Preliminary Testing of A Web-Based Lung Cancer Screening Decision Coaching Tool for Older Chinese American Smokers and Their Providers.

OBJECTIVES: To examine the acceptability of a culturally targeted lung cancer screening decision aid developed for older Chinese Americans with a smoking history and primary care providers serving this patient population. METHODS: Study participants reviewed a web-based decision aid (DA) for lung cancer screening named "Lung Decisions Coaching Tool (LDC-T)." Participants completed a baseline survey and were invited to join an interview. During the interview, participants engaged with the Lung Decisions Coaching Tool and then completed standardized measures of acceptability, usability, and satisfaction. RESULTS: Chinese American smokers (N =22) and Chinese American physicians (N=10) rated the acceptability and usability of a patient version and provider versions of the LDC-T, respectively. Patient version demonstrated high levels of acceptability, usability and satisfaction. Most participants rated the information provided as good or excellent, the amount of tool information was just right, and they thought the tool would be useful for making a screening decision. The tool was well received by participants for ease of use and well-integrated functions. Furthermore, participants indicated they would like to use the tool to help prepare for lung cancer screening shared decision-making with their provider. Similar results were found for the provider version of the LDC-T. CONCLUSIONS: Lung cancer screening represents an evidence-based approach to reducing lung cancer morbidity and mortality among chronic high-frequency smokers. Study results suggest the acceptability of a culturally targeted lung cancer screening decision aid for Chinese American smokers and providers. Additional research is needed to determine the effectiveness of the DA in increasing appropriate levels of screening in this underserved population.

From iatrogenic harm to iatrogenic violence: corruption and the end of medicine.

This paper seizes Ivan Illich's recurring notion of corruption to reflect on medicine's immanent spiral of maleficence. For Illich, the institutionalization of any 'good' necessarily corrupts it, and the institutionalization of health and care under the tutoring hand of medicine has produced counterproductive consequences on every plane. The paper explores the nemetic character of contemporary biomedicine - whose growth in technique has meant a corresponding growth in its capacity for corruption and harm - in an autoethnographic project that apprises and names the escalation from iatrogenic harm to iatrogenic violence that the author discovered at two UK hospitals in 2014. In January, she went to the hospital for a colonoscopy; in November, she finally left, disabled and unmade. In the interim, she suffered infection, sepsis, pneumonia, cardiac arrest, and - worst of all - a factitious psychiatrizing diagnosis embedded in spiralling loops of iatrogenic harm. By reflecting critically on this experience, interlocuting personal memory and writings with doctors' inscribed notes and insights from medical anthropology, the paper elucidates an iatrogenic spiral, showing how unknowable bodies pose an insurmountable epistemic and existential challenge to medicine's technic mandate, how medicine locates and uses an 'epistemic escape valve' in the face of such challenges, and how snowballing nosocomial harm escalates into brutality and vice. The argument, in short, is that iatrogenic violence (destructive, subjective or agentic, and intentional) is the natural endpoint of iatrogenic harm (destructive but objective or systemic, and unintentional).

An innovative intervention to improve respectful maternity care in three Districts in Ethiopia.

BACKGROUND: Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions. METHODS: Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data. RESULTS: Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations. CONCLUSION: This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner.

Attitudes Towards Cancer Patients: A cross-sectional study of Omani patients and attendees at a university teaching hospital.

OBJECTIVES: Many cancer patients experience social difficulties and feelings of isolation. This study aimed to evaluate patients' and attendees' attitudes towards cancer patients. METHODS: A cross-sectional study was conducted of patients and attendees attending Sultan Qaboos University Hospital (SQUH), Muscat, Oman, from December 2018 to March 2019. RESULTS: A total of 1,190 people participated (response rate: 91.5%). The majority (90.7%) did not express reluctance to help cancer patients. Most agreed that cancer patients were productive (76.2%) and are respected by the public (75.0%). However, many participants (63.1%) felt that cancer patients might face difficulties getting married. Multivariate analysis showed that participants who had a family history of cancer or had previously been a caregiver for cancer patients were more likely to believe that cancer patients could be productive (odds ratio [OR] = 1.92, 95% confidence interval [CI]: 1.31-2.82; P <0.05). Less-educated participants were more likely to believe that cancer patients feared not being productive (OR = 1.49, 95% CI: 1.01-2.19; P <0.05). Male and single participants were more likely to perceive that cancer patients faced difficulties getting married (OR = 1.56, 95% CI: 1.20-2.02 and OR = 1.68, 95% CI: 1.22-2.32, respectively; P <0.05 each). CONCLUSION: Patients and attendees attending SQUH in Oman appeared to have positive and supportive attitudes towards cancer patients, although some felt that cancer patients might encounter social obstacles. Healthcare professionals should consider reassuring cancer patients of such positive sentiments. Governmental and non-governmental organisations should act to promote a supportive environment for cancer patients in Oman.

Moving forward: Recommendations to overcome existing structural racism.

A critical need exists to address structural racism within academic and community medicine and surgery and determine methods that will serve to repair its long-standing effects and alleviate the associated negative consequences. Because of our broad skillset and the populations we serve, vascular surgeons are uniquely positioned to identify and address the effects of structural racism in our places of work and for the populations we treat. Our goal is to discuss the effects of racism on healthcare outcomes and provide recommendations on how to combat these through equitable practices such as the diversification of the vascular surgery workforce, inclusivity as partners and leaders, and the promotion of improved outcomes among our most vulnerable patients from racial and ethnic minority groups. It is imperative that we stand for antiracism within our field through our societies, journals, clinical trials, training programs, clinical practice groups, and leadership.

Doctors' practice and attitudes towards red blood cell transfusion at Mthatha Regional Hospital, Eastern Cape, South Africa: A mixed methods study.

BACKGROUND: Unnecessary blood transfusion exposes recipients to potential harms. AIM: The aim of this study was to describe blood transfusion practice and explore doctors' attitudes towards transfusion. SETTING: A hospital providing level 1 and 2 services. METHODS: A mixed-methods study design was used. In the cross-sectional descriptive component, a sample was taken from patients transfused over a 2-month period. Blood use was categorised as for medical anaemia or haemorrhage, and appropriate or not. The qualitative component comprised a purposeful sample for focus group and individual semi-structured interviews. RESULTS: Of 239 patients sampled, 62% were transfused for medical anaemia and 38% for haemorrhage. In the medical anaemia group, compliance with age-appropriate transfusion thresholds was 69%. In medical anaemia and haemorrhage, 114 (77%) and 85 (93.4%) of recipients had orders for ≥ 2 red blood cell (RBC) units, respectively. In adults ≥ 18 years old with medical anaemia, 47.1% of orders would have resulted in a haemoglobin (Hb) 8 g/dL. Six doctors participated in focus group and eleven in individual interviews. There was a lack of awareness of institutional transfusion guidelines, disagreement on appropriate RBC transfusion thresholds and comments that more than one RBC unit should always be transfused. Factors informing decisions to transfuse included advice from senior colleagues, relieving symptoms of anaemia and high product costs. CONCLUSION: Most orders were for two or more units. In medical anaemia, doctors' compliance with RBC transfusion thresholds was reasonable; however, almost half of the orders would have resulted in overtransfusion. The attitudes of doctors sampled suggest that their transfusion practice is influenced more by institutional values than formal guidelines.

Treating risk, risking treatment: experiences of iatrogenesis in the HIV/AIDS and opioid epidemics.

This paper explores how poor health outcomes in the HIV/AIDS and opioid epidemics in the United States are undergirded by iatrogenesis. Data are drawn from two projects in Southern California: one among men who have sex with men (MSM) engaging with pre-exposure prophylaxis to HIV (PrEP) and the other in a public hospital system encountering patients with chronic pain and opioid use disorder (OUD). Ethnographic evidence demonstrates how efforts to minimize risk via PrEP and opioid prescription regulation paradoxically generate new forms of risk. Biomedical risk management paradigms engaged across the paper's two ethnographic field sites hinge on the production and governance of deserving patienthood, which is defined by providers and experienced by patients through moral judgments about risk underlying both increased surveillance and abandonment. This paper argues that the logic of deservingness disconnects clinical evaluations of risk from patients' lived, intersectional experiences of race, class, gender, and sexuality. This paper's analysis thus re-locates patients in the context of broader historical and sociopolitical trajectories to highlight how notions of clinical risk designed to protect patients can in fact imperil them. Misalignment between official, clinical constructions of risk and the embodied experience of risk borne by patients produces iatrogenesis.

An Aboriginal and Torres Strait Islander Cardiac Rehabilitation program delivered in a non-Indigenous health service (Yeddung Gauar): a mixed methods feasibility study.

BACKGROUND: There is limited evidence of Aboriginal and Torres Strait Islander people attending cardiac rehabilitation (CR) programs despite high levels of heart disease. One key enabler for CR attendance is a culturally safe program. This study evaluates improving access for Aboriginal and Torres Strait Islander women to attend a CR program in a non-Indigenous health service, alongside improving health workforce cultural safety. METHODS: An 18-week mixed-methods feasibility study was conducted, with weekly flexible CR sessions delivered by a multidisciplinary team and an Aboriginal and/or Torres Strait Islander Health Worker (AHW) at a university health centre. Aboriginal and Torres Strait Islander women who were at risk of, or had experienced, a cardiac event were recruited. Data was collected from participants at baseline, and at every sixth-session attended, including measures of disease risk, quality-of-life, exercise capacity and anxiety and depression. Cultural awareness training was provided for health professionals before the program commenced. Assessment of health professionals' cultural awareness pre- and post-program was evaluated using a questionnaire (n = 18). Qualitative data from participants (n = 3), the AHW, health professionals (n = 4) and referrers (n = 4) was collected at the end of the program using yarning methodology and analysed thematically using Charmaz's constant comparative approach. RESULTS: Eight referrals were received for the CR program and four Aboriginal women attended the program, aged from 24 to 68 years. Adherence to the weekly sessions ranged from 65 to 100%. At the program's conclusion, there was a significant change in health professionals' perception of social policies implemented to 'improve' Aboriginal people, and self-reported changes in health professionals' behaviours and skills. Themes were identified for recruitment, participants, health professionals and program delivery, with cultural safety enveloping all areas. Trust was a major theme for recruitment and adherence of participants. The AHW was a key enabler of cultural authenticity, and the flexibility of the program contributed greatly to participant perceptions of cultural safety. Barriers for attendance were not unique to this population. CONCLUSION: The flexible CR program in a non-Indigenous service provided a culturally safe environment for Aboriginal women but referrals were low. Importantly, the combination of cultural awareness training and participation in the program delivery improved health professionals' confidence in working with Aboriginal people. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) 12618000581268, http://www.ANZCTR.org.au/ACTRN12618000581268.aspx , registered 16 April 2018.

'If relevant, yes; if not, no': General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory.

CONTEXT: The use of ethnic identifiers in health systems is recommended in several European countries as a means to identify and address heath inequities. There are barriers to implementation that have not been researched. OBJECTIVE: This study examines whether and how ethnicity data can be collected in Irish general practices in a meaningful and acceptable way. METHODS: Qualitative case study data generation was informed by Normalization Process Theory (NPT) constructs about 'sense' making and 'engagement'. It consisted of individual interviews and focus group discussions based on visual participatory techniques. There were 70 informants, including 62 general practitioner (GP) users of diverse ethnic backgrounds recruited through community organisations and eight GPs identified through an inter-agency steering group. Data were analysed according to principles of thematic analysis using NPT. RESULTS: The link between ethnicity and health was often considered relevant because GP users grasped connections with genetic (skin colour, lactose intolerance), geographic (prevalence of disease, early years exposure), behavioural (culture/food) and social determinant (housing) factors. The link was less clear with religion. There was some scepticism and questions about how the collection of data would benefit GP consultations and concerns regarding confidentiality and the actual uses of these data (e.g. risk of discrimination, social control). For GPs, the main theme discussed was relevance: what added value would it bring to their consultations and was it was their role to collect these data? Their biggest concern was about data protection issues in light of the European Union (EU) General Data Protection Regulation (GDPR). The difficulty in explaining a complex concept such as 'ethnicity' in the limited time available in consultations was also worrying. CONCLUSIONS: Implementation of an ethnicity identifier in Irish general practices will require a strong rationale that makes sense to GP users, and specific measures to ensure that its benefits outweigh any potential harm. This is in line with both our participants' views and the EU GDPR.

Evaluation of practical experiences of German speaking radiation oncologists in combining radiation therapy with checkpoint blockade.

The results of this survey reveal current clinical practice in the handling of combined radioimmunotherapy with Immune Checkpoint Inhibitors (RT + ICI). We aim to provide a basis to open a discussion for clinical application of RT + ICI by analyzation of experts' assessment. We conducted a survey with 24 items with a focus on side effects of RT + ICI, common practice of scheduling and handling of adverse events. After pilot testing by radiation oncology experts the link to the online survey was sent to all members of the German Society of Radiation Oncology (DEGRO). In total, 51 radiation oncologists completed the questionnaire. Pulmonary toxicity under RT + ICI with ICIs was reported most frequently. Consensus was observed for bone and soft tissue RT of the limbs in favor for no interruption of ICIs. For cranial RT half of the participants do not suspend ICIs during normofractionated radiotherapy (nfRT) or stereotactic hypofractionated RT (SRT). More participants pause ICIs for central than for peripheral thoracic region. Maintenance therapy with ICIs is mostly not interrupted prior to RT. For management of RT associated pneumonitis under durvalumab the majority of 86.3% suggest corticosteroid therapy and 76.5% would postpone the next cycle of ICI therapy. The here obtained assessment and experiences by radiation oncologists reveal a large variability in practical handling of combined RT + ICI. Until scientific evidence is available a discussion for current clinical application of RT + ICI should be triggered. Interdisciplinary consensus guidelines with practical recommendations are required.

Intersecting stigma and HIV testing practices among urban refugee adolescents and youth in Kampala, Uganda: qualitative findings.

INTRODUCTION: HIV-related risks may be exacerbated in humanitarian contexts. Uganda hosts 1.3 million refugees, of which 60% are aged under 18. There are knowledge gaps regarding HIV testing facilitators and barriers, including HIV and intersecting stigmas, among urban refugee youth. In response, we explored experiences and perspectives towards HIV testing strategies, including HIV self-testing, with urban refugee youth in Kampala, Uganda. METHODS: We implemented a qualitative study with refugee cisgender youth aged 16 to 24 living in Kampala's informal settlements from February-April 2019. We conducted five focus groups with refugee youth, including two with adolescent boys and young men, two with adolescent girls and young women and one with female sex workers. We also conducted five key informant (KI) interviews with government, non-government and community refugee agencies and HIV service providers. We conducted thematic analyses to understand HIV testing experiences, perspectives and recommendations. RESULTS: Participants (n = 49) included young men (n = 17) and young women (n = 27) originally from the Democratic Republic of Congo [DRC] (n = 29), Rwanda (n = 11), Burundi (n = 3) and Sudan (n = 1), in addition to five KI (gender: n = 3 women, n = 2 men; country of origin: n = 2 Rwanda, n = 2 Uganda, n = 1 DRC). Participant narratives revealed stigma drivers included fear of HIV infection; misinformation that HIV is a "Ugandan disease"; and blame and shame for sexual activity. Stigma facilitators included legal precarity regarding sex work, same-sex practices and immigration status, alongside healthcare mistreatment and confidentiality concerns. Stigma experiences were attributed to the social devaluation of intersecting identities (sex work, youth, refugees, sexual minorities, people living with HIV, women). Participants expressed high interest in HIV self-testing. They recommended HIV self-testing implementation strategies to be peer supported and expressed concerns regarding sexual- and gender-based violence with partner testing. CONCLUSIONS: Intersecting stigma rooted in fear, misinformation, blame and shame, legal precarity and healthcare mistreatment constrain current HIV testing strategies with urban refugee youth. Findings align with the Health Stigma and Discrimination Framework that conceptualizes stigma drivers and facilitators that devalue intersecting health conditions and social identities. Findings can inform multi-level strategies to foster enabling HIV testing environments with urban refugee youth, including tackling intersecting stigma and leveraging refugee youth peer support.

Re-examining Norms of Disrespect and Abuse in the Second Stage of Labor in Tanzanian Maternity Care.

Globally, the widespread occurrence of disrespect and abuse (D&A) on maternity wards is well-documented. Using ethnography and cultural consensus analysis we explore how the practice of midwives hitting women who are in the second stage of labor (pushing) has become a locally accepted form of care in Tanzania if a baby's life appears to be at risk. This analysis interrogates the deep uncertainty of birth outcomes in this setting that may motivate abuse during this time. Seriously engaging with local discourses on abuse and care sheds light on hegemonic norms and power dynamics and is critical for improving maternity services.

Using social network tools to facilitate cultural adjustment of self-initiated Malaysian female expatriate nurses in Saudi Arabia.

BACKGROUND: This research study aims to:(1) identify and explore the social network communication tools used to facilitate the adjustment process of Malaysian female expatriate nurses working in the Kingdom of Saudi Arabia (hereafter "the Kingdom" or "SA") who are accompanied by neither their spouses nor families and (2) determine how these tools facilitate their adjustment to their new environment. Emphasis is placed on this particular group of respondents primarily due to the dearth of research conducted on female expatriate nurses. METHOD: We conducted a preliminary study using semi-structured interviews with sixteen (16) Malaysian female expatriate nurses working in SA to obtain a broader understanding of their experiences with cross-cultural adaptation and their use of social media tools to connect with their families and friends in their home country. RESULTS: This study uncovers numerous social media communication tools being used by female expatriate nurses to help curb their loneliness and lessen the culture shock of living and working in a foreign country. Continuous engagement with these tools helps Malaysian female expatriate nurses maintain their emotional stability, thereby enabling them to remain mentally strong and ultimately prolonging their stay in SA. CONCLUSIONS: This study's outcomes contribute significantly to the knowledge of the government, various organizations, and aspiring female expatriate nurses in the healthcare industry because the results can assist female expatriate nurses during the adjustment period, enabling them to work efficiently and successfully in the host country.