Experiences of stigma in healthcare settings among adults living with HIV in the Islamic Republic of Iran.

BACKGROUND: People living with HIV (PLHIV) sometimes experience discrimination. There is little understanding of the causes, forms and consequences of this stigma in Islamic countries. This qualitative study explored perceptions and experiences of PLHIV regarding both the quality of healthcare and the attitudes and behaviours of their healthcare providers in the Islamic Republic of Iran. METHODS: In-depth, semi-structured interviews were held with a purposively selected group of 69 PLHIV recruited from two HIV care clinics in Tehran. Data were analyzed using the content analysis approach. RESULTS AND DISCUSSION: Nearly all participants reported experiencing stigma and discrimination by their healthcare providers in a variety of contexts. Participants perceived that their healthcare providers' fear of being infected with HIV, coupled with religious and negative value-based assumptions about PLHIV, led to high levels of stigma. Participants mentioned at least four major forms of stigma: (1) refusal of care; (2) sub-optimal care; (3) excessive precautions and physical distancing; and (4) humiliation and blaming. The participants' healthcare-seeking behavioural reactions to perceived stigma and discrimination included avoiding or delaying seeking care, not disclosing HIV status when seeking healthcare, and using spiritual healing. In addition, emotional responses to perceived acts of stigma included feeling undeserving of care, diminished motivation to stay healthy, feeling angry and vengeful, and experiencing emotional stress. CONCLUSIONS: While previous studies demonstrate that most Iranian healthcare providers report fairly positive attitudes towards PLHIV, our participants' experiences tell a different story. Therefore, it is imperative to engage both healthcare providers and PLHIV in designing interventions targeting stigma in healthcare settings. Additionally, specialized training programmes in universal precautions for health providers will lead to stigma reduction. National policies to strengthen medical training and to provide funding for stigma-reduction programming are strongly recommended. Investigating Islamic literature and instruction, as well as requesting official public statements from religious leaders regarding stigma and discrimination in healthcare settings, should be used in educational intervention programmes targeting healthcare providers. Finally, further studies are needed to investigate the role of the physician and religion in the local context.

Muslim breast cancer survivor spirituality: coping strategy or health seeking behavior hindrance?

We explored the role of religiosity and spirituality on (i) feelings and attitudes about breast cancer, (ii) strategies for coping with breast cancer, and (iii) health care seeking behaviors among breast cancer survivors in Iran. We conducted in-depth semistructured interviews with 39 breast cancer survivors. We found that spirituality is the primary source of psychological support among participants. Almost all participants attributed their cancer to the will of God. Despite this, they actively have been engaged with their medical treatment. This is in surprising contrast to Western cultures in which a belief in an external health locus of control diminishes participation in cancer screening, detection, and treatment. These findings can help researchers to provide a framework for the development of appropriate and effective culturally sensitive health interventions.

Colorectal cancer screening among underserved minority population: discrepancy between physicians' recommended, scheduled, and completed tests.

OBJECTIVE: This study examines the correlates of: (1) health care provider recommendation of CRC testing; (2) provider scheduling for recommended CRC testing using sigmoidoscopy, colonoscopy, or double-contrast barium enema; and (3) adherence to CRC scheduling among underserved minority populations. METHODS: Medical record and schedule logbook reviews and interviewer-administered surveys. SETTING: Large urban safety-net, outpatient primary care setting in Los Angeles County. PARTICIPANTS: 306 African-American and Latino patients aged 50 years and older. RESULTS: A vast majority of minority patients do not receive standard CRC testing in urban safety-net primary care settings. Of those patients who were actually scheduled for sigmoidoscopy or colonoscopy, almost half completed the procedure. Completing CRC testing was associated with marital status, co-morbid chronic physical conditions, number of risk factors for colorectal cancer, and lower perceived barriers to CRC testing. CONCLUSION: Effective interventions to reduce CRC mortality among underserved minority populations require an integrated approach that engages patients, providers, and health care systems. PRACTICE IMPLICATIONS: Designing interventions that (1) increase physician-patient communications for removing patients' perceived barriers for CRC testing and (2) promote a non-physician-based navigator system that reinforces physicians' recommendation are strongly recommended.

Correlates of complementary and alternative medicine utilization in depressed, underserved african american and Hispanic patients in primary care settings.

OBJECTIVES: This study seeks to examine the correlates of complementary and alternative medicine (CAM) use in depressed underserved minority populations receiving medical care in primary care settings. METHODS: A prospective study using interviewer-administered surveys and medical record reviews was conducted at 2 large outpatient primary care clinics providing care primarily to underserved African American and Hispanic individuals located in Los Angeles, California. A total of 2321 patients were screened for depression. Of these, 315 met the Patient Health Questionnaire-9 criteria for mild to severe depression. RESULTS: Over 57% of the sample reported using CAM sometimes or often (24%) and frequently (33%) for treatment of their depressive symptoms. Controlling for demographic characteristics, lack of health care coverage remained one of the strongest predictors of CAM use. Additionally, being moderately depressed, using psychotherapeutic prescription medications, and poorer self-reported health status were all associated with increased frequency of CAM utilization for treating depression. CONCLUSIONS: The underserved African American and Hispanic individuals meeting the diagnostic criteria for depression or subsyndromal depression use CAM extensively for symptoms of depression. CAM is used as a substitute for conventional care when access to care is not available or limited. Since CAM is used so extensively for depression, understanding domains, types, and correlates of such use is imperative. This knowledge could be used to design interventions aimed at improving care for depression.

Alternative healthcare use in the under-served population.

OBJECTIVE: To apply the Behavioral Model for Vulnerable Populations to the examination of the correlates of alternative healthcare utilization among Hispanic and African-American adults residing in public housing. DESIGN: Cross-sectional survey of a community-based sample. SETTING: Urban public housing communities in the county of Los Angeles. PARTICIPANTS: A geographically defined random sample of 287 African-American and Latino heads of households from three urban public housing communities. RESULTS: The use of alternative health care was assessed with three indices reflecting how frequently respondents used alternative sources of health care: 1) to prevent sickness; 2) to treat sickness; and 3) to substitute for conventional health care. Multivariate analysis of data indicates that lower education, greater perceived racial discrimination, and poorer health status were associated with the use of alternative health care to prevent sickness. Furthermore, greater perceived racial discrimination, greater financial strain, and poorer health status were associated with the use of alternative health care to treat sickness. In addition, four variables were associated with increased frequency of alternative healthcare utilization as a substitute for conventional care, namely: 1) diminished belief that powerful individuals (such as healthcare professionals) control one's health; 2) greater perception of racial discrimination; 3) greater financial strain; and 4) reduced access to health care. CONCLUSION: Enabling characteristics helped explain the use of alternative health care to treat sickness as a substitute for conventional health care, but not to prevent sickness, in this population. Perceived racial discrimination was the strongest correlate for each type of alternative healthcare use, while health status was also a strong predictor. The use of alternative health care for prevention and for substitution should be examined separately in disadvantaged minority populations.

Effect of Pancreas Tonic (an ayurvedic herbal supplement) in type 2 diabetes mellitus.

Although there is widespread use of herbal dietary supplements that are believed to benefit type 2 diabetes mellitus, few have been proven to do so in properly designed randomized trials; their efficacy for intermediate-term glucose control remains unclear. Pancreas Tonic is a botanical mixture of traditional Indian Ayurvedic herbs currently available as a dietary supplement. We report the results of a single-center, randomized, double-blind, placebo-controlled 3-month trial of Pancreas Tonic in type 2 diabetic patients inadequately treated with diet/lifestyle or stable doses of sulfonylureas and/or metformin for at least 3 months. Patients with type 2 diabetes for >/= 1 year were entered into 2 strata of hemoglobin A(1c) (HbA(1c)) levels (stratum 1: 8.0% to 9.9%; stratum 2: 10.0% to 12.0%). All subjects began a 1-month single-blind placebo run-in phase, followed by randomization in a 2:1 ratio of active treatment: placebo, to 3 months of double-blind treatment with either Pancreas Tonic or matching placebo (2 capsules 3 times a day). Concurrent oral agents were continued unchanged throughout the study. The primary outcome was the change in HbA(1c) from randomization; results of each stratum were analyzed independently. The baseline characteristics of 36 subjects who completed the study were comparable between treatment groups. Nineteen subjects entered stratum 1 and 17 entered stratum 2. A statistically significant reduction of HbA(1c) from randomization to end-of-study was seen in the stratum 2 subjects (Pancreas Tonic: 10.1% +/- 1.0% to 8.8% +/- 1.9%, P =.004; placebo: 10.8% +/- 1.4% to 11.2% +/- 1.8%, not significant [NS]). No significant HbA(1c) reductions were seen in the stratum 1 subjects. There were no significant treatment-related differences in the fasting plasma glucose (FPG), lipids, body mass index (BMI), body composition, blood pressure, insulin sensitivity estimates using the minimal model, glucose and insulin responses to a meal challenge, quality of life, adverse events, or other safety indices between treatment groups. Pancreas Tonic was well tolerated. Treatment with Pancreas Tonic (2 capsules 3 times per day) for 3 months significantly improved glucose control in type 2 diabetic patients with HbA(1c) levels between 10.0% to 12.0%. This study represents the first properly designed, prospective intervention trial of therapy with an Ayurvedic herbal supplement for intermediate-term glucose control in type 2 diabetes.