The road to tuberculosis treatment in rural Nepal: A qualitative assessment of 26 journeys

BACKGROUND: The fact that tuberculosis can be treated with the DOTS strategy (Directly Observed Treatment, Short-course) is not enough to control the disease. Patients have to find their way to tuberculosis treatment first. To better understand the route to tuberculosis treatment in rural Nepal we interviewed twenty-six patients under treatment. METHODS: In semi-structured interviews patients shared their disease history and health seeking behaviour. The analysis focused on the encounters with the health care system before enrolment in the tuberculosis treatment program. RESULTS: Patient routes often started in the medical shop and led via intricate routes with multiple providers to facilities with higher qualified and more competent staff where tuberculosis was diagnosed. Several factors influenced the route to tuberculosis treatment. Besides known patients factors (such as severity of complaints, the ability to pay for services, availability of services and peer support for choosing a provider) specific health services factors were also identified. These included the perceived quality, costs and service level of a provider, and lack of provider initiated referral. Self referral because of waned trust in the provider was very common. In contrast, once tuberculosis was considered a possible diagnosis, referral to diagnostic testing and tuberculosis treatment was prompt. CONCLUSION: Patient routes towards tuberculosis treatment are characterised by self referral and include both private and public health care providers. Once tuberculosis is suspected referral for diagnosis and treatment is prompt. Given the importance of the private practitioners in the patient routes, quality improvement initiatives need to address not only the public sector but the private health care sector as well

Understanding human functioning using graphical models

<p>Abstract</p> <p>Background</p> <p>Functioning and disability are universal human experiences. However, our current understanding of functioning from a comprehensive perspective is limited. The development of the International Classification of Functioning, Disability and Health (ICF) on the one hand and recent developments in graphical modeling on the other hand might be combined and open the door to a more comprehensive understanding of human functioning. The objective of our paper therefore is to explore how graphical models can be used in the study of ICF data for a range of applications.</p> <p>Methods</p> <p>We show the applicability of graphical models on ICF data for different tasks: Visualization of the dependence structure of the data set, dimension reduction and comparison of subpopulations. Moreover, we further developed and applied recent findings in causal inference using graphical models to estimate bounds on intervention effects in an observational study with many variables and without knowing the underlying causal structure.</p> <p>Results</p> <p>In each field, graphical models could be applied giving results of high face-validity. In particular, graphical models could be used for visualization of functioning in patients with spinal cord injury. The resulting graph consisted of several connected components which can be used for dimension reduction. Moreover, we found that the differences in the dependence structures between subpopulations were relevant and could be systematically analyzed using graphical models. Finally, when estimating bounds on causal effects of ICF categories on general health perceptions among patients with chronic health conditions, we found that the five ICF categories that showed the strongest effect were plausible.</p> <p>Conclusions</p> <p>Graphical Models are a flexible tool and lend themselves for a wide range of applications. In particular, studies involving ICF data seem to be suited for analysis using graphical models.</p

Experience of Health Complaints and Help Seeking Behavior in Employees Screened for Depressive Complaints and Risk of Future Sickness Absence

Introduction The aim of this study was to examine the associations between on the one hand depressive complaints and risk of future sickness absence and on the other hand experience of health complaints and help seeking behavior in the working population. Methods Cross-sectional data were used from employees working in the banking sector (n = 8,498). The screening instrument included measures to examine the risk of future sickness absence, depressive complaints and help seeking behavior. Results Of employees reporting health complaints, approximately 80% had already sought help for these complaints. Experience of health complaints and subsequent help seeking behavior differed between employees with mild to severe depressive complaints and employees at risk of future sickness absence. Experience of health complaints was highest in employees identified with both concepts (69%) compared with employees identified at risk of future sickness absence only (48%) and with mild to severe depressive complaints only (57%). In those employees identified with one or both concepts and who had not sought help already, intention to seek help was about 50%. Conclusions From a screening perspective, employees who do not experience health complaints or who do not have the intention to seek help may refuse participation in early intervention. This might be a bottleneck in the implementation of preventive interventions in the occupational health setting

What is psychiatry? Co-producing complexity in mental health

What is psychiatry? Such a question is increasingly important to engage with in light of the development of new diagnostic frameworks that have wide-ranging and international clinical and societal implications. I suggest in this reflective essay that ‘psychiatry' is not a singular entity that enjoins consistent forms of critique along familiar axes; rather, it is a heterogeneous assemblage of interacting material and symbolic elements (some of which endure, and some of which are subject to innovation). In underscoring the diversity of psychiatry, I seek to move towards further sociological purchase on what remains a contested and influential set of discourses and practices. This approach foregrounds the relationships between scientific knowledge, biomedical institutions, social action and subjective experience; these articulations co-produce both psychiatry and each other. One corollary of this emphasis on multiplicity and incoherence within psychiatric theory, research and practice, is that critiques which elide this complexity are rendered problematic. Engagements with psychiatry are, I argue, best furthered by recognising its multifaceted nature

Obesity and normal birth: A qualitative study of clinician’s management of obese pregnant women during labour

Background: Currently one-fifth of women in the UK are obese. Obese, pregnant woman are at an increased risk of experiencing complications of labour and serious morbidity. However, they are also more likely to undergo medical interventions such as induction of labour and caesarean section which in themselves confer additional health risks for obese women such as wound infection and deep vein thrombosis. Reducing unnecessary interventions and increasing normal birth rates for obese women would substantially improve their postnatal health and wellbeing and reduce the burden of NHS resources required to care for them post operatively. This research aimed to explore practitioners&rsquo; experiences of and strategies for providing intrapartum care to obese women.&nbsp; Method: A qualitative methodology was adopted, focus groups and individual interviews were conducted with health professionals. Audio recordings were transcribed verbatim and data analysed using a framework approach.&nbsp; Results: Twenty-four health professionals participated; Six Consultant Obstetricians two Consultant Anaesthetists and 16 midwives. Three key themes emerged from the data: medicalisation of obese birth; promotion of normal obese birth; and the complexities and contradictions in staff attitudes and behaviours. The overall interpretation is that positive approaches to obese birth offer opportunities to promote normal birth. However, many health professionals find the provision of intrapartum care to obese women challenging, and attitudes and behaviours towards the promotion of normal birth are heterogeneous, complex and contradictory.&nbsp; Conclusion: The care of obese women during labour is generally medicalised and focussed on the associated risks. However, although there are conflicting views on how to care for obese women, some practitioners do strive to promote normality and optimise the potential for normal birth by challenging current practices and utilise some &lsquo;interventions&rsquo; in order to facilitate normality and mobility during childbirth. Obesity is a major and growing health problem and a major cause of morbidity and mortality for pregnant women. It is essential that more positive proactive guidelines are available to maximise normal birth if the postnatal health of obese women is to be improved

Healthism and the experiences of social, healthcare and self-stigma of women with higher weight

This study analyses how the discourse of healthism contributes to the social construction of weight stigma in women with higher-weight. In-depth semi-structured interviews were conducted with nine women who had undergone bariatric surgery and had lived with higher-weight during many years. A thematic analysis from a latent and constructionist perspective showed how the discourse of healthism was behind the experiences of stigma lived by the participants in the social and healthcare field. Even instances of self-stigma were found in our data. This study also illustrates how people influenced by healthism assumed individualism and the importance of body shape, core values of neoliberal consumer societies. In this way, people tended to blame women with higher-weight for their weight and to discriminate against for being far from the socially established ideal body. The findings can be useful to prevent weight stigmatization and to promote more appropriate and respectful strategies for obesity prevention and treatment