Self-reported goals of older patients with type 2 diabetes mellitus

OBJECTIVES: New diabetes mellitus guidelines from the American Geriatrics Society promote the individualization of treatment goals and plans for patients aged 65 and older. Communicating with older patients about such complex medical decisions presents new challenges for providers. The self-reported healthcare goals, factors influencing these goals, and self-care practices of older patients with diabetes mellitus were explored. DESIGN: Exploratory study involving semistructured interviews. SETTING: Four clinics of a midwestern, urban academic medical center. PARTICIPANTS: Patients aged 65 and older with type II diabetes mellitus (N=28). MEASUREMENTS: Semistructured, one-on-one interviews were conducted. Interviews were audiotaped, transcribed, and evaluated for recurring themes using a grounded theory approach. RESULTS: The majority of patients expressed their healthcare goals in a social and functional language, in contrast to the biomedical language of risk factor control and complication prevention, even when specifically asked about goals for diabetes mellitus care. Patient's predominant healthcare goals centered on maintaining their independence and their activities of daily living (71%). Medical experiences of friends and family (50%), social comparison with peers (7%), and medical professionals (43%) shaped patients' goals. Self-reported medication adherence and glucose monitoring was high, but more than one-quarter of patients failed to adhere to any dietary recommendations, and one-third failed to adhere to their exercise regimens. CONCLUSION: As diabetes mellitus care recommendations for older patients grow more complex, providers could enhance their communication about such medical decisions by exploring patients' specific circumstances and reframing diabetes mellitus treatment goals in patients' own language. These may be crucial steps to developing successful individualized care plans.     

Communicating about Alcohol Consumption to Nonharmful Drinkers with Hepatitis C: Patient and Provider Perspectives

Background Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis. Objective This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear. Design We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program. Results We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing “stop completely” were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in “medical language” than were GI providers. Conclusions To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.     

Understanding oral health beliefs and practices among Cantonese‐speaking older Australians

Aim: The present study was conducted to explore how older immigrants from Hong Kong or Southern China manage their oral health in Melbourne. Methods: We used six focus groups involving 50 Cantonese‐speaking immigrants who were 55 years and over and living in Melbourne. Results: Four major themes relevant to oral health care emerged from the discussion: (i) traditional Chinese health beliefs; (ii) traditional medicine and oral health; (iii) attitudes towards dentists; and (iv) access to oral health‐care services. Language, communication and cost of dentistry were identified as major barriers to oral health care. Conclusion: Older Chinese immigrants in Melbourne have concerns about oral health care that are similar to other ethnic groups, they want more oral health‐related support from government, and many of they return to China or Hong Kong for dental treatment.     

The influence of spiritual beliefs and practices on the treatment preferences of African Americans: a review of the literature

Spirituality is an important part of African-American culture and is often cited as an explanation for the more-aggressive treatment preferences of some African Americans at the end of life. This paper reviews the literature on spiritual beliefs that may influence the treatment decisions of African Americans. Medline 1966 to February 2003, Psych Info 1872 to February 2003, and CINAHL 1982 to February 2003 were searched for studies exploring spiritual beliefs that may influence the treatment preferences of African Americans. All candidate papers were examined for quality, and data were extracted on study population, design, analysis, and results to identify recurrent themes. Forty studies met inclusion criteria. Recurrent themes describing spiritual beliefs that may influence the treatment preferences of African Americans throughout the course of illness include the following: spiritual beliefs and practices are a source of comfort, coping, and support and are the most effective way to influence healing; God is responsible for physical and spiritual health; and the doctor is God's instrument. Spiritual beliefs specifically addressing treatment preferences at the end of life include: only God has power to decide life and death, there are religious prohibitions against physician-assisted death or advance directives limiting life-sustaining treatments, and divine intervention and miracles occur. For some African Americans, spiritual beliefs are important in understanding and coping with illness and may provide a framework within which treatment decisions are made. Given the growing ethnic diversity of the United States, some understanding of the complexities of culture and spirituality is essential for healthcare providers.     

Communicating About Alcohol Consumption to Nonharmful Drinkers with Hepatitis C: Patient and Provider Perspectives

Background  Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis. Objective  This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear. Design  We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program. Results  We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing “stop completely” were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in “medical language” than were GI providers. Conclusions  To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV. The online version of the article can be found at .     

Promising Strategies to Support COVID-19 Vaccination of Healthcare Personnel: Qualitative Insights from the VHA National Implementation

BackgroundIn August 2021, up to 30% of Americans were uncertain about taking the COVID-19 vaccine, including some healthcare personnel (HCP).ObjectiveOur objective was to identify barriers and facilitators of the Veterans Health Administration (VHA) HCP vaccination program.DesignWe conducted key informant interviews with employee occupational health (EOH) providers, using snowball recruitment.ParticipantsParticipants included 43 VHA EOH providers representing 29 of VHA’s regionally diverse healthcare systems.ApproachThematic analysis elucidated 5 key themes and specific strategies recommended by EOH.Key ResultsImplementation themes reflected logistics of distribution (supply), addressing any vaccine concerns or hesitancy (demand), and learning health system strategies/approaches for shared learnings. Specifically, themes included the following: (1) use interdisciplinary task forces to leverage diverse skillsets for vaccine implementation; (2) invest in processes and align resources with priorities, including creating detailed processes, addressing time trade-offs for personnel involved in vaccine clinics by suspending everything non-essential, designating process/authority to shift personnel where needed, and proactively involving leaders to support resource allocation/alignment; (3) expect and accommodate vaccine buy-in occurring over time: prepare for some HCP’s slow buy-in, align buy-in facilitation with identities and motivation, and encourage word-of-mouth and hyper-local testimonials; (4) overcome misinformation with trustworthy communication: tailor communication to individuals and address COVID vaccines “in every encounter,” leverage proactive institutional messaging to reinforce information, and invite bi-directional conversations about any vaccine concerns. A final overarching theme focused on learning health system needs and structures: (5) use existing and newly developed communication channels to foster shared learning across teams and sites.ConclusionsExpecting deliberation allows systems to prepare for complex distribution logistics (supply) and make room for conversations that are trustworthy, bi-directional, and identity aligned (demand). Ideally, organizations provide time for conversations that address individual concerns, foster bi-directional shared decision-making, respect HCP beliefs and identities, and emphasize shared identities as healthcare providers.KEY WORDS: COVID-19, vaccination, healthcare personnel, employee occupational health, qualitative research     

An examination of HIV/AIDS patients who have excellent adherence to HAART

This paper examines the attitudes and beliefs of HIV/AIDS patients with excellent adherence to highly active antiretroviral therapy (HAART) and how they differ from those with suboptimal adherence. Forty-four persons with HIV/AIDS, 28 men and 16 women, participated in a qualitative semi-structured interview which was based on the Health Belief Model. The main outcomes were themes consistent with several dimensions of this model, reflecting differences in the health-related attitudes and beliefs of the excellent adherers compared to the suboptimal adherers. Patients with excellent adherence voiced the following themes when compared to less adherent patients: (1) believed adherence rates needed to be 90-100% for medication efficacy; (2) trusted their primary providers greatly; (3) took medications even when actively using substances of abuse; (4) were open about their HIV status and received substantial social support; (5) cited staying healthy as their key motivator; (6) were not actively depressed; all had normal CESD scores. Our study suggests that patients with excellent adherence to HAART differ from their less adherent counterparts in terms of key health-related attitudes and beliefs. Identifying and studying excellent adherers provides new insights and strategies for enhancing adherence to HAART.     

Cross Disciplinary Role Agreement is Needed When Coordinating Long‐Term Opioid Prescribing for Cancer: a Qualitative Study

BackgroundCancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers.ObjectivesTo understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer–related pain in a large integrated healthcare system.DesignQualitative research.ParticipantsWe conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs).ApproachWe deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus.ResultsTheme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines.ConclusionsOur findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06747-z.KEY WORDS: pain, opioids, cancer, qualitative research, veterans     

Biomedical healthcare and African traditional healing in the management of HIV and AIDS: complimentary or competing cosmologies?

In South Africa, African traditional healers and biomedical practitioners play important roles in the management of HIV and AIDS, but provide healthcare services in isolation of each other, despite legislative recognition of both types of healing. An interpretive, qualitative research approach was employed to elicit the views of both groups regarding the feasibility of collaboration. Semi-structured interviews were conducted with a sample of 20 participants with 10 persons from each group. Key findings were that African traditional healers referred their patients to hospitals but never received referrals from biomedical health care practitioners. The traditional healers took precautions to avoid drug interactions between their medicines and antiretrovirals (ARVs). Biomedical healthcare practitioners recommended that traditional medicine only be used externally to avoid interaction with ARVs. Lack of shared knowledge, poor dosages and medical complications due to the use of African traditional medicine were viewed as threats to the collaboration between the two groups, while open communication, research into the efficacy, scientific administration and proper dosages of African traditional medicine were articulated as facilitating factors. The main conclusion was that biomedical practitioners, traditional healers and government officials responsible for formulating healthcare policies need to be involved in devising a framework that would facilitate ways of encouraging collaboration between these two healthcare systems.     

ADHERING TO BEHAVIOUR CHANGE IN OLDER PRE‐DIALYSIS POPULATIONS—WHAT DO PATIENTS THINK? A QUALITATIVE STUDY

Background: Chronic Kidney Disease (CKD) is associated with the development of serious co‐morbidities. Patients with CKD are encouraged to adhere to regimens to lower this risk. This study aimed to explore the experiences of patients attempting to integrate lifestyle changes into their lives. Method: Face‐to‐face recorded interviews were conducted with nine consenting patients with CKD Stage 4 under the care of a consultant nephrologist. Each recording was analysed by two independent investigators using thematic analysis. Results: Five themes emerged: Self in relation to others, Control, Adherence, Beliefs about treatment and illness and Uncertainty. Participants highlighted the importance of personal support and recounted their sense of being a burden on close family. They described how they approached disclosure about their condition, their beliefs regarding treatment and their decision making processes and how these factors impacted on adherence to behaviour change. Conclusion: Practical support from family and healthcare professionals, a willingness to disclose their condition and help to make good decisions in difficult circumstances were identified as important factors in supporting success with behaviour change.     

Setting research priorities in tobacco control: a stakeholder engagement project

Background and Aims

The Cochrane Tobacco Addiction Group (TAG) conducts systematic reviews of the evidence for tobacco cessation and prevention interventions. In 2016 TAG conducted a priority‐setting, stakeholder engagement project to identify where further research is needed in the areas of tobacco control and smoking cessation.

Design

The project comprised two surveys and a workshop. A range of stakeholders participated, including members of the public (smokers and ex‐smokers), clinicians, researchers, research funders, health‐care commissioners and public health organizations. The first survey phase identified unanswered research questions in the field of tobacco control. The second phase asked participants to rank these, with overall rankings calculated by combining scores across participants. The workshop allowed attendees to discuss prioritization of topics and questions in more depth. Workshop discussions were transcribed and analysed thematically, and a final voting activity at the close of the workshop allowed participants to choose topics to prioritize and to de‐prioritize.

Findings

A total of 304 stakeholders (researchers, health professionals, smokers and ex‐smokers, guideline developers, research funders and policymakers, representing 28 countries) identified 183 unanswered research questions. These were categorized into 15 research categories. A total of 175 participants prioritized categories and questions in the second survey phase, with ‘electronic cigarettes’; ‘addressing inequalities’; and ‘mental health and other substance abuse’ prioritized as the top three categories. Forty‐three stakeholders attended the workshop and discussed reasons for and against category prioritization. Prioritized research categories largely mirrored those in the survey stage, although ‘treatment delivery’ also emerged as a key category. Five cross‐cutting themes emerged: efficacy; relative efficacy; cost effectiveness; addressing inequalities; and different types of evidence.

Conclusions

There are many unanswered questions in the field of tobacco control. Stakeholders highlighted electronic cigarettes, addressing inequalities and mental health and other substance abuse as key areas for further research, and efficacy, relative efficacy, cost‐effectiveness and use of non‐randomized studies as important themes cutting across research areas. Future prioritization work would benefit from targeting non‐US and non‐UK stakeholders explicitly and from examining where priorities may differ based on stakeholder group.     

Management of diabetes in Indigenous communities: lessons from the Australian Aboriginal population

Type 2 diabetes mellitus and other chronic cardio‐metabolic conditions are significant contributors to the large disparities in life expectancy between Indigenous and non‐Indigenous Australians. Type 2 diabetes is more prevalent from a young age among Indigenous Australians and is often preceded by a cluster of risk factors, including central obesity, dyslipidaemia, albuminuria and socio‐economic disadvantage. Management of type 2 diabetes in Australian Indigenous peoples can be challenging in the setting of limited resources and socio‐economic disadvantage. Key strategies to address these challenges include working in partnership with patients, communities and primary healthcare services (PHC, Aboriginal community controlled and government services) and working in a multidisciplinary team. Population prevention measures are required within and beyond the health system, commencing as early as possible in the life course.     

Illness representations and cultural practices play a role in patient-centered care in childhood asthma: experiences of Mexican mothers

Objective: Patients’ cultural health beliefs and behaviors may conflict with biomedical healthcare values and practices potentially leading to non-adherence with asthma treatment regimens. To optimize shared decision-making, healthcare providers should understand and be sensitive to these cultural beliefs and behaviors and negotiate an asthma management plan acceptable to parents. The purpose of this study was to obtain the perspective of Mexican mothers regarding (1) their experiences of living with a child with asthma, (2) their understanding of the nature of asthma, and (3) how their cultural beliefs influence asthma management. Methods: A qualitative, phenomenological study design was employed to assess mothers’ lived experiences with and perceptions of their child’s asthma. Individual in-depth interviews were conducted with a purposeful sample of 20 Mexican mothers of children ages 5–17 years with asthma. An inductive, theory-driven, phenomenological analysis approach was used to elicit thematic findings. Results: Mothers expressed a symptomatic perception of asthma and limited understanding of the disease. Most believe the disease is present only when their child is symptomatic. Many are surprised and puzzled by the unpredictability of their child’s asthma attacks, which they report as sometimes “silent”. The inconsistency of triggers also leads to frustration and worry, which may reflect their concerns around daily controller medication use and preference for alternative illness management strategies. Conclusions: Our clinical encounters should be refocused to better understand the context of these families’ lives and the cultural lens through which they view their child’s asthma.     

Pemetrexed plus platinum or gemcitabine plus platinum for advanced non‐small cell lung cancer: final survival analysis from a multicentre randomized phase II trial in the East Asia region and a meta‐analysis

Background and Objective: Pemetrexed plus platinum has shown efficacy as a first‐line treatment for advanced non–small cell lung cancer (NSCLC), but little is known about its efficacy and safety in East Asian patients. We report the final analysis of overall survival (OS) from a multicentre, randomized, phase II trial in chemotherapy‐naive Chinese patients with advanced NSCLC. An additional meta‐analysis was performed to systematically evaluate pemetrexed/platinum as first‐line treatment for advanced NSCLC. Methods: Eligible patients received up to six cycles of pemetrexed, 500 mg/m² plus cisplatin, 75 mg/m² (day 1) or gemcitabine, 1000 mg/m² (days 1 and 8) plus cisplatin, 75 mg/m² (day 1). OS and toxicity were assessed. Results: A total of 254 patients were randomized, and 251 were eligible for inclusion in the efficacy and safety analyses. Median OS in the pemetrexed/cisplatin arm was 15.3 months, compared with 16.9 months in the gemcitabine/cisplatin arm [hazard ratio (HR) 1.09; 95% confidence interval (CI) 0.80–1.48; log‐rank P = 0.4888). There was a trend towards improved survival in both arms. Patients in the pemetrexed/cisplatin arm showed a lower incidence of drug‐related grade 3 to 4 leukopenia and thrombocytopenia. Meta‐analysis showed that pemetrexed‐platinum treatment was associated with 19% longer survival among females (HR 0.81; 95% CI 0.69–0.96) and 17% longer survival among patients with non‐squamous cell lung cancer (HR 0.83; 95% CI 0.73–0.95). Conclusions: In Chinese patients with advanced NSCLC, pemetrexed/cisplatin treatment resulted in comparable OS outcomes and was better tolerated than gemcitabine/cisplatin. Meta‐analysis supports the use of pemetrexed‐platinum as first‐line treatment for female patients and those with the non‐squamous cell subtype of advanced NSCLC.