Patients' perceptions and experiences of taking oral glucose-lowering agents: a longitudinal qualitative study.

AIMS: The aims of this study were to examine Type 2 diabetic patients' expectations, perceptions and experiences of oral glucose-lowering agents (OGLAs), including their reasons for taking/not taking these drugs as prescribed and to provide recommendations for developing interventions to improve OGLA adherence. METHODS: Longitudinal, qualitative study using repeat in-depth interviews with patients (n = 20) over 4 years following clinical diagnosis. Respondents were recruited from primary and secondary care settings across Lothian, Scotland, UK. RESULTS: Despite experiences of side-effects, dislikes and concerns about taking multiple drugs and a belief that OGLAs could themselves cause one's diabetes to progress, most respondents appeared motivated to take these drugs as prescribed. This motivation seemed to arise from respondents' experiences of taking OGLAs and observing them to 'work'. Some respondents described feeling better after taking OGLAs, others, typically those who were asymptomatic, used blood glucose self-monitoring and/or glycated haemoglobin results to observe and evidence the effects of their OGLAs. Most respondents demonstrated a 'passive' expectation that health professionals should be responsible for decisions about medications. Hence, non-adherence typically resulted from forgetfulness rather than ambivalence about either medication or consultation style. Respondent concern about OGLA's largely centred upon lack of knowledge about the medication and what to do when doses were missed. CONCLUSION: The findings call for multifaceted strategies to promote adherence. These could include education to address misconceptions and advise patients how to respond to missed doses; reminders to help patients remember to take their drugs; and structured feedback on the impact of OGLAs on glycaemic control.

Cerebral autoregulation is impaired in cardioinhibitory carotid sinus syndrome.

OBJECTIVES: To compare changes in cerebral autoregulation in response to controlled, lower body negative pressure-induced hypotension in patients with carotid sinus syndrome (CSS) and case controls. DESIGN: Prospective case controlled study. SETTING: Secondary and tertiary referral falls and syncope service. PATIENTS: 17 consecutive patients with CSS and 11 asymptomatic controls. INTERVENTIONS: Hypotension insufficient to cause syncope induced by lower body negative pressure (minimum 30 mm Hg fall in systolic blood pressure (SBP)) during concomitant transcranial Doppler ultrasonography. MAIN OUTCOME MEASURES: Cerebral autoregulation (systolic, diastolic and mean middle cerebral arterial blood flow velocities and cerebrovascular resistance) with continuous end-tidal carbon dioxide and haemodynamic monitoring. RESULTS: Cerebral autoregulatory indices differed significantly between patients with CSS and controls. Systolic, diastolic and middle cerebral arterial blood flow velocities were, respectively, 9.2 m/s (95% confidence interval (CI) 2.9 to 15.4 m/s), 4.7 m/s (95% CI 1.5 to 7.9 m/s) and 6.9 m/s (95% CI 2.5 to 11.4 m/s) slower in patients with CSS. Cerebrovascular resistance was significantly greater in patients with CSS than in controls at SBP nadir and suction release; differences were 0.9 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s) and 0.8 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s), respectively. End-tidal carbon dioxide and systemic haemodynamic variables were similar for patients and controls at baseline and during lower body negative pressure. CONCLUSIONS: Cerebral autoregulation is altered in patients with CSS. This difference may have aetiological implications in the differential presentation with falls and drop attacks rather than syncope.

Issues of cause and control in patient accounts of Type 2 diabetes.

Patients experience considerable difficulties in making and sustaining health-related lifestyle changes. Many Type 2 diabetes patients struggle to follow disease risk-management advice even when they receive extensive information and support. Drawing on a qualitative study of patients with Type 2 diabetes, the paper uses discourse analysis to examine their accounts about disease causation and disease management, and the implications for how they respond to their condition and health services advice. As it is a multifactorial disease, biomedical discourse around Type 2 diabetes is complex. Patients are encouraged to grasp the complicated message that both cause and medical outcomes related to their condition are partly, but not wholly, within their control. Discursive constructions identified from respondent accounts indicate how these two messages are deployed variously by respondents when accounting for disease causation and management. While these constructions (identified in respondent accounts as 'Up to me' and 'Down to them') are a valuable resource for patients, equally they may be deployed in a selective and detrimental way. We conclude that clear messages from health professionals about effective disease management may help patients to position themselves more effectively in relation to their condition. More importantly, they might serve to hinder the availability of inappropriate and potentially harmful patient positions where patients either relinquish responsibility for disease management or reject all input from health professionals.

Diabetes service provision: a qualitative study of newly diagnosed Type 2 diabetes patients' experiences and views.

AIMS: To explore newly diagnosed Type 2 diabetes patients' views about Scottish diabetes services at a time when these services are undergoing a major reorganization. To provide recommendations to maximize opportunities brought by the devolvement of services from secondary to primary healthcare settings. METHODS: Qualitative panel study with 40 patients newly diagnosed with Type 2 diabetes, recruited from hospital clinics and general practices in Lothian, Scotland. Patients were interviewed three times over 1 year. The study was informed by grounded theory, which involves concurrent data collection and analysis. RESULTS: Patients were generally satisfied with diabetes services irrespective of the types of care received. Most wanted their future care/review to be based in general practice for reasons of convenience and accessibility, although they disliked it when appointments were scheduled for different days. Many said they lacked the knowledge/confidence to know how to manage their diabetes in particular situations, and needed access to healthcare professionals who could answer their questions promptly. Patients expressed a need for primary care professionals who had diabetes expertise, but who had more time and were more accessible than general practitioners. Patients who had encountered practice lead nurses for diabetes spoke particularly positively of these professionals. CONCLUSIONS: Nurses with diabetes training are particularly well placed to provide information and support to patients in primary care. Ideally, practices should run 'one-stop' diabetes clinics to provide structured care, with easily accessible dietetics, podiatry and retinopathy screening. Newly diagnosed patients may benefit from being made more aware of specific services provided by charitable organizations such as Diabetes UK.

'Urine testing is a waste of time': newly diagnosed Type 2 diabetes patients' perceptions of self-monitoring.

AIMS: To date, there is no convincing evidence that non-insulin treated patients who undertake self-blood glucose monitoring (SBGM) have better glycaemic control than those who test their urine. This has led to a recommendation that non-insulin dependent patients undertake urine testing, which is the cheaper option. This recommendation does not take account of patients' experiences and views. This study explores the respective merits of urine testing and SBGM from the perspectives of newly diagnosed patients with Type 2 diabetes. METHODS: Qualitative study using repeat in-depth interviews with 40 patients. Patients were interviewed three times at 6-monthly intervals over 1 year. Patients were recruited from hospital clinics and general practices in Lothian, Scotland. The study was informed by grounded theory, which involves concurrent data collection and analysis. RESULTS: Patients reported strongly negative views of urine testing, particularly when they compared it with SBGM. Patients perceived urine testing as less convenient, less hygienic and less accurate than SBGM. Most patients assumed that blood glucose meters were given to those with a more advanced or serious form of diabetes. This could have implications for how they thought about their own disease. Patients often interpreted negative urine results as indicating that they could not have diabetes. CONCLUSIONS: Professionals should be aware of the meanings and understandings patients attach to the receipt and use of different types of self-monitoring equipment. Guidelines that promote the use of consistent criteria for equipment allocation are required. The manner in which negative urine results are conveyed needs to be reconsidered.

Dependent behaviours and beliefs: a qualitative study of older long-term smokers with arterial disease.

AIMS: To examine the reasons for continuing to smoke provided by a sample of long-term older smokers who have arterial disease (a smoking-related condition) and the implications of those beliefs for current smoking behaviour and future smoking intent. DESIGN: Qualitative semi-structured interview study with face-to-face interviews using 'life grids'. Setting and participants. Twenty-two long-term older smokers, with arterial disease, who were participants of a larger qualitative study of Life Course Influences on Patterns of Persistent Smoking. MEASUREMENT: Qualitative semi-structured interviews explored how respondents' described their relationship to smoking, using life grids to capture changes in patterns of cigarette usage across the life course. FINDINGS: Older smokers with arterial disease defined their relationship to smoking in either dependent terms or functional terms (to fulfil specific purposes). The two types of relationship appeared to be associated more with different degrees of control smokers described exercising over their habit than with their levels and patterns of usage. Some older smokers with arterial disease who showed dependent patterns of behaviour did not believe they were dependent, and some who showed non-dependent patterns of usage did not think of themselves as smokers even though they smoked. The immediate, functional and material benefits which these smokers attributed to smoking appeared to outweigh anticipated immediate and/or long term health-related benefits of quitting. CONCLUSIONS: How smokers define their relationship to cigarettes does not necessarily correspond to levels and patterns of usage.

"They're doing people a service"-qualitative study of smoking, smuggling, and social deprivation.

OBJECTIVES: To examine the behaviour and attitudes related to smoking and contraband tobacco products among smokers in two socially deprived areas. DESIGN: Cross sectional study with qualitative semistructured interviews, augmented by smokers' day grid. SETTING: Two areas of socioeconomic deprivation in Edinburgh. PARTICIPANTS: 50 male and 50 female smokers aged 25-40 years randomly selected from general practitioners' lists from two health centres, each located in an area of deprivation. RESULTS: Most smokers wanted to quit but felt unable to because of the importance of smoking in their daily routine and their addiction to nicotine. Strategies for maintaining consumption levels in the face of increasing cigarette prices and low income included purchasing contraband cigarettes and tobacco. Vendors were contacted through social networks, family, and friends as well as common knowledge of people and places, particularly pubs where contraband was available. Most users of contraband considered that smugglers were providing a valuable service. Purchasing contraband tobacco was viewed as rational in the face of material hardship. Many smokers criticised the government for its high tobacco taxation and the lack of local services to help them to stop smoking. CONCLUSIONS: Smokers in deprived areas perceive a lack of support to help them to stop smoking. Cigarette and tobacco smuggling is therefore viewed positively by low income smokers as a way of dealing with the increasing cost of cigarettes. Smokers in areas of deprivation may thus show little support for tackling smuggling until more action is taken to deal with the material and personal factors that make it difficult for them to quit.

Principles in practice: reflections on a 'postpositivist' approach to evaluation research.

User participation is currently seen as an ethically appropriate way to proceed when researching disadvantaged groups and it is encouraged by funding agencies. However, the literature rarely discusses the methodological and practical implications for researchers attempting to incorporate user participation into evaluation studies which are informed from an epistemologically opposed (positivist) research paradigm. The paper explores this issue by drawing on the evaluation of a community-based smoking intervention to describe and reflect upon the recruitment, training and employment of local residents as survey interviewers. While the evaluation methodology adopts a quasi-experimental approach, the appointment of local residents as survey interviewers reflects an alternative (interpretive) research tradition. The combined strategy constitutes a postpositivist methodology in that it combines a data collection strategy more akin to interpretive social science while retaining a positivistic epistemological framework. The paper describes some logistics of this approach and problems encountered during the course of survey. While many of the problems described may be routinely associated (although seldom aired) with survey work, particularly in disadvantaged areas, the paper suggests they are also a function of the postpositivist research strategy which we adopted. The failure to involve interviewers in the conception and development of the evaluation meant that they lacked identification with our endeavour and this had practical implications for the survey interviewing. Although the survey was successfully executed and the employment of local residents was a valuable and worthwhile experience, the authors recognize that this narrow conception of user involvement meant that many of the potential benefits (both to the research and the participants) associated with participatory approaches were forfeited.

Accounts of Quitting among Older Ex-smokers with Smoking-related Disease.

This article uses a discourse analytic method to explore how a sample of ex-smokers with smoking-related illness position themselves, and are positioned by, the language they use in their accounts of quitting. The article suggests that discursive constructions (having 'no choice' and getting 'another chance') used by the respondents position them in a way that constrains behaviour by closing down the option of smoking and/or opening up the possibility of change. In each telling, the respondents' (non-smoking) identities are confirmed anew and this affirmation may assist in sustaining the change and provide protection against relapse. Moreover, the article suggests that the development and exchange of these stories may contribute to the growth of shared beliefs about the experience of quitting, opening up the option of quitting for current smokers. In so doing, accounts of quitting provided by ex-smokers undermine or resist dominant social understandings that even among those highly motivated to stop smoking, quitting is a difficult, if not impossible, endeavour.

Smokers at risk: implications of an institutionally bordered risk-reduced environment.

The paper draws on an evaluation of a workplace smoking policy implemented at Edinburgh University to examine some implications for smokers at work. While the objective of institutional risk-reduced environments is to diminish or control the level of risk behaviour within, they may have unanticipated implications for participants who are unwilling or unable to adapt. Data presented in the paper suggest that the University smoking policy carried its own risk. That is, the policy did not impact equally upon all members of the organisation but was experienced as divisive in contributing towards and sustaining social inequalities among staff.

'I'll worry about that when it comes along': osteoporosis, a meaningful issue for women at mid-life?

This paper reports findings from a qualitative study of the health concerns and perceptions of health risks and osteoporosis of women in the age group 40-55 years. Osteoporosis has been increasingly put forward in the popular and scientific press as an important issue for women in mid-life. A variety of preventive measures, including use of hormone replacement therapy (HRT), are suggested. The medicalization of women's experiences and associated use of HRT at this point in the life course is the subject of considerable debate in the medical, social scientific and feminist literatures, although, to date, this issue has received less attention in health promotion. Much of this debate is informed by quantitative and survey data, and there is a lack of in-depth qualitative information on women's own views. This study casts doubt on the salience of osteoporosis for women at mid-life. Our qualitative research suggests that, unless they had experiential knowledge which had rendered osteoporosis particularly salient, most women in this study evidenced a surprising degree of disinterest in this health issue. To make sense of this disinterest we examined women's wider accounts of their lives, health and the lifecourse, and the menopause. These findings would appear to present a challenge for those in health promotion who might wish to emphasize early preventive strategies for osteoporosis.

Chemical, pathological and toxicological studies of the effects of RICOM-1013-J of Ricinus communis var minor on women volunteers and rodents.

RICOM-1013-J (Ricinus communis var minor) administered orally once to each of 12 women volunteers at a dose of 2.5-2.7 g per 8 months, protected against pregnancy over a period of 7-8 months of study. A study of the effect of a contraceptive dose (20 mg/kg) on metabolic parameters in rat (food and water in-take, urine and faecal output and body weight) over a period of 4 months showed a slight decrease in all the parameters in the first 1-8 weeks. This effect was reversible attaining pretreatment levels from week 16. The LD(50) in an acute toxicity test in mice was 63.1 +/- 16.0 g/kg s.c. Determination of blood urea, sodium (Na(+)), potassium (K(+)), chloride (Cl(-)) and bicarbonate (HCO$_¿3¿ ¿-¿$)as a measure of renal function and alkaline phosphatase (ALP), transaminases (GPT and GOT) and transpeptidases (GGT) as a measure of liver function showed that liver function profiles in pretreated rats were not significantly different from control (p < 0.05) on day 21 to day 150. However, serum levels of ALP and GGT at day 120 to day 150 were moderately but significantly elevated (p > 0.05) compared with the control. There were no significant changes in renal function profiles in pretreated rats (p < 0.05) compared with the control. The results of the liver and renal function profiles in women volunteers showed that there were no significant (p < 0.05) changes in renal functions on day 206 following RICOM-1013-J administration. However, serum levels of ALP and GGT showed a slight rise in about 70% of volunteers, whereas bilirubin and transaminases levels were normal. The present results indicate a very high efficacy and margin of safety of RICOM-1013-J in women volunteers. The increase in ALP and GGT in both animal and women volunteers suggest mild intrahepatic cholestatic changes which may be attributed to an oestrogenic effect of RICOM-1013-J.

Preliminary clinical investigation of the contraceptive efficacy and chemical pathological effects of RICOM-1013-J of Ricinus communis var minor on women volunteers.

The seeds of Ricinus communis Linn, RICOM-1013-J, administered as a single oral dose of 2.3-2.5 g once per 12 months protected against pregnancy in 50 women volunteers for a period of one year. The antifertility and contraceptive efficacy of the seed was demonstrated in this study. Clinical observation revealed very minimal side effects. Some of the side effects investigated included headache, nausea, vomiting, weight gain, loss of appetite, raised blood pressure and dysmenorrhoea. Furthermore, both the renal and liver functions were not affected as revealed by urea, electrolyte and creatinine values as well as total bilirubin, conjugated bilirubin, serum albumin, total protein and transaminases values when compared with control values. In addition cholesterol and phospholipids were not significantly altered. When all these results are considered together, it seems unlikely that the antifertility and contraceptive efficacy of RICOM-1013-J is due to hormonal mechanisms alone since side effects, renal and liver function, and cholesterol effects attributable to oestrogen and/or progesterone were minimal in the volunteers.

Pharmacological actions of Heteromorpha trifoliata ("dombwe") on rat isolated muscle preparations.

OBJECTIVE: To investigate the effects of Heteromorpha trifoliata on rat uterine and skeletal muscle. DESIGN: Laboratory based study using experimental animals. Investigating the effects of the plant extract and agonists on isolated muscle preparations. SETTING: Department of Physiology, University of Zimbabwe. SUBJECTS: 28 Sprague-Dawley rats. MAIN OUTCOME MEASURES: Amplitude of contraction of uterine smooth muscle and skeletal muscle. RESULTS: Experiments were performed on the isolated rat uterus preparation in which strips of myometrium were placed in tissue baths filled with Kreb's solution. The aqueous extract of the root bark of Heteromorpha trifoliata ("dombwe") contracted the rat uterus. The contractions were not antagonised by atropine but were blocked by both cyproheptadine and verapamil. In addition, "dombwe" induced a contracture of the rat diaphragm muscle in the presence of alcuronium. CONCLUSIONS: The contractile effects on the uterus appear to involve stimulation of 5-HT2 receptors leading to an increase in calcium influx into the smooth muscle cell. Promotion of calcium influx could also explain the effects observed on the skeletal muscle preparation since the contracture induced by "dombwe" occurred in the presence of the nicotinic antagonist, alcuronium. In view of the effects of "dombwe" on other smooth muscle preparations (from previous work) it appears that the pharmacological profile of the crude aqueous extract of the root bark of Heteromorpha trifoliata is complex and suggestive of the presence of more than one active ingredient.

Non-traumatic paraplegia [correction of paraplegis] in a Zimbabwean population--a retrospective survey.

OBJECTIVES: To ascertain the aetiology of non-traumatic paraplegia in a Zimbabwean population and to compare findings with other studies from Africa. DESIGN: Retrospective survey over a six year period. SETTING: National Rehabilitation Centre, Ruwa, Zimbabwe. SUBJECTS: 159 patients referred to the National Rehabilitation Centre with non-traumatic paraplegia. RESULTS: The commonest causes of non-traumatic paraplegia were neoplasms (28% of cases) of which a third were metastatic, followed by tuberculosis (TB) (27%). Transverse myelopathy of unknown aetiology was diagnosed in 11% of cases and 6% had Guillain Barré syndrome. Miscellaneous conditions included: degenerative bone and joint conditions, degenerative cord disorders and infections. In 7% of cases no diagnosis was reached. On admission all patients were confined to wheelchairs. On discharge 49% had regained some degree of mobility. A year after discharge 48% were known to be alive and 18% had died. The fate of 34% was not known. CONCLUSIONS: The aetiology of non-traumatic paraplegia in a Zimbabwean population is similar to that reported from other African countries, with tumours and tuberculosis accounting for over half the cases. Survival appears to be related not only to the primary condition but also to the severity of the disability.

Problems, struggles and some success with spinal cord injury in Zimbabwe.

Spinal cord injury is a common occurrence in Zimbabwe and carries with it a high morbidity and mortality. In the past almost all patients discharged from hospital were dead within a year. Reasons for this high mortality are presented. The establishment of the National Rehabilitation Centre has had a profound impact on the survival of these individuals as well as on improving their quality of life. The results of a retrospective survey on the mortality and life situation of individuals with spinal cord injuries sustained through trauma are presented. However major unresolved problems are inadequate housing, lack of financial support, practically no prospect of employment and depression compounded by boredom.

Peripheral neuropathy in individuals with HIV infection in Zimbabwe.

Peripheral neuropathy is associated with HIV infection. The prevalence and types of peripheral neuropathy encountered in a randomly-selected HIV infected African population at different stages of disease were investigated. HIV positive individuals were categorized into 1 of 3 groups: asymptomatic, symptomatic and AIDS. HIV negative individuals formed the control group. Nerve conduction data were obtained using standard electrophysiological procedures and CD4+ levels were measured. The type of neuropathy was determined from the history, clinical presentation and electrophysiological abnormalities. The prevalence of peripheral neuropathy was 44%: subclinical neuropathy (SCN) accounted for 56%, acute inflammatory demyelinating polyneuropathy (AIDP) for 15% and distal symmetrical polyneuropathy (DSPN) for 22% of cases of neuropathy. SCN was found in all categories whereas AIDP predominated in the symptomatic category and DSPN in individuals with AIDS. The pattern and frequency of neuropathies seen in our African population is similar to that reported from other continents.

The effects of Heteromorpha trifoliata on gastrointestinal smooth muscle of the guinea pig.

The effects of an aqueous extract of the root bark of H. trifoliata on various smooth muscle preparations were investigated. The extract had no contractile or relaxant effect on guinea pig gastrointestinal smooth muscle (n = 6), trachea (n = 4), taenia coli (n = 6), nor did it affect the spontaneously-beating atrium (n = 5). However, H. trifoliata antagonized ileal contractions induced by acetylcholine, histamine, serotonin (n = 6 for each dose of agonist) and potassium chloride (n = 4) in a concentration-dependent manner. The antagonism was considered to be non-competitive and non-specific in nature. It is concluded that H. trifoliata antagonizes the effects of these various agonists by either preventing calcium influx into the smooth muscle cell, or inhibiting the calcium-induced calcium release mechanism, or preventing the release of calcium from the sarcoplasmic reticulum, or by preventing the binding of calcium to calmodulin. The antagonistic effects exerted by H. trifoliata could explain its rational use in traditional medicine to alleviate abdominal spasms.

Advances in electrodiagnosis in Zimbabwe. Part II: "Evoked potentials".

This paper is a short review of the electrodiagnostic technique of "evoked potentials", a technique recently introduced to Zimbabwe. The types of evoked potentials recorded, the method of recording and their clinical applications are discussed. Abnormal evoked potentials from a variety of neurological disorders are illustrated. "Advances in electrodiagnosis in Zimbabwe" Part I discussed peripheral nerve conduction measurements and electromyography. This paper (Part II) will review the physiological basis of "Evoked Potentials" and their clinical applications.