Exploring informed choice in the context of prenatal testing: findings from a qualitative study

Purpose This study explored whether and how a sample of women made informed choices about prenatal testing for foetal anomalies; its aim was to provide insights for future health policy and service provision. Methods We conducted semi‐structured interviews with 38 mothers in Ottawa, Ontario, all of whom had been offered prenatal tests in at least one pregnancy. Using the Multi‐dimensional Measure of Informed Choice as a general guide to analysis, we explored themes relevant to informed choice, including values and knowledge, and interactions with health professionals. Results Many, but not all, participants seemed to have made informed decisions about prenatal testing. Values and knowledge were interrelated and important components of informed choice, but the way they were discussed differed from the way they have been presented in scientific literature. In particular, ‘values’ related to expressions of women’s moral views or ideas about ‘how life should be lived’ and ‘knowledge’ related to the ways in which women prioritized and interpreted factual information, through their own and others’ experiences and in ‘thinking through’ the personal implications of testing. While some women described non‐directive discussions with health professionals, others perceived testing as routine or felt pressured to accept it. Conclusions Our findings suggest a need for maternity care providers to be vigilant in promoting active decision making about prenatal testing, particularly around the consideration of personal implications. Further development of measures of informed choice may be necessary to fully evaluate decision support tools and to determine whether prenatal testing programmes are meeting their objectives.     

Socio-economic status and health care utilization in rural Zimbabwe: findings from Project Accept (HPTN 043)

Zimbabwe's HIV epidemic is amongst the worst in the world, and disproportionately effects poorer rural areas. Access to almost all health services in Zimbabwe includes some form of cost to the client. In recent years, the socio-economic and employment status of many Zimbabweans has suffered a serious decline, creating additional barriers to HIV treatment and care. We aimed to assess the impact of i) socio-economic status (SES) and ii) employment status on the utilization of health services in rural Zimbabwe. Data were collected from a random probability sample household survey conducted in the Mutoko district of north-western Zimbabwe in 2005. We selected variables that described the economic status of the respondent, including: being paid to work, employment status, and SES by assets. Respondents were also asked about where they most often utilized healthcare when they or their family was sick or hurt. Of 2,874 respondents, all forms of healthcare tended to be utilized by those of high or medium-high SES (65%), including private (65%), church-based (61%), traditional (67%), and other providers (66%) (P=0.009). Most respondents of low SES utilized government providers (74%) (P=0.009). Seventy-one percent of respondents utilizing health services were employed. Government (71%), private (72%), church (71%), community-based (78%) and other (64%) health services tended to be utilized by employed respondents (P=0.000). Only traditional health services were equally utilized by unemployed respondents (50%) (P=0.000). A wide range of health providers are utilized in rural Zimbabwe. Utilization is strongly associated with SES and employment status, particularly for services with user fees, which may act as a barrier to HIV treatment and care access. Efforts to improve access in low-SES, high HIV-prevalence settings may benefit from the subsidization of the health care payment system, efforts to improve SES levels, political reform, and the involvement of traditional providers.     

The role of wages in the migration of health care professionals from developing countries

Several countries are increasingly relying on immigration as a means of coping with domestic shortages of health care professionals. This trend has led to concerns that in many of the source countries - especially within Africa - the outflow of health care professionals is adversely affecting the health care system. This paper examines the role of wages in the migration decision and discusses the likely effect of wage increases in source countries in slowing migration flows.This paper uses data on wage differentials in the health care sector between source country and receiving country (adjusted for purchasing power parity) to test the hypothesis that larger wage differentials lead to a larger supply of health care migrants. Differences in other important factors affecting migration are discussed and, where available, data are presented.There is little correlation between the supply of health care migrants and the size of the wage differential between source and destination country. In cases where data are available on other factors affecting migration, controlling for these factors does not affect the result.At current levels, wage differentials between source and destination country are so large that small increases in health care wages in source countries are unlikely to affect significantly the supply of health care migrants. The results suggest that non-wage instruments might be more effective in altering migration flows.     

健康宣教在直肠癌围手术期患者中的作用

目的 探讨健康宣教在直肠癌围手术期患者中的实施作用.方法 将2009年1月～2011年10月入某院治疗的58例直肠癌围手术期患者随机分为干预组和对照组两组,治疗组采用常规护理方式,干预组采用健康宣教护理干预,所有患者在人院时和术前后ld以及手术后d7进行问卷调查评估,分别进行SAS焦虑量表和体力状况ECOG评分量表自评,并比较两组患者的手术效果.结果 患者术后干预组的排气时间、排便时间、住院天数均显著短于对照组;并发症发生率显著低于对照组,P＜ 0.05;下床活动时间差异无统计学意义,P＞ 0.05;两组患者术前SAS评分差异无统计学意义,P＞ 0.05;经健康宣教护理干预后,术前1d、术后1d和术后7d的SAS评分均显著低于对照组,P＜ 0.05;健康宣教前后两组患者的ECOG评分分别显著低于干预前,且两组在干预后的ECOG评分差异有统计学意义,P＜0.05.结论 在直肠癌患者围手术期实施健康宣教护理干预,能提高手术的治疗效果,提高患者的生存质量,是一种有效的护理方式.     

The role of education in complex health decisions: evidence from cancer screening

This paper uses data on real and perceived cancer risks and cancer screening behavior to test the allocative efficiency theory. Specifically, it explores whether the educated make better-informed health decisions. I propose that (1) when educated individuals are better informed, they are more likely to incorporate variation in risk factors when they report their personal cancer risk, and (2) as risk varies, the better educated will react more strongly by adopting preventive behaviors such as cancer screening. The results support for both predictions. Further, using data on attitudes toward breast health, I explore a possible mechanism: educated women are more receptive to scientific evidence and hold fewer nonscientific beliefs.     

The rhetoric of informed choice: perspectives from midwives on intrapartum fetal heart rate monitoring

OBJECTIVE: To investigate midwives' attitudes, values and beliefs on the use of intrapartum fetal monitoring. DESIGN: Qualitative, semi-structured interviews. SUBJECTS AND SETTING: Fifty-eight registered midwives in two hospitals in the North of England. RESULTS: In this paper two main themes are discussed, these are: informed choice, and the power of the midwife. Midwives favoured the application of informed choice and shared a unanimous consensus on the definition. However, the idealistic perception of informed choice, which included contemporary notions of empowerment and autonomy for women expressing an informed choice, was not reportedly translated into practice. Midwives had to implement informed choice on intrapartum fetal monitoring within a competing set of health service agendas, i.e. medically driven protocols and a political climate of actively managed childbearing. This resulted in the manipulation of information during the midwives' interactions with women. This ultimately meant that the women often got the choice the midwives wanted them to have. CONCLUSIONS: The information that a midwife imparts may consciously or subconsciously affect the woman's uptake and understanding of information. Therefore, the midwife has a powerful role to play in balancing the benefits and risk ratios applicable to fetal heart rate monitoring. However, a deeply ingrained pre-occupation with technological methods of intrapartum fetal monitoring over many years has made it difficult for midwives to offer alternative forms of monitoring. This has placed limits on the facilitation of informed choice and autonomous decision making for women.     

Chronic illness from the perspective of patients and health professionals: a qualitative study in Mexico

Chronic diseases are leading causes of morbidity, mortality, and increasing expenditures in numerous countries. However, little is known about how chronic diseases are perceived and managed by social actors. This article aims to compare the perspectives of health professionals and patients towards chronic diseases, besides analyzing the relationship between these two groups. A qualitative, multi-center study was conducted in three Mexican cities: Guadalajara, San Luis Potosí, and Mexico City. Participants included chronically ill individuals, physicians, and other health professionals from primary and secondary health care centers. Data collection used focus groups and interviews. The data were analyzed using discourse analysis. Participants' perceptions varied, from the medicalized view of physicians to that of patients focused on illness and the lifeworld. The participants agreed that there are unequal relationships between health professionals, families, and the chronically ill, but that relationships are more equal among the chronically ill themselves. The article includes by discussing various implications of the findings.     

'Ignorance is bliss sometimes': constraints on the emergence of the 'informed patient' in the changing landscapes of health information

In this paper we describe and analyse results from an empirical study designed to provide insight into factors facilitating and/or inhibiting the emergence of the much-heralded 'informed patient' and its sociological equivalent, the 'reflexive patient' or 'reflexive consumer'. In particular, we seek to examine the relationship between information and empowerment in a healthcare context and assess the significance of the Internet in mediating this relationship. The paper draws on data from interviews with 32 mid-life women concerned to know about HRT for the relief of menopausal symptoms. Having analysed these women's 'information practices', we conclude that constraints on the emergence of the informed patient identity exist within both patient and practitioner communities and within the space occupied by both in the medical encounter. In particular, in this paper we identify a tension caused by the emphasis on 'information for choice' in the informed patient discourse which itself obscures the potential conflict between lay and expert/medical knowledges in the clinical encounter.     

The tipping point of change in Anorexia Nervosa (AN): Qualitative findings from an online study

The aim of this study was to understand factors related to treatment and/or recovery from self-reported Anorexia Nervosa (AN), including ‘the tipping point of change’. An online questionnaire was developed and administered from December 2014 to December 2015 to individuals ≥18 years of age with AN in the past or currently who were recruited through eating disorder organizations in Australia and the United Kingdom. Responses to a specific qualitative question on ‘the tipping point of change’ were analyzed using conventional content analysis (CCA). One hundred sixty-one participants completed some or all of the questionnaire; only 67 women (41.61%) answered Question six on ‘the tipping point of change’, and analyses were restricted to data from these women. The themes identified were: 1) realizing the loss of something valuable, 2) the risk of losing something valuable, and 3) something to live for/stay well for. These results are important for health-care providers as they work with patients to identify life experiences, including ‘loss/potential loss’ and ‘the need for preservation’, that have personal significance. Some patients may realize that ‘enough is enough’; something needs to change. These intrinsic motivating factors may also be the impetus for eventual recovery for some individuals.     

Explaining health marginalisation of the lower educated: the role of cross-national variations in health expenditure and labour market conditions

Several studies have shown ample cross-national variation in the risk that lower educated people run to be in poor health. However, explanations for this cross-national variation are still scarce. In this article we aim at filling this lacuna by investigating to what extent cross-national variation in the health gap between the lower and higher educated in Europe is explained by governmental health expenditure, namely, how much governments contribute to a country's total healthcare costs, and labour market conditions, that is, unemployment rates and modernisation of the labour market. We used information from the European Social Survey (ESS) 2002-2008 on more than 90,000 individuals in 32 European nations, and estimated hierarchical models with cross-level interactions to test our expectations. Our results show that the relative risk of being in poor health of lower educated individuals is smaller in countries where the government spends much on healthcare and with a highly modernised labour market.     

Perceived health in lung cancer patients: the role of positive and negative affect

Purpose  

To examine the association of affective experience and health-related quality of life in lung cancer patients, we hypothesized that negative affect would be positively, and positive affect would be negatively, associated with perceived health.