Overlooking health acculturation : a grounded theory study illustrating the complexity of intercultural consultation in Swedish primary care

Background: Intercultural consultations are perceived as complex by physicians and when asked why, ‘cultural differences’ are often mentioned. With increasing patient diversity in primary care, because of increasing global migration, there is a need to address this. Cultural competence has long been considered useful in health care, one reason being that it may aid in addressing disparities of health. Nonetheless, there is no clear agreement on how to facilitate cultural training for family medicine residents. Aim: The overall aim was to explore the physician-patient interaction in intercultural consultations in primary care, while considering how to apply the findings in a family medicine residency training context. Methods: A grounded theory approach was used for Studies I and III, in which patients with foreign backgrounds and family medicine residents were interviewed on their experiences of intercultural consultations in primary care. Analysis of the interviews also directed the aim for Study II, a systematic literature review exploring the informal curriculum of family medicine. Study IV was guided by ideas from the previous studies as it included developing and testing the use of virtual patient cases in cultural training in a family medicine context. Data was collected through semi-structured interviews and analyzed using qualitative content analysis. Finally, a core variable theory, generated through grounded theory methodology and based on data from Studies I-IV and additional material, is also proposed in this thesis. Results: The core variable theory generated in this work was labelled ‘overlooking health acculturation’ and incorporates how acculturation may take place through intercultural interactions in a primary care context but remains unrecognized. Acculturation is an established concept, but health has to the best of my knowledge so far been discussed only in terms of its outcome. This thesis argues it should also be considered a dimension and suggests the concept ‘health acculturation’ to describe changes in an individual’s external practices and internal domains, related to health and illness, when being exposed to another culture. The core variable theory was built on data from Studies I-IV. Studies I and III identified behaviors and approaches in the consultation which did not seem to facilitate mutual understanding or consider the process of acculturation. Despite general agreement that cultural competence should be part of medical training, in Swedish primary care it has not been applied in a way that residents seem to find relevant; instead, informal learning is relied on, as illustrated in Study II. Study IV showed that cultural training for family medicine residents may be facilitated through interactive virtual patient cases stimulating discussion and reflection. Conclusions: This is I believe a first attempt to outline a core variable theory of what happens in the physician-patient interaction in intercultural consultations in a Swedish primary care context. In summary, the process of acculturation was overlooked, possibly reflecting its being disregarded in residency training. To address this, three suggestions on how to facilitate cultural training for residents are proposed: discuss and disclose the informal curriculum, apply existing knowledge on informal learning and add contemporary perspectives on culture, such as the proposed ‘health acculturation’

Health-related quality of life in Huntington’s Disease patients: a comparison of proxy assessment and patient self-rating using the disease-specific Huntington’s Disease health-related quality of life questionnaire (HDQoL)

Huntington’s disease (HD) is a fatal, neurodegenerative disease for which there is no known cure. Proxy evaluation is relevant for HD as its manifestation might limit the ability of persons to report their health-related quality of life (HrQoL). This study explored patient–proxy ratings of HrQoL of persons at different stages of HD, and examined factors that may affect proxy ratings. A total of 105 patient–proxy pairs completed the Huntington’s disease health-related quality of life questionnaire (HDQoL) and other established HrQoL measures (EQ-5D and SF-12v2). Proxy–patient agreement was assessed in terms of absolute level (mean ratings) and intraclass correlation. Proxies’ ratings were at a similar level to patients’ self-ratings on an overall Summary Score and on most of the six Specific Scales of the HDQoL. On the Specific Hopes and Worries Scale, proxies on average rated HrQoL as better than patients’ self-ratings, while on both the Specific Cognitive Scale and Specific Physical and Functional Scale proxies tended to rate HrQoL more poorly than patients themselves. The patient’s disease stage and mental wellbeing (SF-12 Mental Component scale) were the two factors that primarily affected proxy assessment. Proxy scores were strongly correlated with patients’ self-ratings of HrQoL, on the Summary Scale and all Specific Scales. The patient–proxy correlation was lower for patients at moderate stages of HD compared to patients at early and advanced stages. The proxy report version of the HDQoL is a useful complementary tool to self-assessment, and a promising alternative when individual patients with advanced HD are unable to self-report

Measures of Learning, Memory and Processing Speed Accurately Predict Smoking Status in Short-term Abstinent Treatment-seeking Alcohol-dependent Individuals

Aim: Chronic cigarette smoking appears to adversely affect several domains of neurocognition in those with alcohol use disorders (AUDs). The primary goal of this study was to identify which measures commonly used to assess neurocognition in AUDs accurately predict smoking status of individuals seeking treatment of alcohol dependence. Methods: Treatment-seeking alcohol-dependent participants (ALC; n = 92) completed a comprehensive neuropsychological battery after 33 ± 9 days of abstinence. Measures significantly different between smoking and non-smoking ALC were entered as predictors in binary logistic regression and discriminant analysis models, with smoking status as the dependent variable. Results: Smoking ALC performed significantly worse than non-smoking ALC on measures assessing processing speed, auditory–verbal and visuospatial learning and memory. Using these measures as predictors, a logistic regression model accurately classified 91% of smokers and non-smokers into their respective groups overall and accounted for 68% of the variance in smoking status. The discriminant analysis confirmed the findings from the logistic regression. In smoking ALC, smoking chronicity was inversely related to performance on multiple measures after controlling for lifetime alcohol consumption. Conclusions: Measures of processing speed, learning and memory robustly predicted the smoking status of ALC with high sensitivity and specificity during early abstinence. The results identified specific measures within a comprehensive neurocognitive battery that discriminated smoking and non-smoking alcohol-dependent individuals with a high sensitivity and specificity. The association of greater smoking chronicity and poorer performance on multiple measures after control for alcohol consumption suggests that chronic smoking adds an additional burden to neurocognitive function in those with alcohol dependence

A questionnaire-based (UM-PDHQ) study of hallucinations in Parkinson's disease

Background: Hallucinations occur in 20-40% of PD patients and have been associated with unfavorable clinical outcomes (i.e., nursing home placement, increased mortality). Hallucinations, like other non-motor features of PD, are not well recognized in routine primary/secondary clinical practice. So far, there has been no instrument for uniform characterization of hallucinations in PD. To this end, we developed the University of Miami Parkinson's disease Hallucinations Questionnaire (UM-PDHQ) that allows comprehensive assessment of hallucinations in clinical or research settings.Methods: The UM-PDHQ is composed of 6 quantitative and 14 qualitative items. For our study PD patients of all ages and in all stages of the disease were recruited over an 18-month period. The UPDRS, MMSE, and Beck Depression and Anxiety Inventories were used for comparisons.Results and Discussion: Seventy consecutive PD patients were included in the analyses. Thirty-one (44.3%) were classified as hallucinators and 39 as non-hallucinators. No significant group differences were observed in terms of demographics, disease characteristics, stage, education, depressive/anxiety scores or cognitive functioning (MMSE) between hallucinators and non-hallucinators. Single mode hallucinations were reported in 20/31 (visual/14, auditory/4, olfactory/2) whereas multiple modalities were reported in 11/31 patients. The most common hallucinatory experience was a whole person followed by small animals, insects and reptiles.Conclusion: Using the UM-PDHQ, we were able to define the key characteristics of hallucinations in PD in our cohort. Future directions include the validation of the quantitative part of the questionnaire than will serve as a rating scale for severity of hallucinations

Medio-Frontal and Anterior Temporal abnormalities in children with attention deficit hyperactivity disorder (ADHD) during an acoustic antisaccade task as revealed by electro-cortical source reconstruction

<p>Abstract</p> <p>Background</p> <p>Attention Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent disorders in children and adolescence. Impulsivity is one of three core symptoms and likely associated with inhibition difficulties. To date the neural correlate of the antisaccade task, a test of response inhibition, has not been studied in children with (or without) ADHD.</p> <p>Methods</p> <p>Antisaccade responses to visual and acoustic cues were examined in nine unmedicated boys with ADHD (mean age 122.44 ± 20.81 months) and 14 healthy control children (mean age 115.64 ± 22.87 months, three girls) while an electroencephalogram (EEG) was recorded. Brain activity before saccade onset was reconstructed using a 23-source-montage.</p> <p>Results</p> <p>When cues were acoustic, children with ADHD had a higher source activity than control children in Medio-Frontal Cortex (MFC) between -230 and -120 ms and in the left-hemispheric Temporal Anterior Cortex (TAC) between -112 and 0 ms before saccade onset, despite both groups performing similarly behaviourally (antisaccades errors and saccade latency). When visual cues were used EEG-activity preceding antisaccades did not differ between groups.</p> <p>Conclusion</p> <p>Children with ADHD exhibit altered functioning of the TAC and MFC during an antisaccade task elicited by acoustic cues. Children with ADHD need more source activation to reach the same behavioural level as control children.</p

Assessing Breakpoint Values in Conservation Decision-Making: for stewardship ethics managing change

Puolen vuosisadan aikaisia maalauskokoelmahallinnon päätöksentekoprosesseja tarkasteltiin Ruotsissa sijaitsevan Skoklosterin linnan historiallisessa talomuseossa takautuvan tapaustutkimuksen ja kokeellisen tutkimusasetelman avuin, jossa Foucaultin laadullinen diskurssianalyysi suoritettiin konservointitiedon viitekehyksessä. Kirjallisista lähteistä koottuja diskurssisisältöjä analysoitiin vuosikymmenittäin vertailemalla näitä kokoelmakuntokartoitustietoihin. Konservointitapausesimerkkien avulla tutkittiin missä määrin konservointitietotaito heijastui ratkaiseviin arvoihin päätöksenteossa. Tapaustutkimus osoittaa konservointitieteen poikkitieteellisyyden olevan haaste päätöksenteolle. Historiallisissa talomuseoissa kankaalle maalatun taiteen kestävän konservoinnin turvaamiseksi tutkimus painottaa esineiden kuntotiedon jakamisen ja käytön merkitystä konservointipäätöksenteossa. Päätöksenteon tulee perustua esineiden merkityksellisyyttä vaurioittavien vahinkotekijöiden tunnistamiseen. Päätöksenteon tueksi suositellaan tutkimusasetelmien rakentamista todellisissa olosuhteissa, missä kuntoarvio-, vauriotekijä- sekä elämänkaaritekijätiedot voidaan harkinnallisesti jakaa konservointipäätöksenteon tueksi historiallisten talomuseoiden kokoelmahallinnoinnissa.Half-century of decision-making processes managing a collection of paintings on canvas were studied in a historical case-study in the historic house museum setting of Skokloster Castle in Sweden. To investigate decision-making in retrospective, an experimental research design was set up by performing a Foucauldian qualitative discourse analysis in a conservation knowledge framework. Discourse content from written sources was analyzed decade vise together with quantified collection condition survey data. Conservation examples were used as a touchstone to discuss breakpoint values reflecting conservation knowledge in decision-making. The historical review shows the challenges in decision-making acknowledging the intrinsic interdisciplinary nature of conservation-restoration. For sustainable conservation-restoration of paintings on canvas housed in historic houses, the study underlines decisions rely on shared knowledge of primary documentation on damage functions affecting significance. Study settings designed in real-life conditions are recommended to support conclusions arrived at assessing state of preservation, damage functions present and life-expectancy for shared and discerned conservation-restoration decisions in historic house museum settings

deficits in FTD and AD Standardised measurement of self-awareness Standardised measurement of self-awareness deficits in FTD and AD

ABSTRACT Background Diminished ability to perceive one&apos;s own impairments, whether cognitive or social, is common in dementia, in particular frontotemporal dementia (FTD), where &apos;lack of insight&apos; is listed as a core diagnostic feature. Yet, there is no currently accepted method for measuring insight in dementia. The most commonly used methods, which involve comparing patients&apos; opinions of their level of impairment with the opinions of care givers or close family members, are subjective and require the participation of a knowledgeable informant. Here, the authors introduce a new method that allows objective quantification of an individual&apos;s awareness of their cognitive abilities and relies upon objective bedside testing. Methods The authors administered several tests of everyday, real-world functions to patients with FTD (n¼10) and Alzheimer&apos;s disease (AD, n¼10) and to control subjects (n¼10). Prior to the tasks, participants were asked to predict their performance using a percentile-based rating system. They were also asked to estimate their performance after task completion. Differences between their self-rated and actual performances were calculated. Results Whereas the control group showed very little discrepancy between pretest predictions, post-task estimates and actual performance (mean difference of 3.9 percentile points for prediction/3.0 percentile points for post-task estimate), both patient groups overpredicted and overestimated their performance, with a significantly greater discrepancy for FTD (49.0/54.3 percentile points) than AD (27.2/28.3 percentile points). Discussion Failures of insight and self-awareness of cognitive dysfunction can be objectively measured in dementia without the assistance of an informant, which will facilitate further study of this key component of higher cognitive functioning

Circling the undefined-A grounded theory study of intercultural consultations in Swedish primary care.

Well-functioning physician-patient communication is central to primary care consultations. An increasing demand on primary care in many countries to manage a culturally diverse population has highlighted the need for improved communication skills in intercultural consultations. In previous studies, intercultural consultations in primary care have often been described as complex for various reasons, but studies exploring physician-patient interactions contributing to the understanding of why they are complex are lacking. Therefore, the aim of this study was to explore intercultural physician-patient communication in primary care consultations, generating a conceptual model of the interpersonal interactions as described by both the patients and the physicians. Using grounded theory methodology, 15 residents in family medicine and 30 foreign-born patients, the latter with Arabic and Somali as native languages, were interviewed. The analysis generated a conceptual model named circling the undefined, where a silent agreement on issues fundamental to the core of the consultation was inadequately presumed and the communicative behaviors used did not contribute to clarity. This could be a possible contributory cause of the perceived complexity of intercultural consultations. Identifying what takes place on an interpersonal level in intercultural consultations might be a first step towards building a common ground for increased mutual understanding, thereby bringing us one step closer to sharing, rather than circling the undefined