Stories of Hope: Young People's Personal Narratives About ADHD Put Into Context of Positive Aspects.

There is a growing acceptance that ADHD is a multi-dimensional disorder in which not all symptoms are associated with deficits or functional impairments. This article contributes to research on the positive aspects of the diagnosis, specifically understanding the positive aspects of living with ADHD. The empirical data was based on individual interviews and self-narratives of 10 young adults with ADHD. Narrative analysis was implemented when investigating their stories. The findings showed that challenges with the diagnosis were not necessarily stably occupied, and for some, the diagnosis was thought of as a benefit and something they would not have been without. Four stories highlighted particularly the context of positive aspects: (1) insight and strategies, (2) targeted efforts, (3) balanced energy, and (4) social skills. These aspects were correlated to both the individual's strengths as well as the strengths and support that could be related to their societal and cultural environment.

Towards a transformative health humanities approach in teaching the Sustainable Development Goals (SDGs).

The adoption of the United Nations' Sustainable Development Goals (SDGs) marks a significant shift in global political agendas, emphasising sustainability in various fields, including health. To engage meaningfully with sustainability, a transformative educational approach is essential. Lange's concept of transformative learning encompasses three levels: personal and cognitive change (micro level), changes in our interactions with others and the environment (meso level) and societal changes (macro level). This paper posits that applying health humanities approaches, particularly narrative medicine, can enhance transformative education at these three levels, leading to a powerful, transformative health humanities framework for teaching sustainability and the SDGs. This interdisciplinary method, which includes reflective self-assessment, exploration of different relational perspectives and social reality comprehension, facilitates transformative learning. However, implementing this transformative strategy requires a critical reassessment of some core principles and methods within the existing health humanities paradigm.

Toward a Values-Informed Approach to Complexity in Health Care: Hermeneutic Review.

Policy Points The concept of value complexity (complexity arising from differences in people's worldviews, interests, and values, leading to mistrust, misunderstanding, and conflict among stakeholders) is introduced and explained. Relevant literature from multiple disciplines is reviewed. Key theoretical themes, including power, conflict, language and framing, meaning-making, and collective deliberation, are identified. Simple rules derived from these theoretical themes are proposed.

Changing praxis from within - an in-depth qualitative exploration of how home visits affected statutory service at a Child Health Clinic.

PURPOSE: This study aims to define critical domains of salutogenic home visits conducted by public health nurses, and how thevisits can supplement a universal Child Health Clinic. DESIGN AND METHOD: A qualitative grounded theory study was conducted among three public health nurses in Stovner district, Oslo, Norway. The nurses were followed for 26 months offering home visits to all first-time parents. Data from focus group discussions, monthly reflection notes and bi-weekly meeting minutes were analysed using qualitative content analysis. RESULTS: Three critical themes emerged: building trust, prenatal visits and maintaining a salutogenic, strength-based approach. Extended public health nurse autonomy facilitated tailored support based on individual family needs. This promoted proportionate universalism to naturally be the gradient of the home visit intensity and kept actions at a universal level. CONCLUSIONS: The key component of family access and utilizing support was building and maintaining trust. Conducting prenatal visits was an important part of the nurse-family relationship, positively affecting later Child Health Clinic follow-up and continued care. PRACTICE IMPLICATIONS: Critical domains and benefits of practicing home visits emerged in this study and disclosed important aspects necessary for family access and utilizing support. By changing the point of entry from postnatal to prenatal, public health nurses-family relationship gets an important head start, positively affecting later follow-up and continued care. A tailored support to new families without using a predefined agenda and a salutogenic, strength-based philosophy can fit the public health nurses' professional beliefs and extend their autonomy.

Renal recipients' knowledge and self-efficacy during first year after implementing an evidence based educational intervention as routine care at the transplantation clinic.

BACKGROUND: Following an implementation plan based on dynamic dialogue between researchers and clinicians, this study implemented an evidence-based patient education program (tested in an RCT) into routine care at a clinical transplant center. The aim of this study was to investigate renal recipients' knowledge and self-efficacy during first year the after the intervention was provided in an everyday life setting. METHODS: The study has a longitudinal design. The sample consisted of 196 renal recipients. Measurement points were 5 days (baseline), 2 months (T1), 6 months (T2), and one-year post transplantation (T3). Outcome measures were post-transplant knowledge, self-efficacy, and self-perceived general health. RESULTS: No statistically significant changes were found from baseline to T1, T2, and T3. Participants' levels of knowledge and self-efficacy were high prior to the education program and did not change throughout the first year post transplantation. CONCLUSION: Renal recipients self-efficacy and insight in post-transplant aspects seem to be more robust when admitted to the hospital for transplantation compared to baseline observations in the RCT study. This may explain why the implemented educational intervention did not lead to the same positive increase in outcome measures as in the RCT. This study supports that replicating clinical interventions in real-life settings may provide different results compared to results from RCT's. In order to gain a complete picture of the impacts of an implemented intervention, it is vital also to evaluate results after implementing findings from RCT-studies into everyday practice.

Epistemologies of evidence-based medicine: a plea for corpus-based conceptual research in the medical humanities.

Evidence-based medicine has been the subject of much controversy within and outside the field of medicine, with its detractors characterizing it as reductionist and authoritarian, and its proponents rejecting such characterization as a caricature of the actual practice. At the heart of this controversy is a complex linguistic and social process that cannot be illuminated by appealing to the semantics of the modifier evidence-based. The complexity lies in the nature of evidence as a basic concept that circulates in both expert and non-expert spheres of communication, supports different interpretations in different contexts, and is inherently open to contestation. We outline a new methodology that combines a social epistemological perspective with advanced methods of corpus linguistics and elements of conceptual history to investigate this and other basic concepts that underpin the practice and ethos of modern medicine. The potential of this methodology to offer new insights into controversies such as those surrounding EBM is demonstrated through a case study of the various meanings supported by evidence and based, as attested in a large electronic corpus of online material written by non-experts as well as a variety of experts in different fields, including medicine.

Towards a translational medical humanities: introducing the cultural crossings of care.

In this introductory essay, we will present a translational medical humanities approach where the humanities are not only an auxiliary to medical science and practice, but also an interdisciplinary space where both medicine and the humanities mutually challenge and inform each other. First, we explore how medicine's attempt to tackle the nature-culture divide is emblematically expressed in the concept and practice of knowledge translation (hereinafter KT). Second, we compare and contrast KT as an epistemic ideology and a socio-medical practice, with concepts and practices of translation developed in the human sciences. In particular, we emphasise Derrida's understanding of translation as inherent in all meaning making, as a fundamentally textual process and as a process necessarily creating difference rather than semantic equivalence. Finally, we analyse a case from clinical medicine showing how a more refined notion of translation can enlighten the interaction between biomedical and cultural factors. Such a translational medical humanities approach also requires a rethinking of the concept of evidence in medicine.

The singular patient in patient-centred care: physiotherapists' accounts of treatment of patients with chronic muscle pain.

A patient-centred approach has gained increasing interest in medicine and other health sciences. Whereas there are discussions about the meaning of a patient-centred approach and what the concept entails, little is known about how the patient as a person is understood in patient-centred care. This article investigates understandings of the patient as a self in patient-centred care through physiotherapy of patients with chronic muscle pain. The material consists of interviews with five Norwegian physiotherapists working in a rehabilitation clinic. Drawing on Kristeva's discussion of subjectivity in medical discourse, the study highlights two different treatment storylines that were closely entwined. One storyline focuses on open singular healing processes in which the treatment was based on openness to a search for meaning and sharing. In this storyline, the "person" at the centre of care was not essentialised in terms of biological mechanisms, but rather considered as a vulnerable, irrational and moving self. By contrast, the second storyline focused on goal-oriented interventions aimed at restoring the patient to health. Here, the person in the centre of the treatment was shaped according to model narratives about "the successful patient"; the empowered, rational, choosing and self-managing individual. As such, the findings revealed two conflicting concepts of the individual patient inherent in patient-centred care. On the one hand, the patient is seen as being a person in constant movement, and on the other, they are captured by more standardised terms designed to focus on a more stable notion of outcome of illness. Therefore, our study suggests that the therapists' will to recognise the individual in patient-centred care had a counterpart involving a marginalisation of the singular.

Ethnography of texts: a literature review of health and female homosexuality in Brazil.

This paper reviews the literature on health and female homosexuality in Brazil and, along the way, outlines an alternative approach to reviewing academic literature. Rather than summarising the contents of previously published papers, we relate to these publications primarily as partakers in the creation of knowledge. Inspired by Actor-Network Theory (ANT), we apply ethnographic methods to understand the papers as study participants endowed with action. We also draw on the notions of inscription and intertextuality to trace the complex relationship between the findings in the articles and the realities outside of them. We claim that 'evidence' is the product of translational processes in which original events, such as experiments, blood tests and interviews, are changed into textual entities. In addition, text production is seen as an absorption of everything else surrounding its creation. When events are turned into articles, the text incorporates the political environment to which original events once belonged. We thus observe a political text inscribed into the written evidence of sexually transmitted infections, and the practice of publishing about scientific vulnerabilities emerges as political action. In contrast with traditional ways of reviewing literature in medical scholarship, this article offers a reminder that although there is a connection between textual evidence and the reality outside publications, these dimensions are not neutrally interchangeable.

How do adolescents with depression experience improvement in psychodynamic psychotherapy? A qualitative study.

BACKGROUND: There is emerging evidence for the effectiveness of psychodynamic psychotherapy for depressive disorders. However, we know less of how this relation-focused therapy mode is experienced and what the patients themselves identify as helpful. Hence, the purpose of this study is to explore adolescents' experiences of factors promoting improvement in psychodynamic therapy. METHODS: Eight female patients participating in a Norwegian study on psychodynamic therapy, the First Experimental Study of Transference Work - In Teenagers (FEST-IT), were included. The participants were offered a total number of 28 sessions. Semi-structured qualitative interviews about experiences with therapy were then conducted and analysed with systematic text condensation and hermeneutic interpretation. RESULTS: The analysis revealed four main themes. 'Exploring oneself' comprises autonomy and acknowledgment, openness, insight and acceptance of oneself. 'Therapist relation and characteristics' includes confidence and trust in and support from the therapist as well as having a trustworthy and experienced therapist. 'Focusing on everyday life' includes learning and practical orientation. 'Time factors' refers to duration and frequency. CONCLUSIONS: Together with a supportive and listening therapist, the adolescents improve by exploring themselves within the frames of a time-limited treatment period. Improvement seems to be experienced through better relations to oneself and to others and by finding one's place in the family, or at school. Adolescents value problem solving and help with concrete challenges. Hence, therapy should be tailored to the needs of adolescents with depression and incorporate the challenges they face in their everyday life. TRIAL REGISTRATION: ClinicalTrials.gov . Id: NCT01531101. Date of registry: 8 February 2012, retrospectively registered.

Acting by persuasion- values and rhetoric in medical certificates of work incapacity: A qualitative document analysis.

When the patient applies for disability benefit in Norway, the general practitioner (GP) is required by the National Insurance Administration (NAV) to confirm that the patient is unfit for work due to disease. Considering the important social role of medical certificates, they have been given surprisingly little attention by the medical critique. They may make essential differences to peoples' lives, legitimise large social costs and, in addition, the GPs report that issuing certificates can be problematic. This article explores values, attitudes and persuasive language in a selection of medical certificates written by GPs. We direct attention to such texts as significant social actors using a mixed rhetoric including certain values and attitudes. When arguing for granting the patient disability benefit, some GPs emphasised the 'worthiness' of the patient by pointing to positive attitudes approved by the national insurance: a will to work and participate, to cooperate and be motivated. Others pointed out the patient's positive character in terms of universally accepted values, called for the reader's (the NAV official) sympathy , understanding and helpfulness or appealed to his/her willingness to be realistic and pragmatic and grant disability benefit (DB). The dialogic style varied: some certifiers-although they argued for disability benefit-showed openness to possible opposing or alternative voices by displaying their own uncertainty. Others addressed the reader to share responsibility, demanding or urging for DB. This shifting rhetoric, we believe, mirrors that the GPs see themselves as the patient's advocate, and that they may find themselves conflicted. We propose further studies within qualitative research to investigate the effect of this rhetoric on the reader, the decision-makers. In addition, to improve the quality and accuracy of these important documents, we suggest that medical schools introduce students to the making of text as a specific skill of medical practice.

Formative research in the development of a salutogenic early intervention home visiting program integrated in public child health service in a multiethnic population in Norway.

BACKGROUND: Few early intervention programs aimed at maternal and child health have been developed to be integrated in the existing Child Health Service in a country where the service is free, voluntary and used by the majority of the eligible population. This study presents the process and the critical steps in developing the "New Mothers" program. METHODS: Formative research uses a mixed method, allowing us to obtain data from multiple sources. A scoping review provided information on early intervention programs and studies, clarifying key elements when framing a new program. Key informant and focus group interviews offered insight of existing challenges, perceptions, identified power structures and offered reflections germane to the identified framework, securing user involvement at all stages. Monthly meetings with the project group enabled feedback loops for the data, securing program advancement. RESULTS: The "New Mothers" program was formed based on a salutogenic theory, emphasizing resistance and strengths. Public health nurses in the existing Child Health Service were to offer universally all first-time mothers and children home visits from gestational week 28 until the child reached 2 years, with motivational interviewing and empathic communication as methods to mentor the mothers, help them identify their strengths and resources, and provide support and information. CONCLUSIONS: Using formative research as mixed method ensures incorporation of detailed information from multiple resources when an early intervention program is developed. This method secured program appropriateness, both culturally and at system level, when integrating new elements in the existing service.

How Knowledge Is Constructed and Exchanged in Virtual Communities of Physicians: Qualitative Study of Mindlines Online.

BACKGROUND: As a response to the criticisms evidence-based practice currently faces, groups of health care researchers and guideline makers have started to call for the appraisal and inclusion of different kinds of knowledge in guideline production (other than randomized controlled trials [RCTs]) to better link with the informal knowledge used in clinical practice. In an ethnographic study, Gabbay and Le May showed that clinicians in everyday practice situations do not explicitly or consciously use guidelines. Instead, they use mindlines: collectively shared, mostly tacit knowledge that is shaped by many sources, including accumulated personal experiences, education (formal and informal), guidance, and the narratives about patients that are shared among colleagues. In this study on informal knowledge, we consider virtual networks of clinicians as representative of the mindlines in the wider medical community, as holders of knowledge, as well as catalysts of knowing. OBJECTIVE: The aim of this study was to explore how informal knowledge and its creation in communities of clinicians can be characterized as opposed to the more structured knowledge produced in guideline development. METHODS: This study included a qualitative study of postings on three large virtual networks for physicians in the United Kingdom, the Netherlands, and Norway, taking the topic of statins as a case study and covering more than 1400 posts. Data were analyzed thematically with reference to theories of collaborative knowledge construction and communities of practice. RESULTS: The dataset showed very few postings referring to, or seeking to adhere to, explicit guidance and recommendations. Participants presented many instances of individual case narratives that highlighted quantitative test results and clinical examination findings. There was an emphasis on outliers and the material, regulatory, and practical constraints on knowledge use by clinicians. Participants conveyed not-so-explicit knowledge as tacit and practical knowledge and used a prevailing style of pragmatic reasoning focusing on what was likely to work in a particular case. Throughout the discussions, a collective conceptualization of statins was generated and reinforced in many contexts through stories, jokes, and imagery. CONCLUSIONS: Informal knowledge and knowing in clinical communities entail an inherently collective dynamic practice that includes explicit and nonexplicit components. It can be characterized as knowledge-in-context in practice, with a strong focus on casuistry. Validity of knowledge appears not to be based on criteria of consensus, coherence, or correspondence but on a more polyphonic understanding of truth. We contend that our findings give enough ground for further research on how exploring mindlines of clinicians online could help improve guideline development processes.

Cultural crossings of care: An appeal to the medical humanities.

Modern medicine is confronted with cultural crossings in various forms. In facing these challenges, it is not enough to simply increase our insight into the cultural dimensions of health and well-being. We must, more radically, question the conventional distinction between the 'objectivity of science' and the 'subjectivity of culture'. This obligation creates an urgent call for the medical humanities but also for a fundamental rethinking of their grounding assumptions.Julia Kristeva (JK) has problematised the biomedical concept of health through her reading of the anthropogony of Cura (Care), who according to the Roman myth created man out of a piece of clay. JK uses this fable as an allegory for the cultural distinction between health construed as a 'definitive state', which belongs to biological life (bios), and healing as a durative 'process with twists and turns in time' that characterises human living (zoe). A consequence of this demarcation is that biomedicine is in constant need of 'repairing' and bridging the gap between bios and zoe, nature and culture. Even in radical versions, the medical humanities are mostly reduced to such an instrument of repairment, seeing them as what we refer to as a soft, 'subjective' and cultural supplement to a stable body of 'objective', biomedical and scientific knowledge. In this article, we present a prolegomenon to a more radical programme for the medical humanities, which calls the conventional distinctions between the humanities and the natural sciences into question, acknowledges the pathological and healing powers of culture, and sees the body as a complex biocultural fact. A key element in such a project is the rethinking of the concept of 'evidence' in healthcare.

Physiotherapists as detectives: investigating clues and plots in the clinical encounter.

This article investigates the clinical reasoning process of physiotherapists working with patients with chronic muscle pain. The article demonstrates how physiotherapists work with clues and weigh up different plots as they seek to build consistent stories about their patient's illness. The material consists of interviews with 10 Norwegian physiotherapists performed after the first clinical encounter with a patient. Using a narrative approach and Lonergan's theory of interpretation, the study highlights how, like detectives, the therapists work with clues by asking a number of interpretive questions of their data. They interrogate what they have observed and heard during the first session, they also question how the patient's story was told, including the contextual and relation aspects of clue production, and they ask why the patient's story was told to them in this particular way at this particular time. The article shows how the therapists configure clues into various plots on the basis of their experience of working with similar cases and how their detective work is pushed forward by uncertainty and persistent questioning of the data.

'Working is out of the question': a qualitative text analysis of medical certificates of disability.

BACKGROUND: Medical certificates influence the distribution of economic benefits in welfare states; however, the qualitative aspects of these texts remain largely unexplored. The present study is the first systematic investigation done of these texts. Our aim was to investigate how GPs select and mediate information about their patients' health and how they support their conclusions about illness, functioning and fitness for work in medical certificates. METHODS: We performed a textual analysis of thirty-three medical certificates produced by general practitioners (GP) in Norway at the request of the Norwegian Labour and Welfare Administration (NAV).The certificates were subjected to critical reading using the combined analytic methods of narratology and linguistics. RESULTS: Some of the medical information was unclear, ambiguous, and possibly misleading. Evaluations of functioning related to illness were scarce or absent, regardless of diagnosis, and, hence, the basis of working incapacity was unclear. Voices in the text frequently conflated, obscuring the source of speaker. In some documents, the expert's subtle use of language implied doubts about the claimant's credibility, but explicit advocacy also occurred. GPs show little insight into their patients' working lives, but rather than express uncertainty and incompetence, they may resort to making too absolute and too general statements about patients' working capacity, and fail to report thorough assessments. CONCLUSIONS: A number of the texts in our material may not function as sufficient or reliable sources for making decisions regarding social benefits. Certificates as these may be deficient for several reasons, and textual incompetence may be one of them. Physicians in Norway receive no systematic training in professional writing. High-quality medical certificates, we believe, might be economical in the long term: it might increase the efficiency with which NAV processes cases and save costs by eliminating the need for unnecessary and expensive specialist reports. Moreover, correct and coherent medical certificates can strengthen legal protection for claimants. Eventually, reducing advocacy in these documents may contribute to a fairer evaluation of whether claimants are eligible for disability benefits or not. Therefore, we believe that professional writing skills should be validated as an important part of medical practice and should be integrated in medical schools and in further education as a discipline in its own right, preferably involving humanities professors.

Expanding the knowledge translation metaphor.

BACKGROUND: Knowledge translation (KT) is a buzzword in modern medical science. However, there has been little theoretical reflection on translation as a process of meaning production in KT. In this paper, we argue that KT will benefit from the incorporation of a more theoretical notion of translation as an entangled material, textual and cultural process. DISCUSSION: We discuss and challenge fundamental assumptions in KT, drawing on theories of translation from the human sciences. We show that the current construal of KT as separate from and secondary to the original scientific message is close to the now deeply compromised literary view of translation as the simple act of copying the original. Inspired by recent theories of translation, we claim that KT can be more adequately understood in terms of a 'double supplement' - on the one hand, KT offers new approaches to the communication of scientific knowledge to different groups in the healthcare system with the aim of supplementing a lack of knowledge among clinicians (and patients). On the other, it demonstrates that a textual and cultural supplement, namely a concern with target audiences (clinicians and patients), is inevitable in the creation of an 'autonomous' science. Hence, the division between science and its translation is unproductive and impossible to maintain. We discuss some possible implications of our suggested shift in concept by drawing on pharmaceutical interventions for the prevention of HIV as a case. We argue that such interventions are based on a supplementary and paradoxical relation to the target audiences, both presupposing and denying their existence. More sophisticated theories of translation can lay the foundation for an expanded model of KT that incorporates a more adequate and reflective description of the interdependency of scientific, cultural, textual and material practices.