The Landscape of Direct-To-Consumer Genetic Testing in Reproductive Health Contexts: An Analytical Framework of Stakeholders and Their Competing Motivations.

We propose a theoretical framework that identifies (a) the different categories of stakeholders and (b) the normative values that drive their attitudes toward direct-to-consumer genetic testing, with an emphasis on the reproductive health contexts. We conducted a literature search using varied combinations of search terms, including direct-to-consumer genetic testing, decision-making, reproductive health, and policy. Using a grounded theory approach to existing literature and in combination with a narrative review, we present a systematic framework of five categories of stakeholders (i.e., genome-driven stakeholders, industry-driven stakeholders, history-driven stakeholders, value-driven stakeholders, and social justice-driven stakeholders) that shape the public's discourse. Moving beyond the dialectical ethics that have governed the public discourse, we also identify the normative values and interests that motivate different stakeholders' attitudes and decision-making through theoretical sampling under the grounded theory. We investigate the competing and conflicting values within the same category of stakeholders. For example, despite being industry-driven stakeholders, medical professionals' attitudes are driven by concerns about standards of care; in contrast, health insurance companies' concerns are centered on profit. We further explore the tensions between these stakeholders that impact their strategic alliances and pose challenges to the practices of direct-to-consumer genetic testing. Finally, we examine how these stakeholders and their corresponding values may shape future development and policies of direct-to-consumer genetic testing in the context of reproductive health.

Doctors, Patients, and Interpreters' Views on the Co-Construction of Empathic Communication in Interpreter-Mediated Consultations: A Qualitative Content Analysis of Video Stimulated Recall Interviews.

Doctors and patients rely on verbal and nonverbal resources to co-construct clinical empathy. In language-discordant consultations, interpreters' communicative actions might compromise this process. We aim to explore doctors, patients, and professional interpreters' perspectives on their own and others' actions during their empathic interaction in interpreter-mediated consultations (IMCs). We analyzed 20 video stimulated recall interviews with doctors, patients, and interpreters using qualitative content analysis. Doctors and patients found ways to connect with each other on the level of empathic communication (EC) that is not limited by interpreters' alterations or disengaged demeanor. Some aspects of doctors and interpreters' professional practices might jeopardize the co-construction of EC in IMCs. The co-construction of EC in IMCs is not only subject to participants' communicative (inter)actions, but also to organizational and subjective factors. These results provide evidence of the transactional process between the behavioral, cognitive, and affective components of clinical empathy in the context of IMCs.

"It's Not Like You Need to Live 10 or 20 Years": Challenges to Patient-Centered Care in Gynecologic Oncologist-Patient Interactions.

The literature suggests that the patient-perspective approach (i.e., eliciting and responding to patients' perspectives, including beliefs, preferences, values, and attitudes) to patient-centered care (PCC) is not a reliable predictor of positive outcomes; however, little is known about why the patient-perspective approach does not necessarily lead to positive outcomes. By using discourse analysis to examine 44 segments of oncologist-patient interactions, we found that providers' use of patient-perspective contextualization can affect the quality of care through (a) constructing the meanings of patient conditions, (b) controlling interpreting frames for patient conditions, and (c) manipulating patient preferences through strategic information sharing. We concluded that providers' use of patient-perspective contextualization is an insufficient indicator of PCC because these discursive strategies can be used to control and manipulate patient preferences and perspectives. At times, providers' patient-perspective contextualization can silence patients' voice and appear discriminatory.

Not just "getting by": factors influencing providers' choice of interpreters.

BACKGROUND: Providers consistently underutilize professional interpreters in healthcare settings even when they perceive benefits to using professional interpreters and when professional interpreters are readily available. Little is known about providers' decision-making processes that shape their use of interpreters. OBJECTIVE: To understand the variety of considerations and parameters that influence providers' decisions regarding interpreters. DESIGN: A qualitative, semi-structured interview guide was used to explore providers' decision making about interpreter use. The author conducted 8 specialty-specific focus groups and 14 individual interviews, each lasting 60-90 minutes. PARTICIPANTS: Thirty-nine healthcare professionals were recruited from five specialties (i.e., nursing, mental health, emergency medicine, oncology, and obstetrics-gynecology) in a large academic medical center characterized as having "excellent" interpreter services. APPROACH: Audio-recorded interviews and focus groups were transcribed and analyzed using grounded theory to develop a theoretical framework for providers' decision-making processes. KEY RESULTS: Four factors influence providers' choice of interpreters: (a) time constraints, (b) alliances of care, (c) therapeutic objectives, and (d) organizational-level considerations. The findings highlight (a) providers' calculated use of interpreters and interpreting modalities, (b) the complexity of the functions and impacts of time in providers' decision-making process, and (c) the importance of organizational structures and support for appropriate and effective interpreter utilization. CONCLUSIONS: Providers actively engage in calculated use of professional interpreters, employing specific factors in their decision-making processes. Providers' understanding of time is complex and multidimensional, including concerns about disruptions to their schedules, overburdening others' workloads, and clinical urgency of patient condition, among others. When providers make specific choices due to time pressure, they are influenced by interpersonal, organizational, therapeutic, and ethical considerations. Organizational resources and guidelines need to be consistent with institutional policies and professional norms; otherwise, providers risk making flawed assessments about the effective and appropriate use of interpreters in bilingual health care.

Health as Submission and Social Responsibilities: Embodied Experiences of Javanese Women With Type II Diabetes.

By examining women's experiences with type II diabetes, we explore how illness can provide resources to construct meanings of everyday life in Javanese culture. We conducted in-depth interviews with 30 female participants in Central Java, Indonesia, and adopted grounded theory for data analysis. We identified four themes that diabetes serves as resources for women in Indonesia to (a) normalize suffering, (b) resist social control, (c) accept fate, and (d) validate faith. We concluded by noting three unique aspects of Javanese women's illness management. First, through the performance of submission, our participants demonstrated spirituality and religiosity as essential elements of health. Second, diabetes empowers individuals in everyday suffering through two divergent processes: embracing submission and resisting control. Finally, diabetes provides opportunities for individuals within a social network to (re)negotiate social responsibilities. In summary, diabetes provides unique resources to empower our participants to obtain voices that they otherwise would not have had.

Bilingual health communication: distinctive needs of providers from five specialties.

Understanding providers' expectations and needs for medical interpreters can provide important insight into the dynamics and process of interpreter-mediated medical encounters. This is one of the first mixed-methods studies on the similarities and differences of providers' views of interpreters across five specialties (i.e., obstetrics/gynecology, emergency medicine, oncology, mental health, and nursing). The two-stage studies include interview data with 39 providers and survey data with 293 providers. We used principal component analysis to identify three components in the survey data that represent providers' views of interpreters: Patient Ally, Health Care Professionals, and Provider Proxy. We then used the interview data as exemplars to illuminate the quantitative findings. Patient Ally was the only component that reached significant differences between different specialties. Providers from different specialty areas differ significantly in their expectations on interpreters' ability (a) to assist patients outside of medical encounters and (b) to advocate for the patient. In particular, nursing professionals place more importance on these two abilities than mental health providers and oncologists. Based on our findings, we proposed three research directions necessary to advance the field of bilingual health communication: to reevaluate and reconceptualize interpreters' appropriate performances with special attention to the Patient Ally dimension, to examine the commonly held attitudes for all providers and the potential tensions within these attitudes, and to identify contextual factors that influence participants' perceptions, evaluations, and choices of interpreters and their corresponding impacts.

Rethinking Interpreter Functions in Mental Health Services.

Interpreters improve access to care for patients with limited English proficiency (LEP), but some studies have reported poorer cultural understanding, relationship quality, and patient satisfaction than with language-concordant care. Use of interpreter roles beyond linguistic conversion (clarifier, cultural broker, or advocate/mediator) may enhance interpreter-mediated care by improving cultural understanding and the therapeutic alliance. As reported in this column, pilot data on interpreter-mediated evaluations of 25 psychiatric outpatients with LEP support this position. The authors found that clarification of the interpreter's role and the session structure improved provider-interpreter collaboration, with two perceived benefits: improved assessment through elicitation of clinically relevant information and stronger therapeutic alliance through "emotion work." Strategies for effectively enhancing provider-interpreter collaboration are discussed.

Integrative Nutritional Counseling Combining Chinese Medicine and Biomedicine for Chinese Americans with Type 2 Diabetes: A Mixed-Methods Feasibility Study.

Objectives: This study describes the development and feasibility of Integrative Nutritional Counseling (INC), a Chinese medicine (CM)+biomedicine-based nutrition curriculum for Chinese Americans with type 2 diabetes. Although Chinese Americans often incorporate CM principles into their diet, scant research has explored how to integrate CM with biomedical nutrition standards in a culturally appropriate manner or if such a program could improve diabetes self-management. Design: This is a 1-month pre-post study design including three points of contact: baseline, in-person class, and 1-month follow-up. Subjects: Participants (n = 15) were Cantonese-speaking/reading Chinese Americans diagnosed with type 2 diabetes who had used some form of CM/medicinal foods in the last 12 months. Interventions and Outcome Measures: The INC program included baseline surveys and a CM intake interview conducted by a licensed acupuncturist. The acupuncturist generated a CM diagnosis, which was shared with the participant, and used this diagnosis to tailor brief nutrition education. To bolster this brief education, a bilingual registered dietitian provided a 2-h group education class in Cantonese to all participants, during which time participants also received a Chinese/English INC booklet. Participants completed surveys immediately after the class and at 1-month follow-up, with qualitative exit interviews. Results: Participants reported improved attitudes and dietary habits aligning directly with INC, and improvement in biomedically valued measures of type 2 diabetes, such as weight loss, and CM-valued measures of digestion/elimination and hot/cold feeling. Satisfaction with INC was high, but challenges included confusion with some INC information, structural barriers, and comorbidities. Conclusions: Chinese Americans with type 2 diabetes and interventionists found integrative nutrition approaches acceptable and feasible. Future research should examine INC with a larger population and explore optimal delivery of INC given reported challenges.

Dimensions of trust: the tensions and challenges in provider--interpreter trust.

In this study we examined the challenges to providers' and interpreters' collaboration in bilingual health care. We conducted in-depth interviews and focus groups with 26 medical interpreters (speaking 17 languages) and 32 providers (from four specialties) in the United States to provide an empirically based framework of provider-interpreter trust. Constant comparative analysis was used for data analysis. We identified four dimensions of trust, theoretical constructs that can strengthen or compromise provider-interpreter trust: interpreter competence, shared goals, professional boundaries, and established patterns of collaboration. In this article we describe how these dimensions highlight tensions and challenges that are unique in provider-interpreter relationships. We conclude with practical guidelines that can enhance provider-interpreter trust, and propose future research directions in bilingual health care.

"I am not a robot!" Interpreters' views of their roles in health care settings.

In this study, I examined interpreters' self-perceived roles and their corresponding communicative goals and strategies. Twenty-six professional interpreters (of 17 languages), 4 patients, and 12 health care providers were recruited for this study, which involved participant observation of medical encounters and in-depth interviews. Constant comparative analysis was used to generate a typology of interpreters' self-perceived roles, which are different from the roles they learned in their training. Different roles reflect differences in interpreters' concern for other participants' goals, institutional goals, and their own communicative goals. Interpreters' desire to maintain neutrality during the medical encounters influences the communicative strategies they adopt when assuming other roles. I conclude the article with the theoretical and practical implications of interpreters' self-perceived roles.

Reconceptulizing Language Discordance: Meanings and Experiences of Language Barriers in the U.S. and Taiwan.

Individuals with language barriers may face challenges unique to a host society. By examining and comparing the sociocultural conditions that can result in providers and patients not sharing the same language in the United States and in Taiwan, I argue that (a) language discordance is a social phenomenon that may entail diverging meanings and experiences in different countries; (b) language-discordant patients may not share similar experiences even if they are in the same country; and (c) disparities in language concordance may be confounded with other disparities and cultural particulars that are unique to a host society. In addition, because English is a dominant language in medicine, language-discordant patients' quality of care in Taiwan can be moderated by their fluency in English.

Interpreters as co-diagnosticians: overlapping roles and services between providers and interpreters.

This study examined medical interpreters' practice of the co-diagnostician role and further explored its practical, institutional, and ethical implications. Twenty-six professional interpreters (of 17 languages), 4 patients, and 12 health-care providers were recruited for this study, which involves participant observation and interviews undertaken in the Midwestern US. Constant comparative analysis was used to develop themes of interpreters' communicative practices. Interpreters justified their role performances by claiming the identity of a member of the health care team and their work as part of the team effort. Their communicative strategies as a co-diagnostician reflect their preconception of the social hierarchy of health-care settings and the emphasis on diagnostic efficacy. I have identified five strategies for the co-diagnostician role. These were assuming the provider's communicative goals; editorializing information for medical emphasis; initiating information-seeking behaviors; participating in diagnostic tasks; and volunteering medical information to the patients. Although many strategies can be attributed to interpreters' effort to conserve providers' time and to bridge the cultural differences, they also pose risks to patients' privacy, clinical consequences, and provider-patient relationships.

Surviving Violence in Everyday Life: A Communicative Approach to Homelessness.

In this narrative review, the author synthesizes the literature on homelessness across various disciplines (e.g., public health, social work, sociology, and communication) to demonstrate how the experiences of homelessness can be created, maintained, and reinforced through communication, including interpersonal interactions and public discourse. By conceptualizing homelessness as a culturally constructed and socially situated phenomenon, the author examines (a) the complex conceptualization of homelessness, (b) everyday violence faced by people who are homeless, and (c) coping strategies of people who are homeless. In summary, homelessness is a complex social phenomenon, involving tensions between individuals, families, and social systems, all of which are situated in the larger sociocultural and sociopolitical contexts of a specific time and place.

Heavy water labeling of keratin as a non-invasive biomarker of skin turnover in vivo in rodents and humans.

Measurement of skin turnover has been problematic in humans. Heavy water (2H2O) labeling has recently been developed as a safe, simple method to study in vivo kinetics of many biosynthetic processes, including DNA and protein synthesis. Here, we apply this approach to the measurement of 2H incorporation into skin keratin and show close agreement between keratin and keratinocyte turnover data in the epidermis of rodents. Elevated turnover rates of both keratin and keratinocytes were observed in the epidermis of the flaky skin mouse, although topical treatments effective in human psoriasis had no effect on either turnover rate in these mice. In humans, keratin turnover was monitored non-invasively by serial tape stripping during and after 2H2O labeling. Kinetic data were consistent with previous estimates of epidermal turnover, with a lag time of 18 days before label appeared at the skin surface and a transit time of 4-5 weeks. Variability in skin keratin turnover rates was present among healthy individuals. In summary, 2H2O labeling of skin keratin represents a non-invasive approach for assessing skin turnover dynamics in pre-clinical models and in human subjects.

Conflicts in how interpreters manage their roles in provider-patient interactions.

Interpreters face challenges because of the various role expectations that others have placed on them and then adopt specific strategies to manage these conflicts. This study examines the conflicts in medical interpreters' role performances, the sources of these conflicts, and interpreters' strategies for resolving conflicts. It is based on in-depth interviews with 26 medical interpreters from 17 languages in the Midwestern area of the USA. The results showed that interpreters experienced four sources of conflicts in their role performances: (a) others' communicative practices, (b) changes in participant dynamics, (c) institutional constraints, and (d) unrealistic role expectations. To resolve conflicts, interpreters justified their roles by identifying the source and location of an assignment, (re)defining the relationships and identities of the provider and the patient, and adopting specific communicative strategies. This study highlights the importance of speaker and contextual factors on interpreters' communicative strategies and management of role conflicts.

Voices of the Homeless: An Emic Approach to the Experiences of Health Disparities Faced by People Who Are Homeless.

People who are homeless are particularly vulnerable to health disparities. Rather than using population statistics to highlight the prevalence or severity of the suffering of people who are homeless, 28 undergraduate students each conducted an in-depth interview with an individual who relied on a local homeless shelter to cope with everyday life. The interview explored the participants' health concerns and strategies for health management. Due to equipment failure and incomplete recording, only 16 interviews are included in this study. The author adopted thematic analysis while focused on preserving the richness of the interactions between the participants who are homeless and the undergraduate students. The author's goal is to provide emic, intimate insights about the struggles and challenges faced by the people who are homeless. The author concluded the study by situating the findings in the larger literature of health disparities experienced by people who are homeless.

"Not Homeless Yet. I'm Kind of Couch Surfing": Finding Identities for People at a Homeless Shelter.

The meanings of homelessness are fluid and socially constructed, providing resources and limitations for individuals to negotiate their identities and relationships in everyday life. In this study, we examine the strategies and corresponding resources utilized by people who are homeless to cope with the labeling of a homeless identity and to redefine their identities. We used constant comparative analysis to examine in-depth interviews with 16 participants (male = 11, female = 5) who access a local homeless shelter in the southwest United States for resources. We identified three strategies that homeless people adopt to cope with the labeling of homeless identity: (a) differentiating oneself from others who are homeless, (b) prioritizing certain aspects of life, and (c) embracing the status of homelessness. Although these strategies have been identified in previous literature, the authors extend this line of research by identifying the common resources people who are homeless utilize when adopting these strategies, which entail important implications for theory development and practical implications.

Conceptualizing emotion in healthcare interpreting: A normative approach to interpreters' emotion work.

OBJECTIVES: By juxtaposing literature in signed language interpreting with that of spoken language interpreting, we provide a narrative review to explore the complexity of emotion management in interpreter-mediated medical encounters. METHODS: We conduct literature search through library databases and Google Scholar using varied combinations of search terms, including interpreter, emotion, culture, and health care. RESULTS: We first examine (a) interpreters' management and performance of others' emotions, (b) interpreters' management and performance of their own emotions, and (c) impacts of emotion work for healthcare interpreters. CONCLUSION: By problematizing the roles and functions of emotion and emotion work in interpreter-mediated medical encounters, we propose a normative model to guide future research and practices of interpreters' emotion management in cross-cultural care. PRACTICE IMPLICATIONS: Quality and equality of care should serve as the guiding principle for interpreters' decision-making about their emotions and emotion work. Rather than adopting a predetermined practice, interpreters should evaluate and prioritize the various clinical, interpersonal, and therapeutic objectives as they consider the best practice in managing their own and other speakers' emotions.

Dynamics of keratinocytes in vivo using HO labeling: a sensitive marker of epidermal proliferation state.

A heavy water ((2)H(2)O) labeling method recently developed to measure cell proliferation in vivo is applied here to the measurement of murine epidermal cell turnover and to investigate conditions in which keratinocyte proliferation is either inhibited or stimulated. The technique is based on incorporation of (2)H(2)O into the deoxyribose moiety of deoxyribonucleotides in dividing cells. Label incorporation and die-away studies in cells isolated from C57BL/6J mouse epidermis revealed the replacement rate to be 34%-44% per wk (half-life of 1.6-2 wk). The kinetics provided evidence of a non-proliferative subpopulation of cells (10%-15% of the total) within the epidermis. Topical administration of 7,12-dimethylbenz(a)anthracene and 12-O-tetradecanoylphorbol-13-acetate for 3 wk increased epidermal cell proliferation by 55% in SENCAR mice. Topical addition of lunasin, an anti-mitotic agent from soy, decreased epidermal cell proliferation modestly though significantly (16% given alone, 9% given with carcinogens). Caloric restriction (by 33% of energy intake) for 4 wk decreased the epidermal cell proliferation rate by 45% in C57BL/6J mice. In summary, epidermal cell proliferation can be measured in vivo using (2)H(2)O labeling in normal, hyper- and hypo-proliferative conditions. Potential applications of this inherently safe method in humans might include studies of psoriasis, wound healing, chemopreventive agents, and caloric intake.