Interpretation in cross-language research: tongues-tied in the health care interview?

Medication prescribing and use is a normative aspect of health care for the elderly, rendering medication taking by elderly persons problematic. In an earlier qualitative study, we examined how medicine-use is negotiated (used/refused/resisted, and assessed against expected outcomes) by older persons with limited fluency in English-the main language of health care in the study setting. In the present article, we describe a reflexive methodological review of that study's design, with a particular focus placed on interpreter-mediated data collection. We illustrate that what was heard in open-ended interviews (what became data) was influenced by not only what was asked and how, but also by how the interpreter 'heard' and conveyed dialogue to and from study participants. We illustrate differing accounts of the dialogue between an interviewer and participant provided via real-time interpretation and through a reflexive re-interpretation of talk-to-text transcripts, reflecting the different stakes in the research, and different capital available to study- and review-interpreters. Implications for research design and practice of cross-cultural and cross-language research are highlighted.

"HIV isn't me ": HIV+ adolescents' experiences in a positive context of support and treatment.

We describe the experiences of a sample of Canadian HIV+ youth whose intact adolescent identities contrast sharply with the expected identity challenges of persons living with a serious, chronic disease. We first showcase the positive HIV+ identities emerging from the successful management of HIV+ status through long-term HIV-related medical care and established pharmaceutical regimes. Second, we describe the medical, familial, and broader social context of support in which these adolescents' are negotiating HIV. Finally, we highlight the youth's expectations of future, specific identity and role challenges regarding intimacy and sexuality-related to disclosure of their private HIV+ identities and their embodied HIV+ status. Continued social and medical supports will be key to their emergence into adulthood as healthy HIV+ persons; with such supports, these youths' experiences highlight the capacity for living optimally with HIV.

Perspective of Pain Clinicians in Three Global Cities on Local Barriers to Providing Care for Chronic Noncancer Pain Patients.

An increasing proportion of the global chronic pain population is managed through services delivered by specialized pain clinics in global cities. This paper describes the results of a survey of pain clinic leaders in three global cities on barriers influencing chronic noncancer pain (CNCP) management provided by those clinics. It demonstrates a pragmatic qualitative approach for characterizing how the global city location of the clinic influences those results. A cross-sectional prospective survey design was used, and data were analyzed using quantitative and qualitative content analysis. Key informants were pain clinicians (n = 4 women and 8 men) responsible for outputs of specialized pain clinics in academic hospital settings in three global cities: Toronto, Kuwait, and Karachi. Krippendorff's thematic clustering technique was used to identify the repetitive themes in the data. All but one of the key informants had their primary pain training from Europe or North America. In Kuwait and Karachi, pain specialists were anesthesiologists and provided CNCP management services independently. In Toronto, pain clinic leaders were part of some form of the multidisciplinary team. Using the results of a question that asked informants to list their top three barriers, ten themes were identified. These themes were artificially organized in three thematic domains: infrastructure, clinical services, and education. In parallel, 31 predefined barriers identified from the literature were scored. The results showed variation in perception of barriers that not only depended on the clinic location but also demonstrated shared experiences across thematic domains. This study demonstrates a simple methodology for informing global and local efforts to improve access to and implementation of CNCP services globally.

Becoming a 'pharmaceutical person': Medication use trajectories from age 26 to 38 in a representative birth cohort from Dunedin, New Zealand.

Despite the abundance of medications available for human consumption, and frequent concerns about increasing medicalization or pharmaceuticalization of everyday life, there is little research investigating medicines-use in young and middle-aged populations and discussing the implications of young people using increasing numbers of medicines and becoming pharmaceutical users over time. We use data from a New Zealand longitudinal study to examine changes in self-reported medication use by a complete birth cohort of young adults. Details of medications taken during the previous two weeks at age 38 are compared to similar data collected at ages 32 and 26, and by gender. Major drug categories are examined. General use profiles and medicine-types are considered in light of our interest in understanding the formation of the young and middle-aging 'pharmaceutical person' - where one's embodied experience is frequently and normally mediated by pharmaceutical interventions having documented benefit/risk outcomes.

The professionalization of Western herbalists: response to new product regulations in Canada.

New Canadian Natural Health Products regulations (NHP regulations) came into law January 1st, 2004 and will be implemented over 6 years. These regulations have the potential to impact a variety of stakeholders, in particular complementary and alternative medicine (CAM) practitioners. In this article, we document Canadian Western herbalist leaders' responses to the new regulations, so as to provide insight into how new healthcare policy serves as a stimulus for the organization of an emerging healthcare profession. The data are derived from key informant interviews with Western herbalist leaders in Canada (n=9). The NHP regulations include "good manufacturing practices" and Western herbalist leaders are concerned that many small companies, often owned and run by Western herbalists, will find the regulations too costly to implement, causing them to reduce the number and diversity of products they manufacture, or go out of business all together. Furthermore, lack of availability of whole plant products could severely restrict the practice of Canadian Western herbalists. In response to this challenge, herbalists are attempting to (i) organize as a more cohesive group, (ii) define their unique body of knowledge and (iii) increase the perceived legitimacy of their practices in the eyes of the public, conventional healthcare practitioners, and regulators, in an attempt to protect their unique practices. An examination of the findings reveals the extent to which external factors (i.e., the new NHP regulations) both provoke and shape the professionalization of this group of healthcare practitioners.

Diagnosed Chronic Health Conditions Among Injured Workers With Permanent Impairments and the General Population.

OBJECTIVE: To profile chronic health conditions of an injured worker sample before and after workplace injury and compare injured workers to a matched community sample. METHODS: Logistic regression analyses compared risk of certain chronic health conditions for permanently disabled injured workers in the pre- and post-injury periods to comparator subsamples from the Canadian Community Health Surveys 2003 and 2009/2010. RESULTS: There were notable health differences between the injured worker and comparator samples for the post-injury period. Injured men and women were more likely to report arthritis, hypertension, ulcers, depression, and back problems than the comparator sample. Injured women were also more likely to report migraine headaches and asthma. CONCLUSIONS: The observed differences suggest that permanently impaired injured workers experience more rapidly accelerated health declines than other aging workers, and this outcome is gendered.

New Canadian natural health product regulations: a qualitative study of how CAM practitioners perceive they will be impacted.

BACKGROUND: New Canadian policy to regulate natural health products (NHPs), such as herbs and vitamins were implemented on January 1st, 2004. We explored complementary and alternative medicine (CAM) practitioners' perceptions of how the new regulations may affect their practices and relationships with patients/consumers. METHODS: This was an applied ethnographic study. Data were collected in fall 2004 via qualitative interviews with 37 Canadian leaders of four CAM groups that use natural products as a core part of their practises: naturopathic medicine, traditional Chinese medicine (TCM), homeopathic medicine and Western herbalism. All interviews were transcribed verbatim and coded independently by a minimum of two investigators using content analysis. RESULTS: Three key findings emerged from the data: 1) all CAM leaders were concerned with issues of their own access to NHPs; 2) all the CAM leaders, except for the homeopathic leaders, specifically indicated a desire to have a restricted schedule of NHPs; and 3) only naturopathic leaders were concerned the NHP regulations could potentially endanger patients if they self-medicate incorrectly. CONCLUSION: Naturopaths, TCM practitioners, homeopaths, and Western herbalists were all concerned about how the new NHP regulations will affect their access to the products they need to practice effectively. Additional research will need to focus on what impacts actually occur as the regulations are implemented more fully.

Understanding Users in the 'Field' of Medications.

The numbers of medicinal drugs available for human consumption have increased rapidly in the past several decades, and physician prescribing practices reflect the growing reliance on medicines in health care. However, the nature of medicines-as-technology makes problematic taken-for-granted relationships among actors involved in the delivery, or who are the recipients of medicines-reliant health care. In this article, I situate the medicine user in the 'field' of medications-where interests, actions and outcomes are continually negotiated among and between the various players-physicians, pharmacists, government regulatory bodies, the pharmaceutical industry and users of medicines. The objective of the paper is to illuminate the complex context in which the medicine-user-the target of the pharmacy profession's service to the public-accesses and uses medicines.

Mental health status of Ontario injured workers with permanent impairments.

OBJECTIVE: Each year, approximately 31,000 Canadian injured worker claimants are certified to have permanent impairments associated with the initial workplace incident. Permanent impairments are characterized by ongoing pain, and limitations in physical function and activity participation--all predisposing factors to mental health problems. Here we examine the post-accident mental health status of a sample of Ontario injured workers with permanent impairments. METHODS: We analyze data from a cross-sectional telephone survey of 494 injured workers. Mental health status is examined using nine dichotomous diagnostic, symptomatic and functional mental health indicators identified by survey respondents as non-present, or having pre- or post-injury onset, and the CES-D. We describe the relationship of these indicators and work injury, demographic and socio-economic factors. RESULTS: Post-injury onset mental health problems are elevated compared to pre-injury onset in seven of nine indicators. Diagnosed depression, medication abuse, inability to concentrate, and sleep problems are elevated compared to general Canadian population prevalence. Diagnosed depression is elevated compared to populations with pain and chronic health conditions. Higher education and pre-injury income are associated with lower depressive symptoms. Men and older individuals are less likely to report a diagnosis of depression. Older individuals are less likely to report concentration problems. CONCLUSION: These data paint a troubling mental health picture among injured workers with permanent impairments. Implications for return-to-work and income recovery, health service access and rehabilitation within and outside the compensation system are discussed.

Older adults living with osteoarthritis: examining the relationship of age and gender to medicine use.

Osteoarthritis (OA) in older adults is a prevalent chronic condition associated with substantial pain and disability. Oral analgesic use is a central component of symptom management. Medication use in this population, however, is complex and must balance the need for symptom control with drug safety concerns. Our study focus was to illustrate and discuss the variability in the medications used to manage OA-related symptoms. We analysed data from a sample of community-dwelling persons aged 55 and older with hip or knee arthritis to examine social and medical factors associated with reported variation in OA drugs. A key finding is that drug types used by OA patients vary by age and gender, independent of disease, and medical and social context. Possible explanations related to patient and professional preferences are considered.

Becoming old as a 'pharmaceutical person': negotiation of health and medicines among ethnoculturally diverse older adults.

Because medication prescribing and use have become a normative aspect of health care for older adults, we seek to understand how individuals navigate prescribed-medication use within the context of aging. We reasoned that, for those who are ambulatory, medication use is likely influenced by ethnocultural meanings of health and experiences with alternative approaches to health care. Accordingly, we conducted a qualitative study, with in-depth interviews, on a diverse sample of older adults in order to identify elderly persons' perceptions and uses of medicines. Our findings depict older adults as active agents--who draw on a lifetime of experience and knowledge--who take responsibility for adherence (or non-adherence) to medicines and their associated effects on their own bodies. We represent the older person as a "pharmaceutical person" whose experiences of aging are inextricably tied up with the negotiation of medicine-reliant health care.

A patient-centered perspective on surgery avoidance for hip or knee arthritis: lessons for the future.

OBJECTIVE: Research indicates that there is a discrepancy between need and patient preference for total joint arthroplasty (TJA), an efficacious and cost-effective treatment for severe hip or knee arthritis. To understand this discrepancy, we conducted qualitative research to assess the illness perceptions and preferred accommodations and coping strategies of patients with advanced osteoarthritis who had expressed a preference to avoid TJA. METHODS: In-depth interviews were conducted with a community sample of 29 men and women who were medically assessed as appropriate candidates for TJA but who had expressed a preference to avoid surgery. Inductive content analysis of text data was used to examine how patients' illness perceptions and preferred coping strategies related to surgery preference. RESULTS: Participants frequently rejected the medicalization of arthritis, normalizing the experience of functional decline and defining it as age normative. Participants drew on a broad set of previous experiences with informal and formal care to make decisions about how to manage their condition. Previous negative encounters in medical and surgical care, including those from a distant past or those experienced vicariously, combined with the perception (reinforced by physicians and others) that doing nothing was a viable option deterred arthritis-related help seeking in the health care system. CONCLUSION: Individuals with arthritis may benefit from additional counseling regarding effective medical and surgical treatments. Physicians may better meet patient needs by gauging patient preferences for a combination of self-management strategies and medical interventions.

Social context and outcomes for the ageing breast cancer patient: considerations for clinical practitioners.

Current incidence, prevalence and survival rates determine that breast cancer is primarily a disease of older women. This integrative essay provides an extensive review of the literature on (i). the social and psychological factors that influence adjustment to breast cancer and survival from it, (ii). the social and health status of older women, and (iii). the medical treatment of older breast cancer patients. It is concluded that while psychological orientation to the disease, coping strategies and functional continuities of breast cancer patients are important for disease outcome, adjustment to and survival from breast cancer by older women may be compromised by the social context - with respect to marriage and intimate ties, social participation, socio-economic status, and mental and physical health. The paper concludes with the suggestion that clinical practitioners need to be aware of the both the resources of, and limitations facing the older breast cancer patient, and with the provision of specific recommendations about the clinical management of this population for nurses and other health professionals.

Children's perceptions of strategies for resolving community health problems.

We examine children's perceptions of the strategies they would use to resolve community health problems. Qualitative analysis using a grounded theory approach showed that 9- to 10-year-old children could conceptualize a range of solutions to hypothetical community health problems. Children's responses reflected an egocentric perspective, one that was centered on self and peers acting on short-term solutions to the immediate problem. Less frequently, children conceptualized broader structural interventions aimed at removing the problem altogether. Children could name resource persons including their friends, family, school personnel and other people in the community. However, outside of their family and peers, their knowledge was non-specific, i.e. it is doubtful that they would actually be able to access the resources. In light of our findings we discuss several important implications for future research. We note that children are interested in changing community conditions that affect their heath. However, their recognition of their marginalized position in adult society and their perception that adults do not take them seriously may be significant barriers to their participation. We suggest that society must rethink the position and roles that are assigned to children so that their valuable potential is not lost.