Involvement in treatment decision-making: its meaning to people with diabetes and implications for conceptualisation

Patient involvement in decision-making is widely regarded as an important feature of good-quality healthcare. Policy-makers have been particularly concerned to ensure that patients are informed about and enabled to choose between relevant treatment options, but it is not clear how patients understand and value involvement. We investigated the meaning of involvement in treatment decision-making for people with diabetes. We conducted semi-structured interviews with 18 people aged between 20 and 79 who had type 1 or type 2 diabetes selected from 4 multi-practitioner outpatient clinics in the Grampian area of Scotland. We used several strategies to probe their understandings of involvement, including a discussion of how they would respond to a question about involvement in treatment decisions that appears on the National Patient Survey used to monitor the quality of healthcare in England. Participants associated involvement in decision-making with a number of features relating to the ethos and feel of healthcare encounters (welcoming; respectful; facilitative of patients' contributions; and non-judgmental); communication about health problems (practitioners attending to patients' views and patients feeling listened to; practitioners giving clear explanations based on their professional knowledge and patients understanding these); and communication about treatments (practitioners explaining treatment rationales in ways that patients understand and enabling patients to feel they have a say). Our findings have implications for practical attempts to involve patients in decisions about their care and for the conceptualisation and assessment of patient involvement. They suggest that practitioners who aspire to facilitate patient involvement should attend to the ethos they foster in consultations and the way they discuss problems as well as to the provision of information about treatment options and the scope patients have to influence decisions. Models and taxonomies of patient involvement in decision-making need to be developed to accommodate both problem-solving phases and the relational and subjective dimensions of involvement.     

Serving in Bosnia made me appreciate living in Bristol: stressful experiences, attitudes, and psychological needs of members of the United Kingdom Armed Forces

Peacekeeping operations form an increasing part of the role of the U.K. Armed Forces. This study identified perceived needs for training before such operations, experiences of stress during deployments, beliefs and attitudes regarding psychological support and debriefing on return, general attitudes toward peacekeeping duties, and positive aspects of the peacekeeping role. Although nearly all peacekeepers were exposed to a variety of experiences, most perceived stress came from professional difficulties and frustrations with the occupational role of being a peacekeeper, rather than from dangerous situations. The exception was a significant fear of land mines. For many, peacekeeping had a positive impact on soldiers' lives, most commonly an appreciation of "things back home." Respondents' opinions about the peacekeeping experience vary greatly. Additional training addressing and exploring potential conflicts between the traditional role of the soldier and the role of the peacekeeper may be useful.     

What “Price” Means When Buying Food: Insights From a Multisite Qualitative Study With Black Americans

Objectives. We explored the role of price in the food purchasing patterns of Black adults and youths.Methods. We analyzed qualitative data from interviews and focus groups with socioeconomically diverse, primarily female, Black adults or parents (n = 75) and youths (n = 42) in 4 US cities. Interview protocols were locality specific, but all were designed to elicit broad discussion of food marketing variables. We performed a conventional qualitative content analysis by coding and analyzing data from each site to identify common salient themes.Results. Price emerged as a primary influence on food purchases across all sites. Other value considerations (e.g., convenience, food quality, healthfulness of product, and family preferences) were discussed, providing a more complex picture of how participants considered the price of a product.Conclusions. Food pricing strategies that encourage consumption of healthful foods may have high relevance for Black persons across income or education levels. Accounting for how price intersects with other value considerations may improve the effectiveness of these strategies.In recent years, increasing attention has been given to the role that the marketing of high-calorie, low-nutrient foods and beverages has in the development of obesity, especially childhood obesity.1,2 Marketing is multifaceted, including the types of products available, where they are available, where and how they are promoted, and what they cost (the “marketing mix”).3 Food marketing variables shape the environments in which food preferences develop and in which consumers make purchasing decisions. These variables must be understood to design policies and programs to facilitate calorically and nutritionally appropriate eating patterns.Although much of the concern about food marketing has focused on children, evidence suggests that food and beverage marketing practices contribute to the higher-than-average risk of obesity and other diet-related diseases in Black persons at all ages.4,5 Black persons are more likely than White persons to be exposed to advertising and other promotions for high-calorie, low-nutrient foods and beverages, and less likely to encounter promotions for healthier alternatives.6–9 In addition, on average, Black neighborhoods have relatively fewer retail food stores that offer a wide variety of foods and relatively more fast-food outlets than other types of restaurants compared with predominantly White neighborhoods.10–15 A higher percentage of Black than White Americans have incomes near the poverty line16 and are, therefore, also affected by the disproportionate promotion and availability of high-calorie, low-nutrient foods in lower-income neighborhoods.10,13,15,17 However, the excess risks of obesity and other diet-related diseases in Black persons are not confined to the lower-income segment of the population.18–21The objective of this study was to explore the role of price in the food purchasing patterns of Black adults and youths. Price is among the strongest, if not the strongest, influences on food purchases (particularly among low-income consumers) and on caloric overconsumption.22,23 Food price may affect caloric consumption through the types or quantities of foods purchased. For example, people may buy relatively inexpensive snack foods and convenience foods that are high in fat and sugar.24 They also may feel less guilty about buying unhealthy foods if they are discounted and may eat relatively more of the products acquired at low cost or stockpiled because of quantity discounts.22,23 Price is mentioned routinely as a major influence on food purchasing decisions by Black consumers and by consumers in general.22,25–31 However, compared with other aspects of marketing, ways in which the price of products affects diet-related disparities experienced by Black adults and youths have been less well studied.Although the foods available and marketed in Black neighborhoods are relatively less healthful compared with foods marketed in White neighborhoods, available evidence does not support the hypothesis of systematic differences in food prices between Black and White neighborhoods.9,32–35 Yet these price comparison studies have not adjusted for neighborhood differences in income, which would determine what prices residents might consider affordable. Nor have they considered several other factors such as the mix of retail outlets available, availability of time and transportation to shop in other neighborhoods, price discounts, consumer food preferences, or food-specific or more general shopping patterns, all of which might influence what people buy at a given cost.22,36 This dearth of comprehensive inquiry calls for a deeper understanding of the role of food prices in purchasing behavior among Black consumers, which will inform potential marketing-related strategies for addressing obesity.     

Return to Work and Cancer: The Australian Experience

Purpose Research suggests that for many cancer survivors, returning to work has a range of benefits. However, considerable barriers have been identified as influencing the quality of return to work outcomes. This study explored the perspectives of Australian cancer survivors, managers and employee assistance program (EAP) professionals to gain an understanding of the return to work process and factors that affect the experience. Methods Focus groups and interviews were conducted with cancer survivors (n = 15), managers (n = 12), and EAP professionals / psychologists (n = 4) from public and private sectors. Thematic analysis was used to analyse the data to identify common and unique themes from the three participant groups. Results A range of drivers were identified including maintaining normality and regaining identity, which could act positively or negatively depending on survivors’ coping ability and self awareness. Analysis revealed communication difficulties in the workplace that impact on emotional and practical support. Negotiating an employee’s return is complex, influenced by the level of consultation with the employee and use of an ad hoc or structured process. Direct and indirect ways of supporting employees with cancer were identified, as was the need for colleague and manager support. Conclusion This study supports previous research findings of the impact of cancer on work, and reveals managers’ lack of knowledge on how to respond appropriately. The process of returning to work is complex, influenced by employees’ and managers’ attitudes, communication skills and coping abilities. Areas for workplace interventions to optimise support for the cancer survivor are described.     

Dental unit waterlines: review and product evaluation

Dental practitioners must be knowledgeable regarding microbial contamination and biofilm formation in dental unit waterlines. Education should stress the need for improvement in the quality of water delivered to patients during treatment. Manufacturers must also play an important role by providing training and education regarding the proper use and maintenance of their systems. Dental facilities, both public and private, need reliable methods to prevent the development of biofilms within DUWs. These methods must be economical and require minimal effort to use on the part of the dental staff. In order for the system to work efficiently, the effluent water that is produced must be compatible with dental materials and be potentially free from toxic or carcinogenic materials. There are numerous models of water filtration units and chemical flushes available to the dental practitioner. However, the Food and Drug Administration have not approved all products currently on the market. Our evaluation of Zerosil, a new waterline-cleaning product, indicates that it is very easy to use and is extremely effective in killing the commonly found microorganisms in dental unit waterlines, as well as eliminating existing biofilms. It is also economical and requires minimum staff time to keep the waterlines clean. Following the initial treatments during week one, the water emanating from the DUWs was free from any viable microorganisms. This effect was present the entire three weeks in which the waterlines were treated. The elimination of viable microorganisms continued into a fourth study week, even though no further treatment of the DUWs was performed. Although the manufacturer recommends weekly treatment of DUWs following the initial treatment regimen, this result indicates that the product has a longer lasting effect than previously thought. Finally, the product can be delivered through any of the commercially available reservoir/bottle water delivery systems. From our study, Zerosil appears to meet the demanding requirements of keeping dental unit waterlines clean. Based on the research that has been done thus far, no universal treatment protocol can be recommended. A combination of approaches may offer the best available assurance of high-quality dental treatment water. Independent water reservoir systems, when used with a periodic chemical treatment protocol, have demonstrated safety and efficacy. Until we reach a point when a recommendation based on thorough evaluations can be made, dental offices should follow current ADA, OSAP, and CDC guidelines: flush waterlines for two to three minutes at the beginning of each day and for 20 to 30 seconds between each patient, and anti-retraction valves should be installed to prevent oral fluids from being drawn into dental waterlines. It is expected that in the near future, the dental practitioner will have a choice of proven systems and products to deal with this issue. Until that time, one should carefully evaluate any product or system being considered to prevent the formation of biofilms in DUWs.     

Cultural diversity and its role in reducing oral health disparities

African-American, Hispanic and Native-American/Alaskan Native dental students and professionals are often referred to as underrepresented minorities (URMs) because of their poor representation in the profession compared to their proportion in the U.S. population. Disparities in oral health services may, in part, be attributable to minority and economically disadvantaged patients' lack of confidence in the dental profession's ability to provide care in a culturally sensitive manner. Increasing diversity within the oral health workforce is one way to address this perception. However, an effective remedy will require all oral health professionals to devote additional attention to diversity and cultural competency issues.