Community efforts to promote vaccine uptake in a rural setting: a qualitative interview study.

Vaccine hesitancy has been identified as one of the top 10 threats to global health. The causes of low vaccine uptake are many and vary at micro and macro levels. However, rural and remote coastal areas in the UK experience unique vaccine inequalities due to high levels of deprivation and their unique and complex access-related problems. This study aimed to explore community efforts to promote vaccine uptake during the COVID-19 pandemic and understand how the COVID-19 vaccination campaign was experienced by the public. We conducted an exploratory descriptive qualitative study using semi-structured interviews with decision-makers, health professionals and community members in Lincolnshire, a predominantly rural county with a long coastline, a large population of white minority ethnicities, and those living in caravan and temporary housing. Data were analysed using conventional content analysis. Overcoming the various access barriers to vaccination uptake involved working with local media stations, local communities and local community groups, translation of information, bringing vaccines closer to the people through pop-up and mobile clinics and provision of transport and ensuring confidentiality. There is a need to employ inclusive targeted non-conventional care interventions whilst dealing with complex problems as occur in rural and remote coastal regions.

Unintended consequences of communicating rapid COVID-19 vaccine policy changes- a qualitative study of health policy communication in Ontario, Canada.

BACKGROUND: The success of the COVID-19 vaccination roll-out depended on clear policy communication and guidance to promote and facilitate vaccine uptake. The rapidly evolving pandemic circumstances led to many vaccine policy amendments. The impact of changing policy on effective vaccine communication and its influence in terms of societal response to vaccine promotion are underexplored; this qualitative research addresses that gap within the extant literature. METHODS: Policy communicators and community leaders from urban and rural Ontario participated in semi-structured interviews (N = 29) to explore their experiences of COVID-19 vaccine policy communication. Thematic analysis was used to produce representative themes. RESULTS: Analysis showed rapidly changing policy was a barrier to smooth communication and COVID-19 vaccine roll-out. Continual amendments had unintended consequences, stimulating confusion, disrupting community outreach efforts and interrupting vaccine implementation. Policy changes were most disruptive to logistical planning and community engagement work, including community outreach, communicating eligibility criteria, and providing translated vaccine information to diverse communities. CONCLUSIONS: Vaccine policy changes that allow for prioritized access can have the unintended consequence of limiting communities' access to information that supports decision making. Rapidly evolving circumstances require a balance between adjusting policy and maintaining simple, consistent public health messages that can readily be translated into action. Information access is a factor in health inequality that needs addressing alongside access to vaccines.

Discourse Communities and the Discourse of Experience.

Discourse communities are groups of people who share common ideologies, and common ways of speaking about things. They can be sharply or loosely defined. We are each members of multiple discourse communities. Discourse can colonize the members of discourse communities, taking over domains of thought by means of ideology. The development of new discourse communities can serve positive ends, but discourse communities create risks as well. In our own work on the narratives of people with interests in health care, for example, we find that patients speak of their illness experiences as victims of circumstance; policy makers construct adverse experiences and challenges as opportunities to be taken; health care workers speak from a mixed perspective, seeing themselves as both victims and opportunists depending on context. To be trapped within the discourse of a particular community is to put at risk the ability to communicate across discourses. Membership of a discourse community can impair the habit of critique, and deny opportunities for heteroglossic discourse. Privileging critique as a mode of discourse perhaps might define the ethical community, suggesting that ethical community may be an antidote to the constraining effects of conventional discourse community.

An exploration of clinical reasoning and practices used by physiotherapists in the rehabilitation of horses following interspinous ligament desmotomy surgery.

INTRODUCTION: Clinical reasoning has not been studied in veterinary physiotherapy and so the methods used and factors involved are unknown. Similarly, the practices of veterinary physiotherapists within a certain rehabilitation programme have not been documented. The aim of this study was to explore the clinical reasoning and practices of veterinary physiotherapists during rehabilitation of horses following interspinous ligament desmotomy surgery. METHODOLOGY: A qualitative approach was taken and six members of the Association of Chartered Physiotherapists in Animal Therapy were interviewed using a semi-structured approach. The data were transcribed and analysed using Thematic Analysis. RESULTS: Five themes were identified as relevant to the participants clinical reasoning. These related to structure of the assessment, modalities and reasoning of treatment, involvement of owner and veterinarian and the impact of comorbidities. The data highlight several different factors that influence clinical reasoning and decision making throughout the rehabilitation. An insight into practices involved is also documented. CONCLUSION: The process of clinical reasoning and decision making described appears complex. The input of both owner and veterinarian are evidently important and require the physiotherapists consideration. Decisions regarding assessment and treatment are influenced by many factors. A mixture of clinical experience and research evidence were used as support.

Does Help Seeking Behavior Change Over Time Following a Workplace Mental Health Intervention in the Coal Mining Industry?

OBJECTIVES: To investigate help seeking behavior and attitudes to mental health in mining employees. METHODS: A pre-post survey study of employees from two Australian coal mines. Data were collected prior to, at baseline, at 6 and 18 months following delivery of the MATES in mining (MIM) peer support mental health intervention. RESULTS: Help seeking behaviors increased, with participants' sex, age, relationship status, shift type, and psychological distress significantly associated with likelihood of seeking help (P <0.05). In relation to stigma, significantly more participants' disagreed that they would be treated differently by friends or colleagues following disclosure of mental illness (P < 0.01). CONCLUSIONS: Results provide an understanding of help seeking behaviors of mining employees; support the MATES in Mining peer support program in the men dominated industry and provide information to guide mental health workplace program development more broadly.

Managing 'shades of grey': a focus group study exploring community-dwellers' views on advance care planning in older people.

BACKGROUND: Community-dwelling consumers of healthcare are increasing, many aging with life-limiting conditions and deteriorating cognition. However, few have had advance care planning discussions or completed documentation to ensure future care preferences are acted upon. This study examines the awareness, attitudes, and experiences of advance care planning amongst older people and unrelated offspring/caregivers of older people residing in the community. METHODS: Qualitative descriptive research, which included focus groups with older people (55+ years) and older people's offspring/caregivers living in an Australian city and surrounding rural region. Data was analysed using an inductive and comparative approach. Sampling was both convenience and purposive. Participants responded to web-based, newsletter or email invitations from an agency, which aims to support healthcare consumers, a dementia support group, or community health centres in areas with high proportions of culturally and linguistically diverse community-dwellers. RESULTS: Eight focus groups were attended by a homogenous sample of 15 older people and 27 offspring/caregivers, with 43% born overseas. The overarching theme, 'shades of grey': struggles in transition, reflects challenges faced by older people and their offspring/caregivers as older people often erratically transition from independence and capacity to dependence and/or incapacity. Offspring/caregivers regularly struggled with older people's fluctuating autonomy and dependency as older people endeavoured to remain at home, and with conceptualising "best times" to actualise advance care planning with substitute decision maker involvement. Advance care planning was supported and welcomed, x advance care planning literacy was evident. Difficulties planning for hypothetical health events and socio-cultural attitudes thwarting death-related discussions were emphasised. Occasional offspring/caregivers with previous substitute decision maker experience reported distress related to their decisions. CONCLUSIONS: Advance care planning programs traditionally assume participants are 'planning ready' to legally appoint a substitute decision maker (power of attorney) and record end-of-life treatment preferences in short time frames. This contrasts with how community dwelling older people and offspring/caregivers conceive future care decisions over time. Advance care planning programs need to include provision of information, which supports older people's advance care planning understanding and management, and also supports offspring/caregivers' development of strategies for broaching advance care planning with older people, and preparing for potential substitute decision maker roles. Development and integration of strategies to support older people's decision-making when in the 'grey zone', with fluctuating cognitive capacities, needs further consideration. Findings support an advance care planning model with conversations occurring at key points across a person's lifespan.

While there's life ... hope and the experience of cancer.

Hope is the subjective probability of a good outcome for ourselves or someone close to us. During mortal extreme experience, observers and participants in the experience hope for life over death. In cancer, the illness/treatment experience is similar to the experience of dying, but with the redeeming element of hope for cure, for life over death. If cure is not obtained, hope for the participant moves to a 'good death'. If the outcome is cure, however, the hope for life has been realised for both participant and observer. Hope, which is always for the future, may now diverge between participant and observer. Observers hope for a return to normality, and use a discourse of normality which emphasises such things as 'getting over it', 'moving on' and 'getting back to normal'. Survivors may not find the realisation of hope for life to be as comfortable as might be expected. After the euphoria of being declared free of disease, about 30% of survivors develop post-cancer distress with death salience. They recognise, whether they want to or not, that they have confronted their own annihilation, and that they will at some stage have to do so again. We all know that we will die, but there is a greater vividness and proximity in that knowledge for someone who has been through mortal extreme experience. Death salience provokes a confrontation with meaning in a person's life. Thus survivors turn inward to their deep selves in order to establish an understanding of what their life projects might become. Observers, on the other hand, find death salience hard to live with, and may turn away from the distressed survivor. The hopes and discourses of survivors and those close to them may have different structures and different objects. These differences may help to explain the frequency with which stress and disruption affect close relationships after cancer and other life-threatening experiences.

The skull beneath the skin: cancer survival and awareness of death.

Terror management theory predicts that people made aware of their own mortality (mortality salience) will seek to boost their self-esteem in order to buffer the anxiety they feel. One common resource to achieve this is strengthening social bonds with an admired in-group. It would also seem to predict that cancer survivors and those close to them would be driven to a greater closeness. A similar closeness might be predicted between those with terminal illness and their families and other supporters. Some empirical observations suggest that there are other forms of death-related salience which do not conform to the predictions of terror management theory. We suggest that some of those who have recovered from cancer may be made death salient, while those close to them remain mortality salient. Death salience seems to turn people inward to the resources and challenges of their deep (subconscious and unconscious) minds, and confronts them with the realities of their deep identities. A third form of salience, dying salience, affects those who have terminal illness. Distinguishing between death salience and mortality salience provides one explanation for the frequency with which close relationships break down after recovery from cancer. The distinctive nature of dying salience raises important questions about the inappropriateness of survivors as providers of support for the dying.

Discourse in different voices: reconciling N = 1 and N = many.

When groups are convened to discuss the making of policy, people are chosen to represent particular interests because they have relevant experience. Different stakeholders, however, may use differing discourses, and particular discourses may be privileged in particular contexts. This means that important contributions to the discussion may not be reflected in final reports. Discursive incommensurability is particularly seen when individual, personal experience is presented in meetings where quantification or "numbers talk" is privileged. While pooled personal experience may carry some weight in such a context, individual anecdote does not. The inclusion of 'consumers' in policy making groups may result in their dysempowerment. Their presence promises that they will have influence, but their voices disappear from the final document. The promise of empowerment is not realised. Dysempowerment may translate into empowerment with time, as it has done with feminism and the HIV/AIDS lobby. In order to speed the process, we suggest some practical means whereby mixed discourses may be generated and monitored. For constructive interchange, each party to the discourse needs to express the interests and arguments relevant to the group he or she represents. Supporting this principle of representation are principles of implicature and radical respect. Implicature is the act of implying what is relevant to others involved in the discourse. Radical respect is a fundamental and foundational respect for others in their roles as representatives of stakeholders with legitimate interests in the topic of the discourse.

Survivorship and discourses of identity.

Personal identity is self-evidently important to us all. Identity is a philosophically complex subject, but there is some agreement that memory, embodiment and continuity are essential components. The sense of memory includes 'future memory', the kind of memory we would like to construct for ourselves as our lives proceed. While the sense of personal identity is internal to the individual, a sense of that person's identity exists in the minds of others. Extreme experiences threaten the element of continuity, because they may bring bodily changes as well as cognitive changes that challenge central values. Restoring or preserving continuity is a major task for survivors. The ways in which people experience discontinuity because of cancer illness, and the ways in which they manage this experience emerges from the narratives of the survivors of cancer and in the narratives of health care workers who look after them. People manage discontinuity by reference to stable 'anchor points' in their beliefs and values; by re-constructing versions of their pre-experience identities, drawing on past memory and finding ways to preserve a continuity between past memory, present experience and constructions of the future; by using the experience to develop established facets of identity; and by imbuing the experience with meaning and recognising the enlarged identity made possible by survival. Those who cannot achieve a sense of continuity may feel alienated from themselves, their friends and family. All these methods of management may be used by one person to negotiate the post-experience identity in its different social interactions. The experience of the survivor can be further understood by recognising the challenge posed by extreme experience to the sense of continuity of both embodied self and memory. A satisfactory discourse of survival has yet to enter the public domain. This lack adds to the burdens of survivors, including those who have survived cancer.