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2.
Anthropol Med ; 28(2): 223-238, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34058932

RESUMO

Opioids, a set of potent pain medications, have numerous known deleterious side effects, ranging from constipation to respiratory depression and death, and yet they are routinely prescribed and administered in biomedical settings. Situated against the backdrop of the US opioid epidemic, this paper examines how the iatrogenic and inadvertent harms and complications caused by opioid administration in clinical settings are experienced by clinicians as forms of moral injury. 'Moral injury' describes a moral agent's experience of perpetrating or being unable to prevent events that are at odds with their moral beliefs and social expectations. This concept powerfully extends Illich's notion of clinical iatrogenesis, which refers to harms experienced by patients; instead, 'moral injury' indexes forms of harm that extend beyond patients to those providing them care. Using an analytic auto-ethnographic approach based on more than a decade of clinical practice in urban hospitals in the Midwestern and Northeastern United States, the authors describe interactions with patients on opioids whose treatment trajectories are fraught with iatrogenic complications, and explore how biomedical institutions and systems further harm vulnerable patients who receive and are addicted to opioids. Though anxious to avoid harming their patients, clinicians are disempowered by hierarchical systems of medical decision-making, which hinder their ability to always act in what they feel are the patient's best interests. This paper highlights the emotional/affective distress and ambivalence experienced by physicians when making decisions about whether to administer or prescribe opioids. Ultimately, the paper demonstrates how iatrogenesis and moral injury are concomitantly produced through cascades of decision-making and local health systems, rather than individual clinical decisions alone.


Assuntos
Analgésicos Opioides , Doença Iatrogênica/etnologia , Epidemia de Opioides , Transtornos Relacionados ao Uso de Opioides/etnologia , Idoso , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Antropologia Médica , Tomada de Decisão Clínica , Humanos , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Estados Unidos/etnologia
3.
BMC Pregnancy Childbirth ; 21(1): 425, 2021 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-34116648

RESUMO

BACKGROUND: Global disparities in maternal mortality could be reduced by universal facility delivery. Yet, deficiencies in the quality of care prevent some mothers from seeking facility-based obstetric care. Obstetric care navigators (OCNs) are a new form of lay health workers that combine elements of continuous labor support and care navigation to promote obstetric referrals. Here we report qualitative results from the pilot OCN project implemented in Indigenous villages in the Guatemalan central highlands. METHODS: We conducted semi-structured interviews with 17 mothers who received OCN accompaniment and 13 staff-namely physicians, nurses, and social workers-of the main public hospital in the pilot's catchment area (Chimaltenango). Interviews queried OCN's impact on patient and hospital staff experience and understanding of intended OCN roles. Audiorecorded interviews were transcribed, coded, and underwent content analysis. RESULTS: Maternal fear of surgical intervention, disrespectful and abusive treatment, and linguistic barriers were principal deterrents of care seeking. Physicians and nurses reported cultural barriers, opposition from family, and inadequate hospital resources as challenges to providing care to Indigenous mothers. Patient and hospital staff identified four valuable services offered by OCNs: emotional support, patient advocacy, facilitation of patient-provider communication, and care coordination. While patients and most physicians felt that OCNs had an overwhelmingly positive impact, nurses felt their effort would be better directed toward traditional nursing tasks. CONCLUSIONS: Many barriers to maternity care exist for Indigenous mothers in Guatemala. OCNs can improve mothers' experiences in public hospitals and reduce limitations faced by providers. However, broader buy-in from hospital staff-especially nurses-appears critical to program success. Future research should focus on measuring the impact of obstetric care navigation on key clinical outcomes (cesarean delivery) and mothers' future care seeking behavior.


Assuntos
Parto Obstétrico , Acesso aos Serviços de Saúde , Povos Indígenas , Cuidado Pré-Natal , Adolescente , Adulto , Feminino , Guatemala , Serviços de Saúde do Indígena , Disparidades em Assistência à Saúde , Humanos , Entrevistas como Assunto , Tocologia , Projetos Piloto , Gravidez , Encaminhamento e Consulta , Adulto Jovem
4.
Ann Emerg Med ; 77(3): 382-383, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33618816

Assuntos
Medicina , Humanos
7.
Glob Public Health ; 16(4): 623-638, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33161879

RESUMO

This qualitative study explores perceptions of chronic kidney disease (CKD) among adults with abnormal estimated glomerular filtration rate (eGFR) in Guatemala, where the burden of CKD is rising. Qualitative semi-structured interviews were conducted with 39 individuals screened for CKD and found to have abnormal eGFR (defined as <90 mL/min/1.73 m2, per Kidney Disease Improving Global Outcomes [KDIGO] guidelines). Interviews occurred in participants' homes in Spanish or Kaqchikel Mayan. Interview notes were coded for dominant themes through an inductive approach. Interviewees had limited awareness of diabetes and hypertension as CKD risk factors, but appreciated the progressive nature of the disease. While most reported willingness to pursue renal replacement therapies, if necessary, they anticipated economic and geographic barriers. Public health interventions should focus on the association between diabetes, hypertension, and CKD. Improvement of primary care and screening infrastructure is imperative in CKD prevention in low- and middle-income countries (LMICs).

10.
West J Emerg Med ; 21(2): 261-271, 2020 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-32191184

RESUMO

INTRODUCTION: Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians' attitudes toward the initiation of buprenorphine treatment in the ED. METHODS: We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital. RESULTS: A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up. CONCLUSION: ED clinicians' perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine.


Assuntos
Atitude do Pessoal de Saúde , Buprenorfina/uso terapêutico , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Transtornos Relacionados ao Uso de Opioides , Adulto , Overdose de Drogas/mortalidade , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/tendências , Feminino , Humanos , Masculino , Antagonistas de Entorpecentes , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/psicologia , Transtornos Relacionados ao Uso de Opioides/terapia , Tempo para o Tratamento , Estados Unidos/epidemiologia
11.
BMC Nephrol ; 21(1): 71, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32111173

RESUMO

BACKGROUND: Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals' perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala. METHODS: Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions. RESULTS: Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services. CONCLUSIONS: Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.


Assuntos
Atitude do Pessoal de Saúde , Alocação de Recursos para a Atenção à Saúde , Hospitais Especializados/organização & administração , Ambulatório Hospitalar/organização & administração , Insuficiência Renal Crônica/terapia , Esgotamento Profissional , Tomada de Decisão Clínica , Guatemala , Hospitais Especializados/normas , Humanos , Ambulatório Hospitalar/normas , Diálise Peritoneal , Recursos Humanos em Hospital/psicologia , Pesquisa Qualitativa , Qualidade da Assistência à Saúde , Diálise Renal , Estresse Psicológico
12.
West J Emerg Med ; 22(1): 41-44, 2020 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-33439802

RESUMO

Racism impacts patient care and clinical training in emergency medicine (EM), but dedicated racism training is not required in graduate medical education. We designed an innovative health equity retreat to teach EM residents about forms of racism and skills for responding to racial inequities in clinical environments. The three-hour retreat occurred during the residency didactic conference to maximize resident participation. We prioritized facilitated reflection on residents' own experiences of race and racism in medicine in order to emphasize these concepts' relevance to all participants. We used workshop, small group, and panel formats to optimize interactivity and discussion. Post-retreat survey respondents indicated that the curriculum successfully promoted awareness of racism in the workplace. Participants also expressed interest in continued discussions about racism in medicine as well as desire for greater faculty and nursing participation in the curriculum. Residency programs should consider incorporating similar educational sessions in core didactic curricula.


Assuntos
Medicina de Emergência/educação , Equidade em Saúde , Internato e Residência , Racismo , Adulto , Currículo , Educação de Pós-Graduação em Medicina , Humanos , Inquéritos e Questionários
13.
BMJ Paediatr Open ; 3(1): e000510, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31531407

RESUMO

Background: There has been limited research on the relationship between contraception and child growth in low-income and middle-income countries (LMICs). This study examines the association between contraception and child linear growth in Guatemala, an LMIC with a very high prevalence of child stunting. We hypothesise that contraceptive use is associated with better child linear growth and less stunting in Guatemala. Methods: Using representative national data on 12 440 children 0-59 months of age from the 2014-2015 Demographic and Health Survey in Guatemala, we constructed multivariable linear and Poisson regression models to assess whether child linear growth and stunting were associated with contraception variables. All models were adjusted for a comprehensive set of prespecified confounding variables. Results: Contraceptive use was generally associated with modest, statistically significant greater height-for-age z-score. Current use of a modern method for at least 15 months was associated with a prevalence ratio of stunting of 0.87 (95% CI 0.81 to 0.94; p<0.001), and prior use of a modern method was associated with a prevalence ratio of stunting of 0.93 (95% CI 0.87 to 0.98; p<0.05). The severe stunting models found generally similar associations with modern contraceptive use as the stunting models. There was no significant association between use of a modern method for less than 15 months and the prevalence ratio of stunting or severe stunting. Conclusions: Contraceptive use was associated with better child linear growth and less child stunting in Guatemala. In addition to the human rights imperative to expand contraceptive access and choice, family planning merits further study as a strategy to improve child growth in Guatemala and other countries with high prevalence of stunting.

16.
J Glob Oncol ; 4: 1-10, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30084698

RESUMO

Purpose Cervical cancer is an important cause of mortality in low- and middle-income countries. Although screening technologies continue to improve, systems of care remain fragmented. It is important to better understand factors that affect use of screening services and loss to follow-up along the care continuum. Methods We conducted a mixed-methods study of a cytology-based screening program in rural Guatemala. A retrospective electronic chart review was performed on data from all patients from 2013 to 2014. We analyzed progression through care and calculated loss-to-follow-up rates. We also analyzed the prior experiences of patients with cervical cancer screening on the basis of self-reported historical data available in the chart review. Structured interviews with a subset of individuals to explore social supports and barriers to screening and engagement in care were conducted at the time of screening. Results The analysis included 515 women (median age, 36 years). Cytologic screening showed concern for neoplastic changes in 0.83%; half resulted in biopsy-proven cervical intraepithelial neoplasia. An additional 9.9% showed severe inflammation. The rate of loss to follow-up was 11.3%. All losses to follow-up occurred for severe inflammation, not for cervical intraepithelial neoplasia. Historical data showed that 73% of the cohort had previously been screened and had high levels of loss to follow-up (57.4%). Qualitative interviews revealed factors that promoted loss to follow-up; these included cost, lack of social supports, transportation, distrust in public facilities, long turn-around times, and failure to return test results or offer follow-up treatments. Conclusions Taken together, these quantitative and qualitative results highlight the need for cervical cancer screening programs in Guatemala to improve uptake of screening services by eligible women and to improve follow-up after a first abnormal screen.


Assuntos
Neoplasias do Colo do Útero/diagnóstico , Adulto , Detecção Precoce de Câncer , Feminino , Guatemala , Humanos , Estudos Retrospectivos
19.
Reprod Health ; 14(1): 148, 2017 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-29132431

RESUMO

BACKGROUND: Disrespectful and abusive maternity care is a common and pervasive problem that disproportionately impacts marginalized women. By making mothers less likely to agree to facility-based delivery, it contributes to the unacceptably high rates of maternal mortality in low- and middle-income countries. Few programmatic approaches have been proposed to address disrespectful and abusive maternity care. OBSTETRIC CARE NAVIGATION: Care navigation was pioneered by the field of oncology to improve health outcomes of vulnerable populations and promote patient autonomy by providing linkages across a fragmented care continuum. Here we describe the novel application of the care navigation model to emergency obstetric referrals to hospitals for complicated home births in rural Guatemala. Care navigators offer women accompaniment and labor support intended to improve the care experience-for both patients and providers-and to decrease opposition to hospital-level obstetric care. Specific roles include deflecting mistreatment from hospital staff, improving provider communication through language and cultural interpretation, advocating for patients' right to informed consent, and protecting patients' dignity during the birthing process. Care navigators are specifically chosen and trained to gain the trust and respect of patients, traditional midwives, and biomedical providers. We describe an ongoing obstetric care navigator pilot program employing rapid-cycle quality improvement methods to quickly identify implementation successes and failures. This approach empowers frontline health workers to problem solve in real time and ensures the program is highly adaptable to local needs. CONCLUSION: Care navigation is a promising strategy to overcome the "humanistic barrier" to hospital delivery by mitigating disrespectful and abusive care. It offers a demand-side approach to undignified obstetric care that empowers the communities most impacted by the problem to lead the response. Results from an ongoing pilot program of obstetric care navigation will provide valuable feedback from patients on the impact of this approach and implementation lessons to facilitate replication in other settings.


Assuntos
Parto Obstétrico/normas , Serviços de Saúde Materna/organização & administração , Navegação de Pacientes/organização & administração , Pessoal Técnico de Saúde , Atitude do Pessoal de Saúde , Continuidade da Assistência ao Paciente/organização & administração , Feminino , Guatemala , Humanos , Imperícia/estatística & dados numéricos , Projetos Piloto , Gravidez , Preconceito , Relações Profissional-Paciente , Melhoria de Qualidade , Qualidade da Assistência à Saúde , Direitos da Mulher
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