, and illness, where all of these states are experienced concurrently and boundaries between them blur. Through observations of patient-doctor interactions, ethnographic interviews with doctors and women seeking treatment for cervical cancer and pre-cancerous abnormalities, I analyze how women try to understand their medical experience. And they do so with the added challenge of little information being shared with them by the doctors who treat them. While patients do not ask many questions of their doctors, this does not mean that women are disinterested in their health. In fact, they develop strategies for eliciting clinical information about their medical conditions and actively seek to make sense of their experiences. By problematizing the concepts of health, disease, and illness, and avoiding the tendency to see these as distinct and contradictory phenomenon, we can gain a better understanding of their interrelatedness, and how people negotiate this borderland.

Adaptation, Psychological↗
PubMed2005

Boundary breaches: the body, sex and sexuality after stoma surgery.

People with limited or no bladder or bowel control, who have had a stoma to manage elimination, have a particular awareness of the proximity of the sites of pleasure and excretion. Drawing on interviews and related ethnography conducted in Australia from 1998 to 2001, this paper explores how men and women with permanent continence problems negotiate their sexuality around their bodily unreliability. Pleasurable sex, idealized, involves losing control. People who are incontinent or rely on a stoma, however, must monitor their bladder and bowel, disguising the stoma and bag and controlling their body in sex as in other circumstances. The need to negotiate bodily boundaries with established partners, or to disclose to new sexual partners, results in self-consciousness and social unease, and people need to reconstruct notions of privacy and dignity so that breaches in bodily control do not undermine the sexual relationship. For many, the stoma undermines self-esteem and body image, while its management confuses the status of the individual as "normal" and the partner as carer or lover.

Adult↗
PubMed2005

Can women's autonomy impede male involvement in pregnancy health in Katmandu, Nepal?

Women's empowerment programs focus primarily on increasing the decision-making power of women, while male involvement/couple-friendly programs emphasize communication and negotiation within couples in making decisions. In-depth-interviews and focus group discussions were conducted to investigate patterns of household decision-making and the context of male involvement behaviors in Katmandu, Nepal. A questionnaire focusing on household decision-making and husbands' roles during pregnancy was administered to 592 pregnant women receiving antenatal services at a large maternity hospital. Multivariate regression techniques were used to compare male involvement behaviors across varying levels of women's autonomy, represented by different decision-making patterns. Higher women's autonomy, as measured by her sole final decision-making power, was associated with significantly lower male involvement in pregnancy health. After adjustment for other covariates, each additional decision in which a woman had final say was associated with a significantly lower likelihood of her husband accompanying her to antenatal care (OR=0.70, p<0.01). Conversely, joint decision-making between the husband and wife was associated with significantly higher levels of male involvement in pregnancy health. For each additional decision made jointly with husbands, women were more likely to discuss health with their husbands (OR=1.47, p<0.001), to make birth preparations (OR=1.19, p<0.05), and to experience a high level of male involvement (OR=1.29, p<0.05). The positive associations between joint decision-making and male involvement imply that couple communication and shared negotiation strategies can improve health practices. These results indicate that programs intended to increase women's empowerment and/or women's health must consider the dynamics and ramifications of including or excluding males in their efforts. Involving husbands and encouraging couples' joint decision-making in reproductive and family health may provide an important strategy in achieving both women's empowerment and women's health goals.

Adult↗
PubMed2005

Community-based participatory research (CBPR) in South Africa: engaging multiple constituents to shape the research question.

Community engagement is an on-going, arduous, and necessary process for developing effective health promotion programs. The challenges are amplified when the particular health issue or research question is not prominent in the consciousness of the targeted community. In this paper, we explore the community-based participatory research (CBPR) model as a means to negotiate a mutual agenda between communities and researchers. The paper is focused on the (perceived) need for cervical cancer screening in an under-resourced community in Cape Town, South Africa. Cervical cancer is a significant health problem in this community and elsewhere in South Africa. Unlike HIV-AIDS, however, many Black South Africans have not been educated about cervical cancer and the importance of obtaining screening. Many may not consider screening a priority in their lives. Our research included extensive consultations and informal interviews with diverse community and regional stakeholders. Following these, we conducted 27 focus groups and 106 demographic surveys with randomly selected youth, parents, local health care personnel, educators and school staff. Focus group data were summarized and analyzed cross-sectionally. Community stakeholders were involved throughout this research. Our consultations, interviews, and focus group data were key in identifying the concerns and priorities of the community. By engaging community stakeholders, we developed a research framework that incorporated the community's concerns and priorities, and stressed the intersecting roles of poverty, violence, and other cultural forces in shaping community members' health and wellbeing. Community members helped to refocus our research from cervical cancer to 'cervical health,' a concept that acknowledged the impact on women's bodies and lives of HIV-AIDS and STDs, sexual violence, poverty, and multiple social problems. We conclude that the research agenda and questions in community-based health research should not be considered immutable. They need to be open to negotiation, creativity, and constant reinvention.

Adult↗
PubMed2005

'Between the demands of truth and government': health practitioners, trust and immunisation work.

Applied and theoretical work on health governance and governmentality has often not engaged with the perspectives of practitioners and, in particular, with their understandings about trust. In this paper, we address these absences through looking at a critical technology of governmentality--child immunisation. We do this, first, by examining theoretical links between risk, trust and knowledge in relation to the governance of health. We then draw on findings from our secondary analysis of qualitative data based on interviews with key actors in primary care in Scotland charged with the delivery of a particular immunisation--the MMR vaccine. While many practitioners, like parents, have typically perceived immunisation--along with other public health initiatives-as obligatory and as part of 'good citizenship', we argue that in relation to MMR and in the context of clinical governance, practitioners are having to engage in complex negotiations about knowledge and trust--negotiations that are at the heart of governing health at a distance.

Autistic Disorder↗
PubMed2006

Developing a cultural model for long-term female urinary incontinence.

The purpose of this study is to examine the subjective experience of long-term urinary incontinence and to show how a cultural model helps define that experience. Using a narrative approach within a cultural models framework, the specific aims are to describe and analyze: (1) what urinary incontinence means; and (2) how that meaning is constructed and negotiated by women living with urinary incontinence. 17 community-dwelling women (from Philadelphia, USA, and its immediate suburbs) participated in semi-structured interviews. Plot types and shared themes were compared with themes that emerged from media representations of female incontinence, and a cultural model was developed. Findings suggest: (1) the meaning of long-term female urinary incontinence is constructed and negotiated as a result of individual and shared experiences; (2) the cultural model constructed by women differs significantly from the professional, primarily biomedical model; and (3) women's narratives provide a method for accommodating similarities and differences between lay and professional models.

Adaptation, Psychological↗
PubMed2005

Postoperative futile care: stopping the train when the family says "keep going".

All surgeons must take risks when providing medical care. No guarantees of protection from a lawsuit exist in any guise. Concerning postoperative futile care, the stakes are high when withdrawal of support seems to be indicated but the surrogate believes in sanctity-of-life and demands continued aggressive care. Open-ended questions posed to the family may initiate a dialog that help the surgeon understand their values and negotiate a resolution. Other preventive measures can also reduce the chance of conflict and potential liability. "Do what's right" is a proverbial motto in surgical training and clinical practice. To some surgeons, it may be to honor the wishes of the family surrogate. To others, the right thing may be to withdraw care in the best interest of the patient. If so, "do what's right" is not just to "stop the train." It also consists of a range of clinical activities, including effective communication, emotional care, and pursuing a fair and open negotiation process established by the institution. Properly conducted, "stopping the train" should incur no greater risk for professional liability than any other challenging procedure that surgeons perform. Withdrawal of futile care should be considered as a procedure, and as such, the skills to deliver it should be mastered like any other.

Conflict, Psychological↗
PubMed2001

Transluminal stent-assisted coil embolization of a vertebral confluence aneurysm: technique report.

BACKGROUND: Recent advances in stent technology have allowed for negotiation of often tortuous posterior circulation intracranial vasculature. Stent-assisted coil embolization is a novel treatment for complex wide-necked aneurysms, as stents provide a buttress that allows for coil deposition while preventing coil herniation into the parent vessel lumen. We describe a case of stent-assisted coil embolization of a complex wide-necked vertebral confluence aneurysm. CASE DESCRIPTION: A 61-year-old woman presented with a Hunt-Hess III, Fisher Grade III subarachnoid hemorrhage secondary to a ruptured vertebral confluence aneurysm demonstrated on angiography. The patient underwent emergent angiography and attempted coiling of a vertebral confluence aneurysm. Because of the aneurysm's complex wide neck and the presence of subclavian steal syndrome, the coils repeatedly herniated into the left vertebral and basilar artery lumina. A flexible coronary stent was deployed across the aneurysm neck, preventing coil herniation and allowing for greater coil deposition. The patient tolerated the procedure and underwent repeat coiling 2 months postoperatively because of mild coil compaction. This resulted in 100% occlusion and the patient is neurologically normal except for a sixth nerve palsy which had been present after the hemorrhage. CONCLUSION: Recent advances in stent technology allow negotiation of the tortuous posterior circulation vasculature. Stent-assisted coil embolization of complex, wide-necked vertebral confluence aneurysms may be an alternative intervention for these surgically challenging lesions.

Aneurysm↗
PubMedDate not supplied

Developmental alterations of ethanol sensitivity in selectively bred high and low alcohol sensitive rats.

Initial sensitivity and acute tolerance to ethanol have been implicated as risk factors in the development of alcoholism in humans. These behaviors were investigated in rats selectively bred for differences in hypnotic sensitivity following their first dose of ethanol in two different experiments. In Experiment 1, developmental profiles of the association between initial sensitivity and acute tolerance induced by a single exposure to ethanol were examined using male and female high, low, and control alcohol sensitive (HAS, LAS, and CAS) rats. Dose-response curves were constructed for duration of the loss of the righting reflex and for blood ethanol concentration (BEC) at the regain of the righting reflex. Animals were tested with a single ethanol dose ranging from 1.5 to 5.0 g/kg at either 15, 25, 40, 70, 120, or 180 days of age (DOA). For each group, acute tolerance to ethanol was estimated by the slope of the regression line using dose of ethanol and mean BEC at regain. In general, all rat lines showed an increase in hypnotic sensitivity to ethanol with age. To a large degree, the lower sensitivity observed in 15 and 25 DOA HAS and LAS rats was associated with an increase in the development of acute ethanol tolerance relative to older rats. Divergence of the LAS and CAS lines was evident by 25 DOA and remained stable with advancing age. However, HAS rats did not differ significantly from CAS rats until 40 DOA, after which the magnitude of the difference continued to increase with age. In Experiment 2, rats were treated with alcohol at 25, 70, or 180 DOA. Rats at 70 or 180 DOA required less ethanol to disrupt their motor coordination on a rotating dowel (rotarod). Blood ethanol levels were determined at the loss and subsequent regain of the ability to negotiate the rotarod. Total duration of inability to negotiate the rotarod also was recorded. HAS rats were less able to remain on a rotarod while under the influence of alcohol relative to LAS and CAS rats regardless of age. However, no evidence of acute tolerance was observed in this experiment and, in fact, there was evidence of reverse tolerance in that all animals had lower BEC values at regain of ability than they did at loss.

Age Factors↗
PubMed2002

Should the US allow prescription drug reimports from Canada?

As a result of public outrage over lower prescription drug prices in Canada, Congress passed legislation that would allow these drugs to be imported into the US. The lower Canadian prices reflect price regulation. Opponents of allowing these imports have argued that the US will import Canadian price controls and that profits of pharmaceutical companies will be hurt. In this paper, a model is developed in which a good sold in the foreign country is subject to a negotiated price which is determined in a Nash bargaining game. When imports back into the home country are allowed, this negotiated price also becomes the domestic price. This causes the home firm to make fewer price concession in the Nash bargaining game. Home firm profits are found to rise under the reimport regime for both of the demand functions analyzed in this paper.

Canada↗
PubMed2002

The legacy of nuclear risk and the founder effect in biotechnology organizations.

In the wake of the Chernobyl nuclear accident and a decline in the public trust of science, the founders of modern biotechnology recognized the strategic importance of risk assessment and regulatory affairs. In an effort to avoid the demonization that was attached to the nuclear industry, the pioneers of modern biotechnology delegated authority for regulatory negotiation and risk management to senior positions in the firm. At the same time, the Biotechnology Industry Organization was handed great latitude and trust with making public pronouncements on issues of bioethics and public policy. The way in which founders and leaders embed norms for negotiating regulation and responding to public perceptions has proved important in the maturation and acceptance of a biotechnology sector.

Biotechnology↗
PubMed2001

Equity in health in unequal societies: meeting health needs in contexts of social change.

The paper explores the implications for health policy of the segmentation of society into social groups with very different levels of income and wealth. Discourses on equity in health are presently dominated by a debate between 'European' and 'American' models of health delivery. This has led to a focus on ideal outcomes rather than practical options for organising and financing health services in poor countries undergoing rapid change. The paper argues for a more explicit acknowledgement of the dynamic character of health development and the political nature of the negotiations regarding the use of government powers. Unregulated markets for health care are neither equitable nor efficient. Government must play a role in supporting the organisation of health services used by different social groups. Countries with low levels of inequality may be able to provide universal access to relatively sophisticated health services. Otherwise, governments need to operate within a segmented system. This means the negotiation of strategies to reduce the burden of sickness and premature death, whilst meeting the needs of different social groups. The discussion is organised in terms of the powers of government to require individuals and institutions to transfer resources for social uses, enforce regulations and generate and disseminate information. The paper concludes that governments committed to equity-enhancing health development need to increase their capacity to facilitate coalition building and manage change. It proposes an international public health legal framework that might include a definition of minimum standards for certain health services, to be underwritten by national and international financial commitments.

Developing Countries↗
PubMedDate not supplied

[Transparency in public sector acquisitions. The case of hospitals in the City of Buenos Aires].

This paper deals with corruption and the lack of transparency in public sector purchases as well as with the main instruments to obtain adequate results in purchase negotiation.Firstly, we discuss how corruption causes concern to national governments, international organizations, academic centers, non-governmental organizations and society in general. The consequences of corruption in Argentina and other Latin American countries are highlighted, especially the effect of corruption on economic growth and the way it creates economic inefficiency and inequality.Secondly, the database created by the Subsecretary of Strategic Management of the Autonomous Government of the City of Buenos Aires is analyzed. The central purpose of this study is to evaluate the impact of the Administrative Reform of 1998 on the prices of 24 products acquired by 13 general acute care hospitals from 1998-1999. The weighted prices, the number of units purchased and the total number of contracts given in this period, as well as the products with the greatest utilization rate, are analyzed. Multivariante analysis was used to identify hospitals with appropriate activity and efficient budget administration (activity and negotiation indicators). Price development was analyzed using the regression technique (ordinary least squares), which demonstrated an 8% reduction in prices for the year 1999. The contribution of each hospital to this variation is presented using dummy variables. Thus, six of the 13 hospitals significantly contributed to the decrease in prices. Of these six, three hospitals also contributed to reduction in price dispersion. The results obtained allow us to conclude that, if public hospitals have adequate purchase negotiation instruments and a uniform legal framework, they can achieve a good level of activity. Furthermore, public hospitals can contribute to reductions in price and price dispersion, at the same time as improving efficiency in the assignation and utilization of resources.

Argentina↗
PubMed1998

Parallel process in clinical supervision: enhancing learning and providing support.

The introduction of clinical supervision in nursing is gaining momentum and is proposed as having numerous benefits for nurses, organizations, and ultimately patient care. The necessity for such supervision has arisen partly from a fundamental shift in the nature and definition of nursing work. The emphasis on individualized, holistic care has led to a change in role from one characterized by professional distance to one in which interpersonal involvement is seen as central. Such a shift, though seen as positive, may lead to increased vulnerability as nurses negotiate the blurred boundaries between the personal and the professional in their relationships with patients. Such boundary negotiation is a legitimate focus for learning and support in clinical supervision. However, as with many aspects of nursing, the subtle processes involved in relationship development are often hidden from consciousness, thus missing potential learning opportunities. One way that such hidden aspects of practice may be explored in clinical supervision is through attendance to the way that such processes are parallelled in the supervisory relationship. Drawing on theory and practice from the fields of counselling and mental health nursing, this paper explores the nature of 'parallelling' in clinical supervision. The implications for clinical supervision in nursing more generally are examined in relation to enhancing learning and providing support for supervisees and supervisors.

Clinical Competence↗
PubMed2002

Participating in decisions about treatment: overt parent pressure for antibiotic medication in pediatric encounters.

This article examines how parents and pediatricians negotiate antibiotic prescribing decisions in cases where parents overtly advocate this medication. Using the methodology of conversation analysis, this paper examines audio and videotaped acute care pediatric encounters and discusses four primary ways in which parents raise antibiotics in pediatric encounters. These formulations vary in their directness with indirect formulations being more common. The article argues that both parents and physicians are oriented to antibiotics as negotiable in and through their interaction. Finally, in contrast with existing research, this study suggests that overtly advocating for antibiotic treatment is relatively unusual; future research will need to incorporate an understanding of the effect of both explicit and implicit ways parents communicate pressure for prescription treatment.

Adult↗
PubMed2002

Cross-cultural encounters between careproviders: rabbis' referral letters to a psychiatric clinic in Israel.

This paper explores the meaning and social functions of referral letters sent to a mental health clinic in Israel by Haredi (ultra-orthodox) rabbis. The letters exemplify social mechanisms by which various institutions and individuals (careproviders, therapists, and other social actors) negotiate different therapies, advice, and interventions in cross-cultural encounters. We argue that beyond the practical functions of the letters, the rabbis-representatives of a "popular" and religious social sphere-use them to negotiate their position in relation to the psychiatric clinic as a representative of a professional and secular sphere. We show that the rabbis "submit" to the professional and secular therapists by using a local adaptation of Western psychological and psychiatric discourses (instead of a religious or mystical discourse), but also that by choosing a letter as their preferred medium of communication (instead of a personal visit to the clinic), they distance themselves from it. We suggest that the rabbis reconstitute, via the letters, social boundaries within their religious community and between their community and secular society. Hence, through analysis of discourses of mental illness in a cross-cultural encounter we examine ways in which illness is practically managed among diverse groups in society. Specifically, we analyze such discourses as part of a power relationship between careproviders who belong to different therapeutic social spheres, using a phenomenological exploration of how mental illness is perceived and constructed as both "a medical problem" and as "social deviance".

Clergy↗
PubMed2003

Television documentary in New Zealand and the construction of doctors by lower socio-economic groups.

The medical profession remains central to the provision of health care and the treatment of illness within contemporary society. However, the image of doctors and the relationship of the profession with the public is contested. The public persona of doctors has been subjected to re-negotiation in recent years as a result of factors such as health care reforms, the increased autonomy of other health professionals, the rise of the health consumer, and well-publicised cases of medical misadventure. We argue that television viewing is one influential way through which images of medical doctors are socially negotiated. This paper explores the construction of doctors through an analysis of television health documentary coverage and the accounts of lower SES participants in New Zealand. It demonstrates how televised depictions of doctors are integrated into the lifeworlds of viewers. We show that multiple and often contradictory representations of doctors, within both television health coverage and the accounts of our participants, conflate the traditional characterization of the caring professional with more recently established characterizations such as the medical entrepreneur and the bungling quack. The result is a complex and contextually variable image of doctors that embodies tensions surrounding public anxiety over health care reform. Recourse to this more pluralistic image of doctors provides a way for participants to work through the dilemmas posed by reduced access to medical care and the uncertainties of medical treatment, while still maintaining support for universal access to medical care.

Attitude to Health↗