Common ground refers to the knowledge shared by two communicating parties to enable communication to occur. We suggest that common ground could enhance collaborative care delivery by serving as the linkage between different healthcare team members. Despite research describing the importance of common ground to facilitate communication, little is known about how common ground forms, moments where it is necessary, and barriers to achieving it. To address this shortcoming we studied collaborative care delivery in two settings and then used Grounded Theory methodology to develop a model of common ground. The model contains four main concepts: moments of common ground, barriers to common ground, fabric of common ground, and consequences of weak common ground. Our findings show that common ground is multi-dimensional with both static and dynamic aspects. The results from this paper help us to better understand collaborative care delivery and how to design information and communication technologies to support it.
common ground; collaboration; communication; healthcare teams
This study aimed to examine the experiences of walking promotion professionals on the range and effectiveness of recruitment strategies used within community based walking programmes within the United Kingdom.
Two researchers recruited and conducted semi-structured interviews with managers and project co-ordinators of community based walking programmes, across the UK, using a purposive sampling frame. Twenty eight interviews were conducted, with community projects targeting participants by age, physical activity status, socio-demographic characteristics (i.e. ethnic group) or by health status. Three case studies were also conducted with programmes aiming to recruit priority groups and also demonstrating innovative recruitment methods. Data analysis adopted an approach using analytic induction.
Two types of programmes were identified: those with explicit health aims and those without. Programme aims which required targeting of specific groups adopted more specific recruitment methods. The selection of recruitment method was dependent on the respondent’s awareness of ‘what works’ and the resource capacity at their disposal. Word of mouth was perceived to be the most effective means of recruitment but using this approach took time and effort to build relationships with target groups, usually through a third party. Perceived effectiveness of recruitment was assessed by number of participants rather than numbers of the right participants. Some programmes, particularly those targeting younger adult participants, recruited using new social communication media. Where adopted, social marketing recruitment strategies tended to promote the ‘social’ rather than the ‘health’ benefits of walking.
Effective walking programme recruitment seems to require trained, strategic, labour intensive, word-of-mouth communication, often in partnerships, in order to understand needs and develop trust and motivation within disengaged sedentary communities. Walking promotion professionals require better training and resources to deliver appropriate recruitment strategies to reach priority groups.
We are a society that is fixated on the health consequences of 'being fat'. Public health agencies play an important role in 'alerting' people about the risks that obesity poses both to individuals and to the broader society. Quantitative studies suggest people comprehend the physical health risks involved but underestimate their own risk because they do not recognise that they are obese.
This qualitative study seeks to expand on existing research by exploring obese individuals' perceptions of public health messages about risk, how they apply these messages to themselves and how their personal and social contexts and experiences may influence these perceptions. The study uses in depth interviews with a community sample of 142 obese individuals. A constant comparative method was employed to analyse the data.
Personal and contextual factors influenced the ways in which individuals interpreted and applied public health messages, including their own health and wellbeing and perceptions of stigma. Individuals felt that messages were overly focused on the physical rather than emotional health consequences of obesity. Many described feeling stigmatised and blamed by the simplicity of messages and the lack of realistic solutions. Participants described the need for messages that convey the risks associated with obesity while minimising possible stigmatisation of obese individuals. This included ensuring that messages recognise the complexity of obesity and focus on encouraging healthy behaviours for individuals of all sizes.
This study is the first step in exploring the ways in which we understand how public health messages about obesity resonate with obese individuals in Australia. However, much more research - both qualitative and quantitative - is needed to enhance understanding of the impact of obesity messages on individuals.
Community-based coalitions have been advocated as a promising mechanism to reduce youth involvement in violence, delinquency, and substance use, but coalitions have not always been successful in ensuring widespread adoption of evidence-based prevention strategies. This paper describes the strategies used by 12 community coalitions to collaborate with schools to select and implement school-based prevention programs, including the barriers to establishing coalition/school partnerships and methods for overcoming these challenges.
In this five-year research project, all communities adopted school-based prevention programs. Coalitions helped achieve this outcome by building relationships with school personnel, fostering champions within the school, creating win/win situations in which schools' needs were addressed, and initiating school-based prevention programs as pilot efforts that were later expanded. While success was achieved in all cases, persistent messaging about the importance of youth problem behaviours was needed to overcome schools' concerns about using academic time to teach prevention messages and replacing current practices with unfamiliar programs.
Findings from this study can be used by coalitions and prevention scientists that want to partner with schools to reach a large population of students with effective prevention programming. The results are also of value to researchers and practitioners interested in fostering widespread dissemination of other types of evidence-based programs.
adoption; school/community partnerships; coalitions; violence prevention
We conducted semi-structured interviews with 33 women attending breast cancer risk counseling at a public hospital high risk clinic to elicit their understandings of their risk and their attitudes towards prevention. Women's views of risk differed from the medical model: many felt they were not “high risk” because they lacked signs and symptoms of cancer and some feared that “dwelling on” one's risk might lead to cancer. While screening was welcomed, taking tamoxifen to prevent cancer was generally seen as harmful and useful only as treatment. Physicians and researchers should recognize and address alternative ways that diverse patients understand risk.
We sought to understand how African American women’s beliefs regarding depression and depression care are influenced by racism, violence, and social context.
We conducted a focus group study using a community-based participatory research approach. Participants were low-income African American women with major depressive disorder and histories of violence victimization.
Thirty women participated in 4 focus groups. Although women described a vicious cycle of violence, depression, and substance abuse that affected their health, discussions about health care revolved around their perception of racism, with a deep mistrust of the health care system as a “White” system. The image of the “strong Black woman” was seen as a barrier to both recognizing depression and seeking care. Women wanted a community-based depression program staffed by African Americans that addressed violence and drug use.
Although violence and drug use were central to our participants’ understanding of depression, racism was the predominant issue influencing their views on depression care. Providers should develop a greater appreciation of the effects of racism on depression care. Depression care programs should address issues of violence, substance use, and racism.
Little is known about African American women’s collection of family health history (FHH) information and use of FHH tools. Most FHH research has investigated tools that use a biomedical paradigm, but other kinds of tools, such as those that include information about family social context, have been developed for use in diverse populations. Using mixed methods, we interviewed 32 African American women about behavioral steps to collecting FHH, family communication about health, and reactions to a biomedical FHH tool. Participants chose one of two FHH tools to take home. A follow-up call three weeks later assessed tool use. Many participants expressed support for writing down FHH information, but at baseline few had done so; most participants who had collected FHH information had done so verbally. Participants reacted positively to the biomedical FHH tool used during the interview, with many saying it allowed them to see patterns in their FHH. At follow-up, 67 % reported using their FHH tool, primarily to promote discussion among family members; only 32 % used the tool to write down FHH information. Although participants thought collecting FHH information was important and had positive reactions to both tools, the majority did not use the tools to write down information and instead collected FHH informally. These findings underline the importance of separating the components of FHH collection behaviors to analyze the steps used in FHH creation. Practitioners should consider additional methods of encouraging patients to create written FHHs in order to share the information with health care providers.
Family health history; Family communication; Racial/ethnic minorities; Cancer
The massive federal welfare reform effort of 1996 contained an inherent assumption that welfare use negatively affected recipients' sense of self-efficacy. Little research attention has been given to examining this assumption. Using in-depth interviews, I explore economic self-efficacy perceptions of 31 young mothers who have experience receiving welfare. Financial choice, they said, was central to their perceptions of themselves as economic agents and therefore to their sense of self-efficacy. Findings presented here detail women's perceptions of their own economic abilities, as well as how welfare receipt, the character of work, and experiences related to parenting in poverty all affected women's opportunities for exercising agency.
self-efficacy; welfare; welfare reform; poverty
Molecular epidemiology studies commonly exhibit missing observations. Methods for extracting correct and efficient analyses from incomplete data are well known in statistics, but relatively few such methods have diffused into applications. I review some areas of incomplete-data research that are relevant to molecular epidemiology, and appeal for greater efforts by statisticians to translate their methods into practice.
Little is known about the use of bush medicine and traditional healing among Aboriginal Australians for their treatment of cancer and the meanings attached to it. A qualitative study that explored Aboriginal Australians' perspectives and experiences of cancer and cancer services in Western Australia provided an opportunity to analyse the contemporary meanings attached and use of bush medicine by Aboriginal people with cancer in Western Australia
Data collection occurred in Perth, both rural and remote areas and included individual in-depth interviews, observations and field notes. Of the thirty-seven interviews with Aboriginal cancer patients, family members of people who died from cancer and some Aboriginal health care providers, 11 participants whose responses included substantial mention on the issue of bush medicine and traditional healing were selected for the analysis for this paper.
The study findings have shown that as part of their healing some Aboriginal Australians use traditional medicine for treating their cancer. Such healing processes and medicines were preferred by some because it helped reconnect them with their heritage, land, culture and the spirits of their ancestors, bringing peace of mind during their illness. Spiritual beliefs and holistic health approaches and practices play an important role in the treatment choices for some patients.
Service providers need to acknowledge and understand the existence of Aboriginal knowledge (epistemology) and accept that traditional healing can be an important addition to an Aboriginal person's healing complementing Western medical treatment regimes. Allowing and supporting traditional approaches to treatment reflects a commitment by modern medical services to adopting an Aboriginal-friendly approach that is not only culturally appropriate but assists with the cultural security of the service.
Carbon dioxide has been monitored in the body using a variety of technologies with a multitude of applications. The monitoring of this common physiologic variable in medicine is an illustrative example of the different levels of evidence that are required before any new health technology should establish itself in clinical practice. End-tidal capnography and sublingual capnometry are two examples of carbon dioxide monitoring that require very different levels of evidence before being disseminated widely. The former deserves its status as a basic standard based on observational data. The latter should be considered investigational until prospective controlled data supporting its use become available. Other applications of carbon dioxide monitoring are also discussed.
biomedical technology assessment; capnography; critical care; evidence-based medicine; physiologic monitoring
Sexuality is a key aspect of women’s physical and psychological health. Research shows both patients and physicians face barriers to communication about sexuality. Given their expertise and training in addressing conditions of the female genital tract across the female life course, obstetrician/gynecologists (ob/gyns) are well-positioned among all physicians to address sexuality issues with female patients. New practice guidelines for management of female sexual dysfunction and the importance of female sexual behavior and function to virtually all aspects of ob/gyn care, and to women’s health more broadly, warrant up-to-date information regarding ob/gyns’ sexual history-taking routine.
To determine obstetrician/gynecologists’ practices of communication with patients about sexuality, and to examine the individual and practice-level correlates of such communication.
A population-based sample of 1154 practicing U.S. obstetrician/gynecologists (53% male; mean age 48 years) was surveyed regarding their practices of communication with patients about sex.
Main Outcome Measures
Self-reported frequency measures of ob/gyns’ communication practices with patients including whether or not ob/gyns discuss patients’ sexual activities, sexual orientation, satisfaction with sexual life, pleasure with sexual activity, and sexual problems or dysfunction, as well as whether or not one ever expresses disapproval of or disagreement with patients’ sexual practices. Multivariable analysis was used to correlate physicians’ personal and practice characteristics with these communication practices.
Survey response rate was 65.6%. Sixty-three percent of ob/gyns reported routinely assessing patients’ sexual activities; 40% routinely asked about sexual problems. Fewer asked about sexual satisfaction (28.5%), sexual orientation/identity (27.7%), or pleasure with sexual activity (13.8%). A quarter of ob/gyns reported they had expressed disapproval of patients’ sexual practices. Ob/gyns practicing predominately gynecology were significantly more likely than other ob/gyns to routinely ask about each of the five outcomes investigated.
The majority of U.S. ob/gyns report routinely asking patients about their sexual activities, but most other areas of patients’ sexuality are not routinely discussed.
Female Sexuality; Patient-Physician Communication; Sexual History-Taking; Female Sexual Health
This Commentary addresses issues related to exposures to teratogens and makes the case for increased research into the safety of medications during pregnancy for mothers and fetuses. Not only are medications commonly used during pregnancy, but evidence points to an increasing prevalence and number of drug exposures experienced by the embryo or fetus, particularly during the critical first trimester of pregnancy. Although the first trimester represents a particularly vulnerable period of organogenesis, exposures during other gestational time periods may also be associated with deleterious outcomes. In addition to the changing (and in many cases unknown) risks to a developing fetus, other challenges to studying medication exposures and their effects during pregnancy include the dramatic changes in physiology that occur in pregnant women and the ethical dilemmas posed by including this vulnerable population in randomized controlled trials of safety and efficacy. However, without adequate knowledge of the pharmacokinetics, pharmacodynamics, efficacy, and safety of medication use in pregnancy, women may be under-dosed to minimize exposure or not treated at all, resulting in inadequate treatment and potential harm to the mother and her baby. The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) is undertaking studies on medications and teratogenic exposures during pregnancy, including alcohol, maternal diabetes, oral hypoglycemic agents, and antiviral medications, through several of its research networks. Although this is a start, there is a critical need for further research on medications used during pregnancy, especially their effects on both the mother and her developing child.
medication; exposure; pregnancy; teratogen; research
Mammography is an important tool in the early detection of breast cancer. However, the perceptual task is difficult and a significant proportion of cancers are missed. Visual search experiments show that miss (false negative) errors are elevated when targets are rare (low prevalence) but it is unknown if low prevalence is a significant factor under real world, clinical conditions. Here we show that expert mammographers in a real, low-prevalence, clinical setting, miss a much higher percentage of cancers than are missed when the mammographers search for the same cancers under high prevalence conditions. We inserted 50 positive and 50 negative cases into the normal workflow of the breast cancer screening service of an urban hospital over the course of nine months. This rate was slow enough not to markedly raise disease prevalence in the radiologists’ daily practice. Six radiologists subsequently reviewed all 100 cases in a session where the prevalence of disease was 50%. In the clinical setting, participants missed 30% of the cancers. In the high prevalence setting, participants missed just 12% of the same cancers. Under most circumstances, this low prevalence effect is probably adaptive. It is usually wise to be conservative about reporting events with very low base rates (Was that a flying saucer? Probably not.). However, while this response to low prevalence appears to be strongly engrained in human visual search mechanisms, it may not be as adaptive in socially important, low prevalence tasks like medical screening. While the results of any one study must be interpreted cautiously, these data are consistent with the conclusion that this behavioral response to low prevalence could be a substantial contributor to miss errors in breast cancer screening.
Despite advances in breast cancer risk assessment and risk reduction technologies, little is still known about how high-risk women make sense of their risk and assess prevention options, particularly among minority and low-income women. Qualitative methods explore the complex meanings and logics of risk and prevention that quantitative approaches overlook.
This study examined how women attending a high risk breast cancer clinic at a public hospital conceptualize their breast cancer risk and think about the prevention options available to them.
Semi-structured interviews were used to gather data from 33 high-risk women (75% African American) between May and August 2004. Interview transcripts were analyzed for recurrent themes and patterns.
Despite general awareness of their objective risk status, many women in this study reported they did not feel “high risk” because they lacked signs and symptoms of cancer. Risk was described as an experienced acute problem rather than a statistical possibility. Women also frequently stated that thinking about cancer might cause it to happen and so it is better not to “dwell on it.” While screening was welcomed, women were generally skeptical about primary prevention. In particular, preventive therapies were perceived to cause problems and were only acceptable as treatment options for a disease.
The body of ideas about risk and prevention expressed by this population differ from the medical model. These findings have implications for risk perception research as well as for the efficacy of risk communication and prevention counseling in clinical contexts.
risk perception; chemoprevention; breast cancer; underserved populations
Using a variety of cognitive or behavioral strategies to manage stressful situations may be more adaptive than relying on a narrow selection. Although research has explored the psychological benefits of a range of coping responses, the physiological impact within and across stressful situations has not been examined. Moreover, research has generally relied upon self-reports of what people believe they generally do across stressful situations, which may be subject to recall bias. This study observed and coded the range of behavioral response strategies young adults (n = 74, mean age 18.1) used to manage a laboratory-based, interpersonal conflict task and collected self-reports of the cognitive strategies used to manage similar stressors. Analyses examined the impact of response range on cortisol activity during the task. Greater range of observed response strategies predicted lower cortisol reactivity (t(133) = 2.65; p = 0.009), whereas the range of self-reported strategies was unrelated to cortisol reactivity (t(133) = 0.53; p = 0.60). Results support observational assessment as an important supplement to self-reports of responses to stress and suggest that the range of strategies used to manage the momentary demands of a stressful situation may help explain individual differences in the impact of stress on physiological systems.
stress; observational assessment; coping; cortisol; reactivity
Burden emerged as an important concept among older adults in a study of how older adults interact with their families around care. The authors conducted 50 semistructured interviews with adults older than the age of 65 years and a spouse or adult child. The sample was stratified by ethnicity thus giving the opportunity to explore both ethnic similarities and differences. Older adults who expressed the concept of burden were more likely to be White compared with older adults who did not express burden. Older respondents discussed burden in relation to not wanting to complicate the busy lives of adult children, guilt about health problems, and concern that children were overly worried about the care of their older family member. The expression and meaning of burden differed according to ethnicity. This study has implications for practice and policies to meet the needs of families and promote the independence of older persons.
family caregivers; chronic illness; family; primary health care; ethnicity
Sider and Clements provide a critical response to my view that there is no independent obligation to seek one's own health. They then argue that such an obligation exists. They are incorrect in their characterisation of my view; their critical discussion of the view they erroneously attribute to me is unconvincing; the positive argument they offer for their own view is unsatisfactory; they misjudge the significance of what is at issue; and they conclude by affirming a position that lacks a due regard for the rights of patients.
Ken Fyke is known as a tough administrator, and he is going to need all of his administrative tricks as first chair of Canadian Blood Services, the new national organization that is taking over responsibility for the nation's blood supply from the Red Cross come September. Fyke says he hopes to work closely with physicians, but they will have to realize where their responsibilities end and his begin.
The Massachusetts Department of Public Health has created the first statewide surveillance system in the nation that tracks both fatal and nonfatal weapon injuries. The authors summarize findings for 1994 and discuss their public health implication. Suicides were the leading cause of firearm fatality, while self-inflicted injuries accounted for only 3% of nonfatal firearm injuries. Risk of violence-related injuries varied dramatically across the state. In Boston, one in 38 black male teenagers ages 15 to 19 was shot or stabbed in 1994, in contrast to one in 56,000 for white females of any age living in suburban communities. In Boston, non-Hispanic black male teenagers were at 41 times higher risk than white male teenagers for gun injuries. Shooting homicides increased sixfold during the late 1980s among black Boston males, while homicides by other means remained stable. In other Massachusetts cities, injury rates were higher among 20 to 24-year-olds than among teenagers, and, in some areas, incidence rates were as high or higher among Hispanic males than among non-Hispanic black males. Between 1985 and 1994, the proportion of firearm injuries caused by semiautomatic pistols increased from 23% to 52%, according to police ballistics data.
Depression is a potentially life-threatening disorder affecting millions of people across the globe. It is a huge burden to both the individual and society, costing over £9 billion in 2000 alone: the World Health Organisation (WHO) cited it as the third leading cause of global disability in 2004 (first in the developed world), and project it will be the leading cause by 2030. The serendipitous discovery of antidepressants has revolutionized both our understanding and management of depression: however, their efficacy in the treatment of depression has long been debated and recently been brought very much into the public limelight by a controversial publication by Kirsch, in which the role of placebo response in antidepressant efficacy trials is highlighted. Whilst antidepressants offer benefits in both the short and long term, important problems persist such as intolerability, delayed therapeutic onset, limited efficacy in milder depression and the existence of treatment-resistant depression.
Falls remain a major public health problem, despite strong growth in the research evidence of effective single and multifactorial interventions, particularly in the community setting. A number of aspects of falls prevention require individual tailoring, despite limitations being reported regarding some of these, including questions being raised regarding the role of falls risk screening and falls risk assessment. Being able to personalise an individual's specific risk and risk factors, increase their understanding of what interventions are likely to be effective, and exploring options of choice and preference, can all impact upon whether or not an individual undertakes and sustains participation in one or more recommendations, which will ultimately influence outcomes. On all of these fronts, the individual patient receiving appropriate and targeted interventions that are meaningful, feasible and that they are motivated to implement, remains central to effective translation of falls prevention research evidence into practice.
Intimate partner violence (IPV) against women is a serious public health issue and is associated with significant adverse health outcomes. The current study was undertaken to: 1) explore physicians’ and nurses’ experiences, both professional and personal, when asking about IPV; 2) determine the variations by discipline; and 3) identify implications for practice, workplace policy and curriculum development.
Physicians and nurses working in Ontario, Canada were randomly selected from recognized discipline-specific professional directories to complete a 43-item mailed survey about IPV, which included two open-ended questions about barriers and facilitators to asking about IPV. Text from the open-ended questions was transcribed and analyzed using inductive content analysis. In addition, frequencies were calculated for commonly described categories and the Fisher’s Exact Test was performed to determine statistical significance when examining nurse/physician differences.
Of the 931 respondents who completed the survey, 769 (527 nurses, 238 physicians, four whose discipline was not stated) provided written responses to the open-ended questions. Overall, the top barriers to asking about IPV were lack of time, behaviours attributed to women living with abuse, lack of training, language/cultural practices and partner presence. The most frequently reported facilitators were training, community resources and professional tools/protocols/policies. The need for additional training was a concern described by both groups, yet more so by nurses. There were statistically significant differences between nurses and physicians regarding both barriers and facilitators, most likely related to differences in role expectations and work environments.
This research provides new insights into the complexities of IPV inquiry and the inter-relationships among barriers and facilitators faced by physicians and nurses. The experiences of these nurses and physicians suggest that more supports (e.g., supportive work environments, training, mentors, consultations, community resources, etc.) are needed by practitioners. These findings reflect the results of previous research yet offer perspectives on why barriers persist. Multifaceted and intersectoral approaches that address individual, interpersonal, workplace and systemic issues faced by nurses and physicians when inquiring about IPV are required. Comprehensive frameworks are needed to further explore the many issues associated with IPV inquiry and the interplay across these issues.
Intimate partner violence inquiry; Barriers and facilitators
During the past 100 years, several theories explaining human atherosclerosis have been postulated and tested. More than anything else, experimental and observational evidence has supported a very strong causal role for dyslipidemia. This has been established as the current paradigm in both biomedical research as well as public health policies. Recently, a novel hypothesis for the etiology of atherosclerosis was presented. The purpose of this commentary is to critically evaluate its validity.
Cholesterol; Mevalonate; Hypothesis