Determinants of Women’s Drug Use During Pregnancy: Perspectives from a Qualitative Study

Maternal and Child Health Journal - Drug use during pregnancy can have negative effects on maternal and child health. However, there is a dearth of data regarding drug use among pregnant women in...     

How can Primary Care Physicians Best Support Contraceptive Decision Making? A Qualitative Study Exploring the Perspectives of Baltimore Latinas

ObjectivesU.S. Latinas experience disproportionately high rates of unintended pregnancy and low rates of consistent contraception use. Not well known are Latinas' perspectives about how primary care physicians (PCPs) might facilitate or deter contraceptive decision making. The theory of planned behavior has been used previously to explain contraceptive behaviors. This study used the theory of planned behavior as a guide to help describe Latinas' perspectives regarding specific factors that influence their contraceptive decision making and to describe their perspectives about the role of PCPs in the decision making.Study Design and MethodsWe conducted focus groups (n = 3) and interviews (n = 8) of Latinas ages 15 to 24 years, recruited from urban primary care sites in Baltimore, Maryland. Concepts from the theory of planned behavior were used to develop a coding scheme and guide identification of themes.ResultsSixteen Latinas participated; all were immigrants.ThemesThe desire to avoid unintended pregnancy is dominant and, not surprisingly, is the main driver of contraceptive intentions. The role of PCPs in contraceptive decision making is to build strong patient relationships through heightened communication and trust. PCPs should develop trust and foster communication by using a shared decision-making approach in contraceptive counseling. Religious norms rarely operate as barriers to contraceptive use, yet positive reinforcement from family, friends, and schools is viewed as supportive.Conclusions and ImplicationsFor this group of young, immigrant Latinas, there is a pervasive desire for effective communication and trusting relationships with PCPs. Findings suggest that providers can facilitate contraceptive decision making for this population by using a shared decision-making approach to contraceptive counseling.     

Who Are the Medical Travelers and What Do They Want?: A Qualitative Study

The ongoing debate on U.S. healthcare reform fueled by increasing cost and poor access to quality healthcare is spurring interest in medical travel. The topic of medical travel—going abroad to seek medical care—has been widely reported in various news outlets. This issue even resulted in a Senate Hearing before the Special Committee on Aging. Despite this popularity, very little empirical research has been conducted to describe and understand medical travelers. To fill this gap, the present study involves in-depth interviews of medical travel facilitators with extensive exposure to and communication with medical travelers. This article has multiple objectives. It aims to develop a demographic and psychographic profile of medical travelers and identify their underlying motives to seek medical care overseas. Based on these insights, it presents a list of propositions to be tested in further research. Finally, it offers practical implications for the healthcare industry.     

The Role of Patient–Provider Communication in Engagement and Re-engagement in HIV Treatment in Bamako,Mali: A Qualitative Study

Mounting evidence in sub-Saharan Africa suggests poor patient-provider communication (PPC) negatively impacts patient engagement (retention in care and adherence to medication) in antiretroviral therapy (ART) programs. In Bamako, Mali, where 36% of ART patients are lost to follow-up within 12 months of initiating treatment, we aimed to define features of positive PPC according to patient values and explore the mechanisms by which these features may sustain engagement and re-engagement according to patient and provider experiences. We conducted 33 in-depth interviews and 7 focus groups with 69 patients and 17 providers in five ART clinics. Regarding sustaining engagement, participants highlighted “establishing rapport” as a foundational feature of effective PPC, but also described how “responding to emotional needs”, “eliciting patient conflicts and perspective” and “partnering to mitigate conflicts” functioned to address barriers to engagement and increase connectedness to care. Patients who had disengaged felt that “communicating reacceptance” may have prompted them re-engage sooner and that tailored “partnering to mitigate conflicts” would be more effective in sustaining re-engagement than the standard adherence education providers typically offer. Optimizing provider skills related to these key PPC features may help maximize ART patient engagement, ultimately improving health outcomes and decreasing HIV transmission in sub-Saharan Africa.     

Partitioned Survival and State Transition Models for Healthcare Decision Making in Oncology: Where Are We Now?

ObjectivesPartitioned survival models (PSMs) are routinely used to inform reimbursement decisions for oncology drugs. We discuss the appropriateness of PSMs compared to the most common alternative, state transition models (STMs).MethodsIn 2017, we published a National Institute for Health and Care Excellence (NICE) Technical Support Document (TSD 19) describing and critically reviewing PSMs. This article summarizes findings from TSD 19, reviews new evidence comparing PSMs and STMs, and reviews recent NICE appraisals to understand current practice.ResultsPSMs evaluate state membership differently from STMs and do not include a structural link between intermediate clinical endpoints (eg, disease progression) and survival. PSMs directly consider clinical trial endpoints and can be developed without access to individual patient data, but limit the scope for sensitivity analyses to explore clinical uncertainties in the extrapolation period. STMs facilitate these sensitivity analyses but require development of robust survival models for individual health-state transitions. Recent work has shown PSMs and STMs can produce substantively different survival extrapolations and that extrapolations from STMs are heavily influenced by specification of the underlying survival models. Recent NICE appraisals have not generally included both model types, reviewed individual clinical event data, or scrutinized life-years accrued in individual health states.ConclusionsThe credibility of survival predictions from PSMs and STMs, including life-years accrued in individual health states, should be assessed using trial data on individual clinical events, external data, and expert opinion. STMs should be used alongside PSMs to support assessment of clinical uncertainties in the extrapolation period, such as uncertainty in post-progression survival.     

Patient Preferences Versus Physicians’ Judgement: Does it Make a Difference in Healthcare Decision Making?

Clinicians and public health experts make evidence-based decisions for individual patients, patient groups and even whole populations. In addition to the principles of internal and external validity (evidence), patient preferences must also influence decision making. Great Britain, Australia and Germany are currently discussing methods and procedures for valuing patient preferences in regulatory (authorization and pricing) and in health policy decision making. However, many questions remain on how to best balance patient and public preferences with physicians’ judgement in healthcare and health policy decision making. For example, how to define evaluation criteria regarding the perceived value from a patient’s perspective? How do physicians’ fact-based opinions also reflect patients’ preferences based on personal values? Can empirically grounded theories explain differences between patients and experts—and, if so, how? This article aims to identify and compare studies that used different preference elicitation methods and to highlight differences between patient and physician preferences. Therefore, studies comparing patient preferences and physician judgements were analysed in a review. This review shows a limited amount of literature analysing and comparing patient and physician preferences for healthcare interventions and outcomes. Moreover, it shows that methodology used to compare preferences is diverse. A total of 46 studies used the following methods—discrete-choice experiments, conjoint analyses, standard gamble, time trade-offs and paired comparisons—to compare patient preferences with doctor judgements. All studies were published between 1985 and 2011. Most studies reveal a disparity between the preferences of actual patients and those of physicians. For most conditions, physicians underestimated the impact of intervention characteristics on patients’ decision making. Differentiated perceptions may reflect ineffective communication between the provider and the patient. This in turn may keep physicians from fully appreciating the impact of certain medical conditions on patient preferences. Because differences exist between physicians’ judgement and patient preferences, it is important to incorporate the needs and wants of the patient into treatment decisions.     

From the Editor of Sexuality and Disability: Are We Still Interested? Are We Still Invested?

Sexuality and Disability -     

‘A Normal Delivery Takes Place at Home’: A Qualitative Study of the Location of Childbirth in Rural Ethiopia

To identify reasons why women who access health facilities and utilise maternal newborn and child health services at other times, do not necessarily deliver at health facilities. Forty-six semi-structured interviews were conducted with mothers who had recently delivered (n = 30) or were pregnant (n = 16). Thematic analysis of the interview data resulted in emerging trends that were critically addressed according to the research objective. Of the 30 delivered cases, 14 had given birth at a health facility, but only 3 of those had planned to do so. The remaining 11 had attended due to long or complicated labours. Five dominant themes influencing location of delivery were identified: perceptions of a normal delivery; motivations encouraging health facility delivery; deterrents preventing health facility deliveries; decision-making processes; and level of knowledge and health education. Understanding the socio-cultural determinants that influence the location of delivery has implications for service provision. Alongside timely health education and maximising the contact between women and healthcare professionals, these determinants should be actively incorporated into maternal newborn and child health policy and programming in ways that encourage the utilisation of health facilities, even for routine deliveries.     

“We were Sad and We were Angry”: A Systematic Review of Parents’ Perspectives on Bullying

Background

The social-ecological systems perspective describes bullying as a complex social phenomenon, influenced by numerous social variables within a child’s school, home, peer, and community environments. As such, it is important to gain the perspective of a wide range of stakeholders within these environments, in order to truly understand bullying and develop effective prevention and intervention programmes.

Objective

Parents’ experiences with bullying remain relatively unexplored. Accordingly, this systematic review aimed to summarise qualitative research examining parents’ experiences with and perceptions of bullying.

Methods

Electronic searches were conducted in the PsycINFO, Education Resources Information Center, ProQuest, A+ Education, and Academic Search Premier databases; reference lists and specific journals were also searched. Selected studies were read thoroughly, and the main findings were categorised into common themes.

Results

Thirteen studies were identified to be included in the review. Six themes emerged: (1) variation in parents’ definitions of bullying, (2) the perception of bullying as normal, and a tendency to blame victims, (3) parents’ strategies for coping with bullying, (4) the negative effects of bullying, (5) issues of disclosure, awareness and support, and (6) the question of responsibility for dealing with bullying.

Conclusions

Parents’ experiences with bullying are varied and diverse. However, parents consistently expressed the need for targeted information and guidelines on how to deal with bullying. Furthermore, greater awareness and understanding of bullying among parents is necessary, along with the acknowledgement of shared responsibility for bullying, and greater collaboration between schools and families.     

What Are the Physical Demands of Sexual Intercourse? A Systematic Review of the Literature

Archives of Sexual Behavior - The aim of this study was to systematically review the literature investigating the physical demands of sexual intercourse and to synthesize the evidence related to...     

Spanning a Decade of Physician Boundary Violations: Are We Improving?

Sexual boundary violations can negatively impact the culture of safety within a medical practice or healthcare institution and severely compromise the covenant of care and physician objectivity. Lack of education and training is one factor associated with physician misconduct that leads to high financial and personal cost. This paper presents a follow-up study of physicians referred to a professional development course in 2001 and presents demographic data from 2001 to present. The paper focuses on the education and remediation progress regarding sexual misconduct by physicians.     

Orphan Drug Pricing and Payer Management in the United States: Are We Approaching the Tipping Point?

The Orphan Drug Act of 1983 paved the way for the development of drugs that treat rare diseases, defined in the United States as those affecting fewer than 200,000 patients. Orphan drugs can cost hundreds of thousands of dollars annually, but insurers have traditionally covered these therapies because the small populations involved did not typically lead to significant cost exposure. Payer sensitivity to the cost of orphan drugs is rising, however, with the accelerated rate of new launches of these agents amid intensified economic pressure. Payers are showing increasing levels of concern and scrutiny about coverage of orphan drugs. A new payer survey conducted between February 2008 and March 2009 provides insights on how payers are managing orphan drugs and the way it is likely to evolve in the future. Survey findings show that the patient share of orphan drug costs is rising and is expected to continue to rise, barring sweeping changes in public health policy. This shift in benefit design could affect patient access to orphan agents and, therefore, drug utilization. Manufacturers will have to invest in research to understand payer impact on the uptake of their orphan drugs in development. They will also benefit from being prepared to develop strategies to ensure patient access to and affordability of their orphan agents.For the past 25 years, manufacturers of orphan drugs have faced few obstacles to reimbursement from private or public insurers, despite prices that can amount to hundreds of thousands of dollars annually in treatment cost. However, payer sensitivity appears to be rising, as the launch rate of orphan drugs accelerates amid increasing pressure to contain costs.Patient access to orphan drugs is rarely denied. The diseases that orphan drugs treat are rare and usually have no treatment alternatives. However, orphan drugs are not immune to management tactics and benefitdesign trends that payers apply to other expensive biologics, injectables, or specialty drugs. To varying degrees, major US payers are using the full range of existing tools to ensure appropriate use of orphan agents. Simultaneously, trends in health plan design have increased the burden on patients through cost-sharing. The result is that even when access to or coverage of orphan drugs is offered, providers and patients face hurdles that can affect utilization.In the absence of health policies that dictate otherwise, payers expect the management of orphan drugs to intensify. Manufacturers, providers, and patients can expect the following strategies from insurers that administrate commercial and Medicare health plans:

• Scrutiny of orphan drug utilization up to and exceeding the $50,000 per-patient per-year threshold
• Increased focus on appropriate use of orphan drugs, often restricting use to approved indications
• Rising burden on patients through cost-sharing (ie, coinsurance, higher copayments), as well as existing annual or lifetime maximum payments.

     

How do Older Employees with Health Problems Remain Productive at Work?: A Qualitative Study

Purpose The goal of this qualitative study was to gain insight into how older employees remain productive at work in spite of health problems. Methods Twenty-six semi-structured telephone interviews were conducted with older employees, 46–63 years of age, who reported a poor health in the Study on Transitions in Employment, Ability, and Motivation. Demographic, health, and work information was gathered, followed by information on adjustments made in response to health problems. Inductive and deductive analyses were done independently by two researchers. Results Four pathways through which poor health could influence productivity were identified: (1) poor health did not influence productivity; (2) poor health created a temporary imbalance in demands and external and internal resources after which adjustments were made and productivity was maintained; (3) adjustments were made in response to an imbalance, but productivity remained reduced; and (4) no adjustments were made and productivity was reduced. Whether and which adjustments occurred was influenced by factors in various domains, such as: visibility of the problem (health), autonomy (work-related), support (relational), and the ability to ask for help (personal). Sustainable productivity was influenced by internal factors that enhanced or hindered the creation of a balance, and by whether appropriate adjustments were made. Conclusions The influence that health can have on productivity depends on the individuals’ unique imbalance and personal disposition. Helpful a priori work place characteristics and personal well-being should be promoted so that a balance between demands and resources can be found in times of poor health.     

Physicians’ Decision Making on Adoption of New Technologies and Role of Coverage with Evidence Development: A Qualitative Study

Objectives

To foster value-based pricing and coverage with evidence development in Germany, certain new diagnostic and treatment methods have been subject to a benefit assessment since 2016 to determine their reimbursement. Although this is a paradigm shift, the German approach is limited to some few specific technologies for which reimbursement is requested. As physicians encounter this regulatory instrument, the aim of the study was to understand physicians’ decision making regarding the adoption of new medical technologies and to identify their perspectives on the evidence base and financing with additional reimbursement systems.

Who Decides? Decision Making and Fertility Preservation in Teens With Cancer: A Review of the Literature

Purpose

The knowledge that cancer treatment may impair fertility in pediatric populations is an emerging aspect of quality of life in this population. However, decision making and use of fertility preservation (FP) among adolescent cancer patients and their families has not been well studied. This review summarizes the available published data on aspects of decision making and FP in adolescent cancer patients.

Methods

An electronic search was performed to identify peer-reviewed studies published between 1999 and 2009 using key Medical Subject Heading terms and inclusion criteria. Inclusion criteria limited eligible studies to those that focused on adolescent decision making in cancer treatment or FP, fertility concerns in pediatric oncology, capacity for decision making, and health decision making in pediatrics. Studies that did not meet at least one of these criteria were excluded.

Results

A total of 29 articles were reviewed and summarized. Three categories of results were seen: a focus on adolescent decision making in oncology, decision making in chronic illness, and decision making in cancer-related infertility and preservation.

Conclusion

Most of the studies showed that adolescents have a strong desire to participate in decisions related to their cancer treatment and many have concerns regarding their future fertility, although barriers often prevented these discussions. More research is needed to explore the role of teenagers and parents in decisions about fertility in relation to cancer treatment.