Remaking critical care: Place, body work and the materialities of care in the COVID intensive care unit.

In this article, we take forward sociological ways of knowing care-in-practice, in particular work in critical care. To do so, we analyse the experiences of staff working in critical care during the first wave of the COVID-19 pandemic in the UK. This moment of exception throws into sharp relief the ways in which work and place were reconfigured during conditions of pandemic surge, and shows how critical care depends at all times on the co-constitution of place, practices and relations. Our analysis draws on sociological and anthropological work on the material culture of health care and its sensory instantiations. Pursuing this through a study of the experiences of 40 staff across four intensive care units (ICUs) in 2020, we provide an empirical and theoretical elaboration of how place, body work and care are mutually co-constitutive. We argue that the ICU does not exist independently of the constant embodied work of care and place-making which iteratively constitute critical care as a total system of relations.

Evaluation of Digitalisation in Healthcare and the Quantification of the "Unmeasurable".

Evaluating healthcare digitalisation, where technology implementation and adoption transforms existing socio-organisational processes, presents various challenges for outcome assessments. Populations are diverse, interventions are complex and evolving over time, meaningful comparisons are difficult as outcomes vary between settings, and outcomes take a long time to materialise and stabilise. Digitalisation may also have unanticipated impacts. We here discuss the limitations of evaluating the digitalisation of healthcare, and describe how qualitative and quantitative approaches can complement each other to facilitate investment and implementation decisions. In doing so, we argue how existing approaches have focused on measuring what is easily measurable and elevating poorly chosen values to inform investment decisions. Limited attention has been paid to understanding processes that are not easily measured even though these can have significant implications for contextual transferability, sustainability and scale-up of interventions. We use what is commonly known as the McNamara Fallacy to structure our discussions. We conclude with recommendations on how we envisage the development of mixed methods approaches going forward in order to address shortcomings.

Evaluating training needs in clinical psychology doctoral programs.

OBJECTIVE: Advances in clinical psychology must be accompanied by advances in training. This study assessed training content, quality, and needs during clinical psychology doctoral programs among current or past doctoral students. METHODS: Current or past clinical psychology doctoral students (N = 343) completed an anonymous survey assessing training experiences and needs. A descriptive-focused exploratory factor analysis (EFA) also examined whether common subgroups of academic interests emerged. RESULTS: Most participants reported that they sought training beyond required coursework, primarily in clinical training, cultural competency, and professional development, and reported having taken one or more unhelpful course, including discipline-specific knowledge requirements. Descriptive results from the EFA demonstrated common training areas of interest: diversity topics, biological sciences, clinical practice, and research methods. DISCUSSION: This study demonstrates that trainees and early career psychologists are aware of their nuanced and in some cases, unmet training needs. CONCLUSION: This work foregrounds the need to adapt extant training opportunities to support the next generation of clinical psychologists.

Turning the gaze: Digital patient feedback and the silent pathology of the NHS.

Online review and rating sites, where patients can leave feedback on their experience of the health-care encounter, are becoming an increasing feature of primary care in the NHS. Previous research has analysed how digital surveillance is re-shaping the clinical gaze, as health-care professionals are subject to increased public monitoring. Here, we draw on an empirical study of 41 GP practice staff to show how the gaze is turning, not simply from the patient to the health-care provider, but additionally to the body politic of the NHS. Drawing on focus group and interview data conducted in five UK practices, we show how discourses of online reviews and ratings are producing new professional subjectivities among health-care professionals and the extent to which the gaze extends not only to individual health-care interactions but to the health-care service writ large. We identify three counter-discourses characterising the evolving ways in which online reviews and ratings are creating new subjects in primary care practices: victimhood, prosumption versus traditional values and taking control. We show how the ways in which staff speak about online feedback are patterned by the social environment in which they work and the constraints of the NHS they encounter on a day-to-day basis.

The INTEND 1 randomized controlled trial of duct endoscopy as an indicator of margin excision in breast conservation surgery.

PURPOSE: With early detection, breast conservation surgery with adequate surgical margins is the standard of care. The aim of this study was to evaluate the use of pre-operative duct endoscopy (DE) to target surgical resection, improve adequate margins and reduce re-excision operations. METHODS: Women with DCIS, stage I and II breast cancer suitable for breast conservation were randomized to DE-assisted wide local excision versus standard wide local excision (without DE). The primary endpoint was margin re-excision rates between the two groups. Secondary end points were: (i) volume differences of the surgical specimen; (ii) whether an extensive in situ component (EIC) influenced successful DE-guided resection. RESULTS: 78 women were randomized: 44 patients to no-DE and 34 patients to the DE group. The median age was 59 (49-65) and 56 (48-64) years in the two groups respectively with mean follow-up of 9.1 (4.2-11.1) years. There were 23 positive findings in 17 women in 30 successful DE procedures (17/30 = 56.7%). The surgical specimen volume, no-DE (17 [IQR 10-29] cm3) and DE 20 [IQR 12-28] cm3), did not differ, p = 0.377. The overall re-excision rate was 20/78 (26%), 9 (20%) and 11 (32% in the no-DE and DE groups, respectively, p = 0.233. CONCLUSIONS: This randomized clinical trial was limited by incomplete accrual. DE did not contribute to improved margin excision rates whether a target lesion was visualized or not. The presence of EIC did not improve efficacy of DE.

Wild data: how front-line hospital staff make sense of patients' experiences.

Patient-centred care has become the touchstone of healthcare policy in developed healthcare systems. The ensuing commodification of patients' experiences has resulted in a mass of data but little sense of whether and how such data are used. We sought to understand how front-line staff use patient experience data for quality improvement in the National Health Service (NHS). We conducted a 12-month ethnographic case study evaluation of improvement projects in six NHS hospitals in England in 2016-2017. Drawing on the sociology of everyday life, we show how front-line staff worked with a notion of data as interpersonal and embodied. In addition to consulting organisationally sanctioned forms of data, staff used their own embodied interactions with patients, carers, other staff and the ward environment to shape improvements. The data staff found useful involved face-to-face interaction and dialogue; were visual, emotive, and allowed for immediate action. We draw on de Certeau to re-conceptualise this as 'wild data'. We conclude that patient experience data are relational, and have material, social and affective dimensions, which have been elided in the literature to date. Practice-based theories of the everyday help to envision 'patient experience' not as a disembodied tool of managerialism but as an embedded part of healthcare staff professionalism.

[Validation of a questionnaire on health literacy among Francophones in situation of linguistic minority]. / Validation d'un questionnaire sur l'alphabétisme en santé des francophones en situation linguistique minoritaire.

OBJECTIVE: This study was designed to develop and test the qualitative validity of a French questionnaire. The questionnaire explored the mechanisms by which Francophone in situation of linguistic minority mobilize their social capital and cultural assets in terms of health literacy. METHODS: We used evidence derived from a previous qualitative study in which we elaborated the characteristics of social capital and cultural assets. Drawing on models of social capital and self-determination of language behaviour in Francophone in situation of linguistic minority, 21 items were developed and assessed to confirm content validity. For this purpose, cognitive interviews were conducted with 92 natural experts. These cognitive interviews tested the linguistic and content validity of the instrument. Consultations with research professionals were also conducted to increase content validity. RESULTS: Parsimony and simplicity were tested by application of the Flesch test. The results demonstrate that 19 questions (93%) corresponded to the general public, relatively simple, and everyday use categories. Natural experts confirmed the readability and simplicity of the questionnaire. CONCLUSION: This study addressed a lack of simple and readable questionnaire for collecting data among Francophone in situation of linguistic minority. The findings underscore the lack of evidence related to the familiar construction of health literacy among members of this population.

The Pharmaceutical Commons: Sharing and Exclusion in Global Health Drug Development.

In the last decade, the organization of pharmaceutical research on neglected tropical diseases has undergone transformative change. In a context of perceived "market failure," the development of new medicines is increasingly handled by public-private partnerships. This shift toward hybrid organizational models depends on a particular form of exchange: the sharing of proprietary assets in general and of intellectual property rights in particular. This article explores the paradoxical role of private property in this new configuration of global health research and development. Rather than a tool to block potential competitors, proprietary assets function as a lever to attract others into risky collaborative ventures; instead of demarcating public and private domains, the sharing of property rights is used to increase the porosity of that boundary. This reimagination of the value of property is connected to the peculiar timescape of global health drug development, a promissory orientation to the future that takes its clearest form in the centrality of "virtual" business models and the proliferation of strategies of deferral. Drawing on the anthropological literature on inalienable possessions, we reconsider property's traditional exclusionary role and discuss the possibility that the new pharmaceutical "commons" proclaimed by contemporary global health partnerships might be the precursor of future enclosures.

'HIV has a woman's face': vaginal microbicides and a case of ambiguous failure.

The case is a primary unit of knowledge production in the field of HIV research, yet the work that is done to construct cases often goes unremarked. In this paper, the case takes centre stage in an analysis of a set of apparent failures in HIV prevention research, namely a series of clinical trials to test vaginal microbicides. Returning to the genesis of the microbicide concept in the early 1990s, I examine how the discourse of women's empowerment was linked to HIV prevention in a way that mobilized a particular vision of the case, which was both politically and scientifically expedient. Drawing on an in-depth empirical study of one particular trial, I show the success of the case in mobilizing funds and interest in the research, as well its success in accounting for the failure of the pharmaceutical technology. Drawing in alternative scientific accounts of the failure of microbicides, however, a different version of events is indicated, in which what can ultimately be said to have failed is not the technology itself, but the act of casing upon which its testing was founded.

Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review.

OBJECTIVES: Given the imperative to scale up integrated tuberculosis (TB) and HIV services in settings where both are of major public health importance, we aimed to synthesise knowledge concerning implementation of TB/HIV service integration. METHODS: Systematic review of studies describing a strategy to facilitate TB and HIV service integration, searching 15 bibliographic databases including Medline, Embase and the Cochrane library; and relevant conference abstracts. RESULTS: Sixty-three of 1936 peer-reviewed articles and 70 of 170 abstracts met our inclusion criteria. We identified five models: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. Referral-based models are most easily implemented, but referral failure is a key risk. Closer integration requires more staff training and additional infrastructure (e.g. private space for HIV counselling; integrated records). Infection control is a major concern. More integrated models hold potential efficiencies from both provider and user perspective. Most papers report 'outcomes' (e.g. proportion of TB patients tested for HIV); few report downstream 'impacts' such as outcomes of TB treatment or antiretroviral therapy. Very few studies address the perspectives of service users or staff, or costs or cost-effectiveness. CONCLUSIONS: While scaling up integrated services, robust comparisons of the impacts of different models are needed using standardised outcome measures.

Self care and wellbeing in the face of COVID-19: Multidisciplinary perspectives and interprofessional experiences.

The human toll which has resulted from the coronavirus disease 2019 pandemic is clearly recognised. No single event in recent times has had such profound effects on health services and their staff wellbeing around the world. Policy making has been led by the requirement for confinement and surveillance to limit spread of the disease, and in clinical settings the impact of the necessity for the use of personal protective measures has caused huge strains on practice clinically and professionally. In this paper we share experiences from the pandemic, explore the social and organisational factors at stake and make some suggestions for both personal wellbeing practice and a systems response to the ongoing staff wellbeing challenges of the pandemic.

Domesticating models: On the contingency of Covid-19 modelling in UK media and policy.

Our article traces the representation of pandemic modelling in UK print media from the emergence of Covid-19 to the early stages of implementing the first UK-wide lockdown in late March 2020. Covid modelling, it is widely assumed, has shaped policy decisions and public responses to the pandemic in unprecedented ways. We analyse how the UK print media has configured modelling as a significant evidence tool in the representation of the pandemic. Interrogating assumptions about infectious disease modelling, we ask why models became the trusted tool of choice for knowing and responding to the Covid pandemic in the UK. Our analysis has yielded four different periods in the evolution of intersecting policy and media frames. Initially, modellers, policymakers and media alike emphasized uncertainty about available data, and hence the speculative character of modelled projections, thus justifying a 'wait and see' approach to government intervention. With growing public pressure for government action, policy and media frames were adjusted to emphasize the importance of timing interventions for best effect, with modelling evidence mobilized to justify inaction. This gave way to a period of crisis, as the press increasingly questioned the reliability of the existing models and policies, leading modellers and policy makers to dramatically revise their projections. Finally, with the imposition of the first UK lockdown, policy and media frames were brought back into alignment with one another, in a process of domestication through which the language of modelling became a basic resource for the discussion of the epidemic. Our epistemological microhistory thus challenges general accounts of the impacts of pandemic modelling and instead emphasizes contingency and interpretative flexibility.

Protocols and participatory democracy in a 'North-South' product development partnership.

Global product development partnerships (PDPs) for new health technologies have become an increasingly important part of the science and development landscape over the past two decades. Polarised positions are adopted by those scrutinising the power and governance of these public-private formations; on the one hand, they are seen as successful social technology innovations, on the other as regressive and imperialistic regimes of neo-colonialism. Answering recent calls for research to examine the actors, governance, context and dynamics of PDPs, this article presents a sociological case study of one particular partnership, the Microbicides Development Programme (MDP). Interviews were conducted with a cross-section of programme staff in the UK and Zambia, and discourses analysed through a Foucauldian lens of governmentality. This article suggests that two tools of government were central to MDP's cohesiveness: institutional discourses of participatory democracy and capacity building and scientific protocols. Through these material-semiotic tools, the scientific community, junior operational researchers and the funder were successfully enrolled into the programme and governed by a central body based in the UK. This article draws on Nikolas Rose's work to discuss these socio-scientific discourses as technologies of government, and provides a non-dualistic account of power and governance in a North-South PDP.

End-user support for a primary care electronic medical record: a qualitative case study of a vendor's perspective.

BACKGROUND: In primary care settings, users often rely on vendors to provide support for health information technology (HIT). Yet, little is known about the vendors' perspectives on the support they provide, how support personnel perceive their roles, the challenges they face and the ways they deal with them. OBJECTIVE: To provide in-depth insight into an electronic medical record (EMR) vendor's perspective on end-user support. METHODS: As part of a larger case study research, we conducted nine semi-structured interviews with help desk staff, trainers and service managers of an EMR vendor, and observed two training sessions of a new client. RESULTS: With a growing client base, the vendor faced challenges of support staff shortage and high variance in users' technical knowledge. Additionally, users sometimes needed assistance with infrastructure, and not just software problems. These challenges sometimes hindered the provision of timely support and required supporters to possess good interpersonal skills and adapt to diverse client population. CONCLUSION: This study highlights the complexity of providing end-user support for HIT. With increased adoption, other vendors are likely to face similar challenges. To deal with these issues, supporters need not only strong technical knowledge of the systems, but also good interpersonal communication skills. Some responsibilities may be delegated to super-users. Users may find it useful to hire local IT staff, at least on an on-call basis, to provide assistance with infrastructure problems, which are not supported by the software vendor. Vendors may consider expanding their service packages to cover these elements.

Satisfaction with Long-Term Aesthetic and 10 Years Oncologic Outcome following Risk-Reducing Mastectomy and Implant-Based Breast Reconstruction with or without Nipple Preservation.

Incidence of bilateral risk-reducing mastectomies (RRMs) is increasing. The aim of this study was to compare satisfaction, aesthetic and oncological outcomes in women undergoing RRM with implant-based reconstruction comparing nipple-sparing mastectomy (NSM) with skin-sparing mastectomy (SSM) (sacrificing the nipple +/− nipple reconstruction). Women who had undergone bilateral RRM between 1997 and 2016 were invited. Aesthetic outcome and nipple symmetry were evaluated using standardized anthropometric measurements. The oncological outcome was assessed at last documented follow up. Ninety-three women (186 breasts) participated, 60 (64.5%) had NSM, 33 (35.5%) SSM. Median time between surgery and participation was 98.4 months (IQR: 61.7−133.9). Of the women, 23/33 (69.7%) who had SSM underwent nipple reconstruction. Nipple projection was shorter in the reconstructed SSM group than the maintained NSM group (p < 0.001). There was no significant difference in overall symmetry (p = 0.670), satisfaction regarding nipple preservation (p = 0.257) or overall nipple satisfaction (p = 0.074). There were no diagnoses of breast cancer at a median follow up of 129 months (IQR: 65−160.6). Women who undergo nipple-sparing RRM maintain long-term nipple symmetry. Nipple projection was less maintained after nipple reconstruction. Although satisfaction with the nipples was higher in the NSM group, this did not reach statistical significance. No breast cancers developed after RRM with long-term follow up.

What drives community adherence to indoor residual spraying (IRS) against malaria in Manhiça district, rural Mozambique: a qualitative study.

BACKGROUND: Malaria control remains a challenge in sub-Saharan Africa. In 2006, the World Health Organization (WHO) reinforced the recommendation of indoor residual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT) to reduce malaria transmission. The National Malaria Control Programme has been reporting high coverage rates of IRS in Mozambique. It is important to establish to what extent these rates are a reflection of community acceptability, and to explore the factors associated with adherence, in order to recommend suitable approaches for interventions of this nature. OBJECTIVE: To understand the implementation process, reception and acceptability of the IRS program in Manhiça district, Southern Mozambique. METHODS: Qualitative data was collected through in-depth interviews, participant observation of IRS activities, informal interviews, and focus group discussions. Study participants comprised householders, community leaders, health care providers, sprayers, and community members. Qualitative data analysis was based on grounded theory. Secondary data from the Manhiça Demographic Surveillance System was used to complement the qualitative data. RESULTS: IRS was well received in most neighbourhoods. The overall coverage rates varied between 29% and 41% throughout the study period. The factors related to adherence to IRS were: immediate impact on insects in general, trust and obedience in the health authority, community leaders' influence, and acquaintance with the sprayers. Fighting malaria was not an important motivation for IRS adherence. There was a perception of limited efficacy of IRS against mosquitoes, but this did not affect adherence. Non-adherence to the intervention was mainly due to the unavailability of key householders, disagreement with the procedures, and the perception that spraying increased the burden of insects. Most respondents strongly favoured bed nets over IRS. CONCLUSION: The study suggests that the contribution of IRS to malaria and mosquito control is not entirely perceived by the beneficiaries, and that other as cost effective interventions such as insecticide-treated nets are favoured over IRS. Adherence to IRS was found to be influenced by socio-political factors. There is a need to redefine the community sensitization approaches in order to make IRS a genuinely participative, acceptable, and sustainable programme.

'Team ethnography visual maps': Methods for identifying the ethnographic object in multiple sites of fieldwork.

Team ethnography is becoming more popular in research. However, there is currently limited understanding of how multiple ethnographers working together actually share their experiences of conducting team ethnography. There is also an associated lack of explanation regarding how evidence and conclusions are drawn from such collective endeavour. This article attempts to address this absence of detail regarding the practice and conduct of team ethnography. In the following account, the authors present details of the design, development and application of 'team ethnography visual maps' and the collaborative reflexivity that took place within 'team ethnography data sessions' that were each embedded within a mixed methods study of frontline services located in six different National Health Service Trusts throughout England (UK). After a presentation of the ethnographic methods and analyses that occurred as part of team ethnography, they are then discussed in terms of their applied and academic value from a methodological perspective.

Critical care work during COVID-19: a qualitative study of staff experiences in the UK.

OBJECTIVE: To understand National Health Service (NHS) staff experiences of working in critical care during the first wave of the COVID-19 pandemic in the UK. DESIGN: Qualitative study using semistructured telephone interviews and rapid analysis, interpreted using Baehr's sociological lens of 'communities of fate'. PARTICIPANTS: Forty NHS staff working in critical care, including 21 nurses, 10 doctors and advanced critical care practitioners, 4 allied health professionals, 3 operating department practitioners and 2 ward clerks. Participants were interviewed between August and October 2020; we purposefully sought the experiences of trained and experienced critical care staff and those who were redeployed. SETTING: Four hospitals in the UK. RESULTS: COVID-19 presented staff with a situation of extreme stress, duress and social emergency, leading to a shared set of experiences which we have characterised as a community of fate. This involved not only fear and dread of working in critical care, but also a collective sense of duty and vocation. Caring for patients and families involved changes to usual ways of working, revolving around: reorganisation of space and personnel, personal protective equipment, lack of evidence for treating COVID-19, inability for families to be physically present, and the trauma of witnessing extreme patient acuity and death on a large scale. The stress and isolation of working in critical care during COVID-19 was mitigated by strong teamwork, camaraderie, pride and fulfilment. CONCLUSION: COVID-19 has changed working practices in critical care and profoundly affected staff physically, mentally and emotionally. Attention needs to be paid to the social and organisational conditions in which individuals work, addressing both practical resourcing and the interpersonal dynamics of critical care provision.

Intravaginal insertion in KwaZulu-Natal: sexual practices and preferences in the context of microbicide gel use.

Intravaginal insertion is often associated with the concept of 'dry' sex. All HIV-prevention microbicides tested to date have been vaginally applied lubricant-based gels. In this paper, we examine whether the use of intravaginal insertions could be in conflict with the introduction of vaginal microbicide gels. The Africa Centre site was part of the Microbicides Development Programme evaluating PRO2000/5 microbicide gel. We conducted in-depth-interviews and focus-group discussions with women enrolled in the trial as well as women and men from the community. The analysis focused on people's knowledge of intravaginal insertion in the community and trial participants' experience of using trial gels. Intravaginal use of a variety of products was widely acknowledged. We found that the experience of using trial gels - which made sex 'hot', 'tight' and 'dry' - matched the desired outcomes of intravaginal insertion. We found that vaginal 'dryness' described the removal of excessive amounts of unusual discharge, rather than the removal of normal vaginal secretions and that intravaginal insertion is not exclusively associated with a desire for 'dry' sex. Study findings provide evidence that vaginal microbicide gels may be more acceptable in communities where intravaginal insertion is practiced than was previously thought.

Re-framing microbicide acceptability: findings from the MDP301 trial.

Microbicides are most usually conceptualised within a disease prevention framework and studies usually define acceptability in terms of product characteristics, willingness to use and risk reduction. This starting point has led to assumptions about microbicides which, rather than being challenged by empirical studies, have tended to foreclose the data and subsequent conceptual models. Few studies take an emic ('insider') perspective or attempt to understand how microbicides fit into the broader context of women's and men's everyday lives. As part of the integrated social science component of the MDP301 Phase III microbicide trial, in-depth interviews were conducted with female trial participants in South Africa, Zambia, Tanzania and Uganda. Women's experiences of the gel challenge several assumptions that have commonly been reiterated about microbicides. Our analysis suggests that current definitions and conceptual frameworks do not adequately account for the range of meanings that women attribute to gel. Even within the context of a clinical trial, it is possible to obtain a richer, ethnographic and cross-cultural concept of acceptability based on women's practice and emic interpretations. We now need to move beyond limited notions of acceptability and consider how microbicides fit into a more holistic picture of women's and men's sexuality and sexual health.