'O'ofaki: a health promotion and community development concept to bring Pasifika people together.

Stable, healthy families are the loto or heart of strong Pacific communities. This paper addresses the problem of a decline in the strength of Pacific families. It introduces and discusses the Tongan concept of O'ofaki, as the way in which shared, core relational commitments can bring Pasifika peoples together to support one another for health and community development. This process is based on a reciprocal sharing of social capital to promote cultural solidarity and social justice. We describe two studies by the lead author, through which the concept of O'ofaki emerged. The first study utilized an action research model while the second study focused on two Pasifika-centric research approaches: talanga, which is a Tongan word for interactive talking for a purpose, and the kakala (Tongan garland) research approach. The latter approach is incorporated within a general inductive methodology as well as luva-the dissemination of the results. Finally, the paper focuses on the components of O'ofaki and its application to Pasifika communities.

Making the improbable probable: communication across models of medical practice.

Cooperation and conversation in the public sphere may overcome historical and other barriers to rational argumentation. As an alternative to evidence-based medicine (EBM) and patient-centered care (PCC), the recent development of a modern version of person-centered medicine (PCM) signals an opportunity for a conversational pluralogue to replace parallel monologues between EBM and its critics, and the calls to EBM to debate its critics. This article draws upon elements of Habermas's theory of communicative action in order to suggest the kind of pluralogue that is required for stakeholders in modern medicine to benefit more from publicly conversing with each other than speaking alone or using debate to argue against each other. This reasoned perspective has lessons for all discourse when deep value-based and epistemological differences cannot be easily adjudicated.

Getting the balance right: thick and thin approaches to harmonizing state particularism and the human right to health.

CONTEXT: The right to health requires States to achieve the highest standard of health attainable for all. A culturally sensitive approach is needed to respect States' interpretation and implementation of the universal right to health, and document their progress. OBJECTIVE: This viewpoint suggests how to harmonize the (i) human right to health and (ii) the particularism of State values and interests. STRATEGY: I describe the 'thickness' with which individual States recognize the right to health, as a dimension of universality, and then implement that recognition, as a dimension of particularism. Recognition and implementation by States need to be thick to demonstrate 'glocal' rationality, as characterizes the right to health as a Webberian ideal type. Examples of variation in the thickness of States' interpretation and implementation of the right to health are discussed. CONCLUSION: It is possible to work towards harmonizing the right to health, and State particularism, by maximizing the thickness with which individual States recognize this right and progressively implement it.

Rethinking researcher bias in health research.

Bias is an ambiguous term, defined in different ways. In conventional usage, it indicates unwarranted prejudice. However, in health research, the notion that bias is invariably bad is biased. Although research bias is an error that is always harmful, researcher bias is a tendency to think in a particular way that may obscure or illuminate attempts to address research questions. Researcher bias begins with pre-judgements whose continuing evaluation infuses the subjectivity of researchers as persons who are socially situated in health sciences focusing on human subjects. Two sets of conditions can make this bias in health researchers useful. The first is volume control. Researchers can vary the loudness of their own and other voices in different research environments. The second condition is smart working. It balances researcher bias against analytic thinking to work creatively with irregularity and uncertainty. Thus, health researchers need to bring their biases to consciousness. A dialectical approach can then engage the biases as conversational partners to innovate health policy that is informed by principles including transparency, good faith and tolerance. Less critical than whether researchers are biased is whose interests their bias serves given their positionality and role.

Modifiable Risk Factors and Change in Cognition of Maori and Non-Maori in Advanced Age: LiLACS NZ.

OBJECTIVE: This study investigated whether previously identified modifiable risk factors for dementia were associated with cognitive change in Maori (indigenous people of New Zealand) and non-Maori octogenarians of LiLACS NZ (Life and Living in Advanced Age; a Cohort Study in New Zealand), a longitudinal study. METHOD: Multivariable repeated-measure mixed effect regression models were used to assess the association between modifiable risk factors and sociodemographic variables at baseline, and cognitive change over 6 years, with p values of <.05 regarded as statistically significant. RESULTS: Modifiable factors associated with cognitive change differed between ethnic groups. Depression was a negative factor in Maori only, secondary education in non-Maori was protective, and obesity predicted better cognition over time for Maori. Diabetes was associated with decreased cognition for both Maori and non-Maori. CONCLUSION: Our results begin to address gaps in the literature and increase understanding of disparities in dementia risk by ethnicity. These findings have implications for evaluating the type and application of culturally appropriate methods to improve cognition.

Exploring Cognitively Loaded Physical Activity Compared With Control to Improve Global Cognitive Function in Older Community-Dwelling Adults With Mild Cognitive Impairment: Systematic Review With Meta-Analysis.

OBJECTIVE: A systematic review with a meta-analysis explored effects of cognitively loaded physical activity interventions on global cognition in community-dwelling older adults (≥65 years of age) experiencing mild cognitive impairment (MCI), compared to any control. METHODS: A literature search was conducted in 4 databases (MEDLINE [OvidSP], PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials [Wiley]) from inception until January 30, 2018. The meta-analysis was conducted with Review Manager 5.3. RESULTS: Six randomized controlled trials (RCTs) with 547 participants were identified. The interventions ranged from 4 to 52 weeks. Baseline and initial follow-up assessments were used. The primary pooled analysis of all RCTs demonstrated a nonsignificant trivial effect (standardized mean difference [SMD] 0.07, 95% confidence interval [CI] -0.44 to 0.58) favoring the intervention. In pooled subanalysis of 4 RCTs (n = 405) using the same global cognition measure (Mini-Mental State Examination) and duration of intervention >12 weeks, the intervention group achieved a small but significant improvement for global cognition (SMD 0.45, 95% CI 0.14 to 0.75). CONCLUSION: When all the RCTs were pooled, the effect of cognitively loaded physical activity intervention on global cognitive function in older adults with MCI remained unclear. The subgroup analysis provides translation evidence for future RCT study designs.

When should patient intuition be taken seriously?

As a style of information processing, intuition involves implicit perceptual and cognitive processes that can be quickly and automatically executed without conscious mental will, such that people know more than they can describe. Patient intuition can influence patient and clinician decision-making and behavior. However, physicians may not always see patient intuition as credible or important, and its management in the clinical setting is poorly understood. This paper takes a step toward suggesting conditions under which patient intuition should be taken seriously. These conditions relate to the credibility or accuracy of the intuitive beliefs held by the patient, and their significance to the patient. Credibility may be increased when the intuitions of patients (1) reflect their individualized knowledge, (2) can complement the common absence of scientific evidence in managing health problems, and (3) can quickly and effectively process key information in complex cognitive tasks. Even intuitions that lack credibility can be subjectively rational and meaningful to patients, and help to shape the decisions they and clinicians make.

Why are self-medication opportunities limited in Austria? An interview study and comparison with other countries.

BACKGROUND: Austria has high health resource use compared to similar countries. Reclassifying (switching) medicines from prescription to non-prescription can reduce pressure on health resources and aid timely access to medicines. Since Austria is less progressive in this area than many other countries, this research aimed to elucidate enablers and barriers to it reclassifying medicines and make recommendations for change in the context of similar research conducted elsewhere. METHODS: Qualitative research using a heuristic approach was conducted in Austria in 2018. Informed by their own "insider" and "outsider" knowledge, the authors identified themes from personal interviews with 24 participants, including reclassification committee members, government officials and stakeholders, before comparing these themes with earlier research findings. RESULTS: Significant barriers to reclassification included committee conservatism, minimal political support, medical negativity and few company applications. Insufficient transparency about committee decisions, expectations of adverse committee decisions and a limited market discouraged company applications. Austria's 'social partnership' arrangement and consensus decision making aided a conservative approach, but the regulator and an alternative non-committee switch process were enabling. Pharmacy showed mixed interest in reclassification. Suggested improvements include increasing transparency, committee composition changes, encouraging a more evidence-based approach by the committee, more pharmacy undergraduate clinical training, and companies using scientific advisory meetings and submitting high quality applications. CONCLUSION: Removing barriers to reclassification would facilitate non-prescription availability of medicines and encourage self-care, and could reduce pressure on healthcare resources.

The Thin Man is His Clothing: Dressing Masculine to be Masculine.

Body image research focuses almost exclusively on women or overweight and obesity or both. Yet, body image concerns among thin men are common and can result, at least in part, from mixed messages in society around how men qua men should dress and behave in order to look good and feel good. Stand-alone interventions to meet these different messages tend to provide men with little therapeutic relief. This conceptual paper draws on literature from the medical humanities; gender and body image studies; the social psychology of clothing; and the author's own lived experience to address this contemporary problem. The paper embraces visual culture as a resource that can frame discussion of how two sets of 'performativity' might reduce male anxiety about thinness. First, thin men could choose repeatedly to wear masculine-looking clothing, which could create their masculinity as a personal aesthetic that strengthens the confidence to harness masculine traits in healthy ways. Secondly, health and allied health service providers could promote and reinforce such dress behavior by offering advice that integrates aesthetic and functional aspects of clothing. Empirical studies are needed to test this dual model of performativity.

Psychological preconditions for flourishing through ultrabilitation: a descriptive framework.

Purpose: Rehabilitation is commonly portrayed as care that seeks to enable persons who are disabled to recover as normal a state of well-being as their personal and social circumstances allow. In contrast, this article frames psychological preconditions for persons living with disabilities to flourish toward, around or even beyond recovery through health care provision before, during or after injury.Method: This conceptual article uses reasoning and creative word play, informed by experience and literature from disciplines including psychology and philosophy.Results: Ultrabilitation promotes seven psychological preconditions of flourishing by persons with disabilities. These interconnected conditions are: apprehension; appetite; "attitude"; ambiguity; autonomy; accountability and ambiopia.Conclusions: Clinicians could partner with persons living with disabilities to promote these mental preconditions for flourishing, and use ultrabilitation to resist potentially destabilizing forces such as social imperatives to recovery and normalcy.Implications for rehabilitationClinicians can support persons with disabilities to optimize mental states that enable them to flourish in everyday life.Apprehension, including awareness of and anxiety about disability and its management, can motivate persons to assent to capabilities to flourish.Apprehension and ambiguity can feed an appetite for personal growth and an attitude that trusts in genuine possibilities for growth through autonomy and accountability.Autonomy frees persons to accept what they cannot change; set and implement challenging but achievable goals in creative ways; and learn to lose control without viewing disability as something that they need to get beyond in order to flourish.

What Happens at Work Comes Home.

Emergency responders (police, fire, ambulance and defence force personnel) risk exposure to dangerous and traumatic events, and the possible subsequent development of post-traumatic stress disorder. Consequently, partners of these emergency responders risk developing secondary traumatic stress (STS) from vicarious exposure to the trauma through communication and engagement with their responders. A mixed-methods study of the partners of emergency responders in New Zealand examined the extent of such partner-associated STS. This article focuses on two research questions: to what extent were risk factors for STS identified within that population, and what did the participants believe may help them to mitigate the impact of STS. An online anonymous survey was developed and eligible participants completed a 17-item STS scale, a social support measure, and answered several open-ended questions. Of the 646 participants, twenty percent appear to be experiencing intrusion, arousal, and avoidance symptoms related to the trauma experienced by their responder. Almost half stated they have little or no emotional/informational support related to their responder's work. Thematic analysis of free-text responses identified the need for additional support and more direct communication/engagement from the organisations for partners to navigate their experiences of STS and the level of social support received and required. The authors conclude with recommendations to emergency responder organisations.

Something in nothing: negative space in the clinician-patient relationship.

Clinicians can easily miss the importance of how what is not present gives depth, perspective, and clues to the real meaning of social action in clinical encounters. This essay addresses examples of commonly overlooked forms of this concept of negative space in the clinician-patient relationship. The examples are negative physical space, which denotes the physical distances that separate clinicians and patients during face-to-face encounters; negative communicative space, which refers to how nonverbal and verbal communication can signify information not exchanged during these visits; and negative longitudinal space, which describes pauses over time and includes what is not said between clinicians and patients between visits. Discussed is how the awareness of these different spaces helps us to let go of our preconceptions, to experience what is there rather than what we expect to find, and to use space sensitively to improve interactions with patients.

Patient error: a preliminary taxonomy.

PURPOSE: Current research on errors in health care focuses almost exclusively on system and clinician error. It tends to exclude how patients may create errors that influence their health. We aimed to identify the types of errors that patients can contribute and help manage, especially in primary care. METHODS: Eleven nominal group interviews of patients and primary health care professionals were held in Auckland, New Zealand, during late 2007. Group members reported and helped to classify types of potential error by patients. We synthesized the ideas that emerged from the nominal groups into a taxonomy of patient error. RESULTS: Our taxonomy is a 3-level system encompassing 70 potential types of patient error. The first level classifies 8 categories of error into 2 main groups: action errors and mental errors. The action errors, which result in part or whole from patient behavior, are attendance errors, assertion errors, and adherence errors. The mental errors, which are errors in patient thought processes, comprise memory errors, mindfulness errors, misjudgments, and-more distally-knowledge deficits and attitudes not conducive to health. CONCLUSION: The taxonomy is an early attempt to understand and recognize how patients may err and what clinicians should aim to influence so they can help patients act safely. This approach begins to balance perspectives on error but requires further research. There is a need to move beyond seeing patient, clinician, and system errors as separate categories of error. An important next step may be research that attempts to understand how patients, clinicians, and systems interact to cocreate and reduce errors.

Shrinking social space in the doctor-modern patient relationship: a review of forces for, and implications of, homologisation.

OBJECTIVE: Forces for modernisation appear to have led to role convergence and reduced social distances between doctors and modern patients. This review aims to document and understand this process in theory and practice, and to consider the implications for modern patients in particular but also non-modern patients and doctors. METHOD: Narrative review of published and grey literature identified from sources including electronic databases, the Internet and reference lists of retrieved works. RESULTS: Forces for role convergence between doctors and modern patients include consumerism and increased patient literacy; socio-technological changes; values convergence; increased licence for doctors to use their emotions in patient care; and structural changes in the social organisation of health care. As a result, modern patients appear to have gained more in health care than they have lost and more than have the non-modern (or less modern) patients. Doctors have lost authority and autonomy in patient care. CONCLUSION: The net impulse toward role convergence is, on balance, a positive development. The differential uptake of modernisation by patients has increased health inequalities between modern and non-modern patients. The need of doctors to accommodate these changes has contributed to a form of reprofessonalisation. PRACTICE IMPLICATIONS: A key challenge is to make available the benefits of modernisation, for example through patient education, to as many patients as possible while minimising the risk of harm. It is important therefore to elucidate and be responsive to patient preferences for modernisation, for example by enlisting the support of the modern patients in overcoming barriers to the modernisation of non-modern patients. There is also a need to support doctors as they redefine their own professional role identity.

Apophenia, unconscious bias and reflexivity in nursing qualitative research.

Nurses routinely engage in pattern recognition and interpretation in qualitative research and clinical practice. However, they risk spontaneously perceiving patterns among things that are not meaningfully related. Although all people are prone to this cognitive bias of "apophenia", nurses may be at increased risk because they commonly produce or at least use qualitative research that can be highly interpretive. Qualitative researchers have been silent on the risk of apophenia and hence on exploring how attention to apophenia could help to indicate and manage such unconscious biases. Therefore this conceptual paper suggests how, in disciplines like nursing, researchers could attend to and use reflexivity on signs of possible apophenia to help bring unconscious biases to awareness. Within safe communities of professional practice, the researchers could cooperate with trusted peers to reflect on how and why they may each perceive patterned phenomena from different perspectives. If one reason is that the researchers, for example, appear to exhibit particular unconscious biases, then dialogue could help them to become aware of, and reflect on the biases. This expansion of researchers' consciousness of bias could inform the management of apophenia and enhance the quality of qualitative research and modern nursing practice.

The Beauty in Perfect Imperfection.

Modern technologies sanction a new plasticity of physical form. However, the increasing global popularity of aesthetic procedures (re)produces normative beauty ideals in terms of perfection and symmetry. These conditions limit the semblance of freedom by people to control their own bodies. Cultural emancipation may come from principles in Eastern philosophy. These reveal beauty in authenticity, including imperfection. Wabi-sabi acclaims beauty in common irregularity, while kintsugi celebrates beauty in visible signs of repair, like scars. These principles resist pressure to medicalize dissatisfaction with healthy bodies and invite multi-sited interventions to educate taste and aesthetic choices.

Psychosomatic Associations Between Thinking Patterns and Parkinson's Disease from a Yoga Philosophy Perspective: A New Zealand Cross-Sectional Study.

When investigating the etiology of diseases, epidemiological observational studies traditionally deemphasize psychosomatic associations. Exploring cognitive behavior provides an insight into how psychosomatic associations affect disease. Yoga philosophy identifies the kleshas (mental afflictions) of ignorance, ego, desire, hatred, and fear of death with disease. This is because individuals' perceptions and beliefs generate and reflect streams of thought that may shape their behavior and manifest as, or predispose them to, particular disease(s). The present study takes a yogic philosophical perspective to help elucidate unexplored associations between thinking about different aspects of life and the severity of Parkinson's disease (PD). The study involved a cross-sectional sample survey. Parkinson's New Zealand selected a random sample of 990 of its members. A self-completed questionnaire was sent to them. It asked questions about how often, over the previous 4 weeks, they had thought about 18 aspects of life commonly associated with the kleshas. A completed questionnaire was returned by 319 people (32%). Respondents thought most about family (87%), health (64%), rest and sleep (57%), food (53%), and the future (52%). They reported thinking least about work (48%), sex (45%), death (42%), and being virtuous (39%). A weak, but hypothesized positive, association (r = 0.2, p < 0.000) was detected between PD severity and thinking about death. The study could not determine whether thinking about death was (1) a cause or consequence of PD severity, and (2) a premorbid behavior. However, the possibility that stress associated with thinking about death accelerates PD progression is consistent with yoga philosophy and with neurophysiological mechanisms associated with the psychosomatic connections. The findings are worthy of future testing. A retrospective cohort study and qualitative research could deepen understanding about the role of kleshas in PD.

Ultrabilitation: beyond recovery-oriented rehabilitation.

PURPOSE: Current rehabilitation models emphasize therapy that attempts to return to "normal" the lives of persons who are disabled. An opportunity is available to scrutinize whether this recovery orientation of rehabilitation is necessarily optimal. METHOD: This conceptual article uses reasoning, informed by experience and a nonsystematic review of literature across diverse disciplines. RESULTS: For some persons with disability, optimizing recovery might be unwanted or insufficient. To expand rehabilitation, we append the Latin "ultra", beyond, to "habilitare", make fit. The resulting term, "ultrabilitate", commits to human flourishing that moves persons toward, around or beyond recovery of particular functioning. CONCLUSIONS: By expanding the scope of disability management, ultrabilitation could inform therapy selection and facilitate human flourishing. Empirical research is needed to test our ideas. Implications for rehabilitation Despite significant progress, rehabilitation limits some people with disabilities. Modern health systems still benchmark therapy for rehabilitation against "normal" or species-typical standards to aid recovery. "Ultrabilitation", meaning "beyond fitness", promotes flourishing, either without an interest in recovery or in moving toward, beyond or around recovery. Biological, social and technological conditions are needed to support ultrabilitation. Ultrabilitation complements rehabilitation when rehabilitation is not sufficient to optimize functioning and personal growth.

Medicines reclassification from a pharmaceutical industry perspective: An international qualitative study.

BACKGROUND: Widening access to medicines through reclassification ('switching') of medicines from prescription to non-prescription is an international trend generally welcomed by community pharmacists. Research has focused on scheduling and committee deliberations affecting reclassification, rather than industry aspects, despite industry's role in driving reclassifications. The research aimed to identify how pharmaceutical industry and product-related factors influence reclassification, and to explore stakeholder acceptability of government or third-party driven reclassifications. METHODS: Sixty-five in-depth, semi-structured interviews were conducted with 80 key informants (including representatives from regulatory bodies, industry, pharmacy and medicine) in developed countries including the United States, the United Kingdom, Japan, Australia, and New Zealand. The questions explored barriers and enablers to reclassification at the local (micro-), regional (meso-) and global (macro-) levels. Analysis of transcribed interviews entailed descriptive and thematic approaches. RESULTS: Pharmaceutical industry decisions to drive medicine reclassification reflect characteristics of the company, product, and external environment at all levels. For the company, financial factors, company focus (e.g. on prescription business versus non-prescription business), and capability in non-prescription medicines and reclassification were common influences. Products with significant non-prescription market potential and a well-known prescription medicine brand name most suited reclassification, usually near patent expiry. Barriers included immediate generic entry post-reclassification, and a short-term profitability and/or prescription business focus. Some countries allow government or a third-party (including pharmacy) to drive reclassifications, with examples of successful reclassifications ensuing. Some industry and other participants held concerns about this practice, particularly in the United States. Concerns included insufficient resourcing, and the pharmaceutical company's business, potentially encouraging product withdrawal or legal challenge. CONCLUSIONS: This study is the first to explore both pharmaceutical industry factors affecting reclassification and acceptability of alternate drivers of reclassification. Factors beyond clinical safety and efficacy and the local reclassification environment can influence reclassification. Pharmacy-driven reclassification might be one alternative.

Interactions between persons-Knowledge, decision making, and the co-production of practice.

There is now broad agreement that ideas like person-centred care, patient expertise and shared decision-making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice. Rather, their incorporation into our thinking and planning of health and social care is essential if we are to respond adequately to the problems that confront us: they need to be seen not as "ethical add-ons" but core components of any genuinely integrated, realistic and conceptually sound account of healthcare practice. This, the tenth philosophy thematic edition of the journal, presents papers conducting urgent research into the social context of scientific knowledge and the significance of viewing clinical knowledge not as something that "sits within the minds" of researchers and practitioners, but as a relational concept, the product of social interactions. It includes papers on the nature of reasoning and evidence, the on-going problems of how to 'integrate' different forms of scientific knowledge with broader, humanistic understandings of reasoning and judgement, patient and community perspectives. Discussions of the epistemological contribution of patient perspectives to the nature of care, and the crucial and still under-developed role of phenomenology in medical epistemology, are followed by a broad range of papers focussing on shared decision-making, analysing its proper meaning, its role in policy, methods for realising it and its limitations in real-world contexts.