Christine Holmberg

Barriers to routine risk-score use for healthy primary care patients: survey and qualitative study.

BACKGROUND Risk scores for the primary prevention of chronic diseases in healthy adults are frequently recommended but often underused by general practitioners (GPs). The objectives of this study were to assess the use of and attitudes regarding the use of risk scores among GPs and to identify possible barriers to use. METHODS Between November 7, 2007, and April 4, 2008, 68 GPs in Berlin, Germany, participated in the survey, and 24 were additionally invited to participate in focus groups. Quantitative data were analyzed descriptively and qualitative data were analyzed according to grounded theory. RESULTS Survey data of 42 GPs indicated that physicians regularly perform risk assessments for healthy patients, although most did not use risk scores. The usefulness of risk scores was rated largely positive. Focus groups revealed some confusion about the definition of risk scores and that participants resisted general use. Barriers to risk-score use were lack of lifestyle recommendations, regulatory constraints, the patients role, and lack of accuracy. Suggestions for improvement included computerized risk prediction for multiple diseases simultaneously, better computer-generated visual presentation, and the integration of lifestyle recommendations. CONCLUSIONS The GPs perceive the routine use of risk scores as infeasible because of regulatory constraints and the nature of the physician-patient relationship. These factors need to be considered to increase risk-score use. Training of physicians could also help somewhat to overcome underuse. Use of computerized approaches that enable the prediction of risks for several chronic diseases simultaneously and improved computer-generated visual presentation may increase acceptance. Risk profiles should further be related to recommendations for health-behavior modification.

My Lived Experiences Are More Important Than Your Probabilities: The Role of Individualized Risk Estimates for Decision Making about Participation in the Study of Tamoxifen and Raloxifene (STAR)

Background: Decision-making experts emphasize that understanding and using probabilistic information are important for making informed decisions about medical treatments involving complex risk–benefit tradeoffs. Yet empirical research demonstrates that individuals may not use probabilities when making decisions. Objectives: To explore decision making and the use of probabilities for decision making from the perspective of women who were risk-eligible to enroll in the Study of Tamoxifen and Raloxifene (STAR). Methods: We conducted narrative interviews with 20 women who agreed to participate in STAR and 20 women who declined. The project was based on a narrative approach. Analysis included the development of summaries of each narrative, and thematic analysis with developing a coding scheme inductively to code all transcripts to identify emerging themes. Results: Interviewees explained and embedded their STAR decisions within experiences encountered throughout their lives. Such lived experiences included but were not limited to breast cancer family history, a personal history of breast biopsies, and experiences or assumptions about taking tamoxifen or medicines more generally. Conclusions: Women’s explanations of their decisions about participating in a breast cancer chemoprevention trial were more complex than decision strategies that rely solely on a quantitative risk–benefit analysis of probabilities derived from populations In addition to precise risk information, clinicians and risk communicators should recognize the importance and legitimacy of lived experience in individual decision making.

The perspectives of older women with chronic neck pain on perceived effects of qigong and exercise therapy on aging: a qualitative interview study

Chronic pain is prevalent in elderly populations. The goals of this study were 1) to understand the results of a randomized clinical trial – Qigong and Exercise Therapy for Elderly Patients with Chronic Neck Pain (QIBANE) – that showed no difference between qigong, exercise therapy, and no-treatment on quality of life, and 2) to understand how elderly individuals with chronic pain experience interventions of qigong and exercise therapy. A qualitative interview study was conducted with 20 QIBANE participants. Interviews asked about motivation for and expectations of trial participation, experiences with the exercise classes (qigong or exercise therapy), and changes in pain experience. Interviews were transcribed, entered into the software program ATLAS.ti, and coded thematically by two coders. Content analysis was performed. All interviewees reflected positively on their QIBANE experience and described their participation in QIBANE as helpful. However, what was discussed in both groups when they talked about “positive experiences” in the study differed between the two groups. For example, themes that emerged in the exercise-therapy group related to difficulties associated with aging and staying physically active. In the interviews with qigong group members, emergent themes related to qigong as a method that improved bodily experiences and influenced daily activities. The effects that exercise therapy and qigong have on an elderly population cannot be captured by health-related quality-of-life measurements, such as the Short Form (36) Health Survey. Broader concepts of quality of life that include the concepts of self-efficacy and positive affect may be more appropriate. The results presented in this study suggest that for this population group, the approach of patient-centered outcomes is especially pertinent in order to design meaningful intervention studies in the elderly. This means that research questions, interventions, and outcome measurements need to take into account the special situation of elderly people.

Making Predictions Computing Populations

Statistics constitute the social universe of which they are gathered. The foundation necessary to develop quantified knowledge about society is the population. If quantified knowledge changes society, the question arises on how individuals become to be represented as population. The population has to be extracted from individuals in a process that we call “populationisation.” This encompasses the development of the individual into a segment of a population through the compilation of individual data into population data and its analysis. To describe the process of populationisation, we follow a statistical risk assessment tool, the German Diabetes Risk Score, from its inception in a cohort study to its entry into the public sphere of German society. The population is extracted from individuals that function as research subjects through an identification number. Preprocessed information is entered into a dynamic database that enables its rearrangement according to main aggregates. Through populationisation, a signified is enacted that can be sliced up and that is equal in all its parts. Now predictions can be computed and fed back to society as tools of moral judgment. The acting individual and “society” are—numerically and literally!—entangled in the production and enactment of risk knowledge.

Individualised risk estimation and the nature of prevention

Statistical risk models hold substantial promise for the practice of cancer prevention by helping to identify high risk populations and subsequently guide decisions about surveillance, further testing and treatments. They have come under criticism for creating new categories of disease-free but ‘at risk’ individuals. We analysed the debate over the interpretation of risk estimates to assess the importance of these models for the practice of cancer prevention. In particular, we focused on the Gail model for breast cancer risk assessment as a case study, because it is widely used and has been promoted directly to consumers. We describe the critiques that have been offered of the Gail model for individualised risk assessment, such as that classification of a new ‘high risk’ category may increase the use of medical intervention in otherwise healthy individuals. We then analyse the primary methodological limitations of individualised risk models, which are often overlooked in the application of these models and interpretation of their results. In particular, the application of statistical risk models like the Gail model to individuals fails to acknowledge the uncertainty surrounding estimates of individual risk. Moreover, putting the focus of risk management at the individual level minimises the influence of important environmental factors on risk, such as social influences and policies that may impact behaviour or outcomes. Overall, the increasing use of individualised risk estimates for individual decision-making may obscure the fact that successful disease prevention requires intervention on all levels, including the political, social, economic and individual level.

Using the framework of corporate culture in “mergers” to support the development of a cultural basis for integrative medicine – guidance for building an integrative medicine department or service

Background An increasing number of clinics offer complementary or integrative medicine services; however, clear guidance about how complementary medicine could be successfully and efficiently integrated into conventional health care settings is still lacking. Combining conventional and complementary medicine into integrative medicine can be regarded as a kind of merger. In a merger, two or more organizations − usually companies − are combined into one in order to strengthen the companies financially and strategically. The corporate culture of both merger partners has an important influence on the integration. Purpose The aim of this project was to transfer the concept of corporate culture in mergers to the merging of two medical systems. Methods A two-step approach (literature analyses and expert consensus procedure) was used to develop practical guidance for the development of a cultural basis for integrative medicine, based on the framework of corporate culture in “mergers,” which could be used to build an integrative medicine department or integrative medicine service. Results Results include recommendations for general strategic dimensions (definition of the medical model, motivation for integration, clarification of the available resources, development of the integration team, and development of a communication strategy), and recommendations to overcome cultural differences (the clinic environment, the professional language, the professional image, and the implementation of evidence-based medicine). Conclusion The framework of mergers in corporate culture provides an understanding of the difficulties involved in integrative medicine projects. The specific recommendations provide a good basis for more efficient implementation.

Perceived outcomes of spiritual healing and explanations - a qualitative study on the perspectives of German healers and their clients

BackgroundLimited research has been conducted on contemporary spiritual healing in European countries. The aim of this article is to report how German healers and their clients experienced and perceived the outcomes of spiritual healing and which explanations they use to describe the perceived effects.MethodsSemistructured interviews and participatory observation was used to collect data from spiritual healers and their clients. Analyses were based on the methodological concept of directed qualitative content analysis. Data was analyzed using MAXQDA software, discussed and reviewed by a multidisciplinary research team consisting of medical anthropologists, medical doctors and a religious studies scholar.ResultsIn total 15 healers and 16 clients participated in this study, 24 interviews with healers, 20 interviews with clients and 8 participatory observations were analyzed. Healers and clients reported outcomes as positively perceived body sensations, increased well-being, positive emotions and symptomatic relief of medical complaints. Clients often described changes in their self-concepts and adapted life values. Explanations for perceived effects included connecting with transcendent sources, construction of meaning, as a result of the client-healer relationship, and as empowerment to make changes. Because the interviewed clients were recruited by the healers, a selection bias towards positive healing experiences is possible.ConclusionWe hypothesize that concepts of meaning construction, resource activation and the utilization of the clients’ expectations help to explain the data. Grounded in the emic perspective, we propose to use the following outcomes for further prospective studies: positive body sensations, changes of self-concepts and values, changes of medical symptoms and complaints. From the etic perspective, physical, emotional, social and spiritual wellbeing, sense of coherence, meaningfulness of life, empowerment, resource activation, change and symptom control should be further explored as potential outcomes.

Perceived challenges to public health in Central and Eastern Europe: a qualitative analysis

BackgroundThere is a major gradient in burden of disease between Central and Eastern Europe compared to Western Europe. Many of the underlying causes and risk factors are amenable to public health interventions. The purpose of the study was to explore perceptions of public health experts from Central and Eastern European countries on public health challenges in their countries.MethodsWe invited 179 public health experts from Central and Eastern European countries to a 2-day workshop in Berlin, Germany. A total of 25 public health experts from 14 countries participated in May 2008. The workshop was structured into 8 sessions of 1.5 hours each, with the topic areas covering coronary heart disease, stroke, prevention, obesity, alcohol, tobacco, tuberculosis, and HIV/AIDS. The workshop was recorded and the proceedings transcribed verbatim. The transcripts were entered into atlas.ti for content analysis and coded according to the session headings. After analysis of the content of each session discussion, a re-coding of the discussions took place based on the themes that emerged from the analysis.ResultsThemes discussed recurred across disease entities and sessions. Major themes were the relationship between clinical medicine and public health, the need for public health funding, and the problems of proving the effectiveness of disease prevention. Areas for action identified included the need to engage with the public, to create a better scientific basis for public health interventions, to identify “best practices” of disease prevention, and to implement registries/surveillance instruments. The need for improved data collection was seen throughout all areas discussed, as was the need to harmonize data across countries.ConclusionsTo reduce the burden of disease across Europe, closer collaboration of countries across Europe seems important in order to learn from each other. A more credible scientific basis for effective public health interventions is urgently needed. The monitoring of health trends is crucial to evaluate the impact of public health programmes.

Perceptions and Attitudes of Egyptian Health Professionals and Policy-Makers towards Pharmaceutical Sales Representatives and Other Promotional Activities

Background Pharmaceutical promotion activities in low and middle-income countries are often neither regulated nor monitored. While Egypt has the highest population and per capita use of medicines in the Arab world, we know very little about pharmaceutical companies promotional activities in the country. Aim To explore and analyze the perceptions of physicians towards promotional and marketing activities of pharmaceutical companies among physicians and pharmacists in Egypt. Methodology Perspectives of different healthcare system stakeholders were explored through semi-structured, in-depth interviews conducted in 2014 in Cairo, Egypt. Interviewees were chosen via purposive sampling and snowball technique. Each interview was recorded and transcribed. Then qualitative, thematic analysis was conducted with the help of NVIVO software. Findings The majority of physicians and pharmacists acknowledged exposure to pharmaceutical promotion. It was commonly believed that interaction with the pharmaceutical industry is necessary and both associated risks and benefits were acknowledged. The interviewed physicians considered themselves competent enough to minimize risks and maximize benefits to their prescribing habits. Views diverged on the extent and magnitude of the risks and benefits of pharmaceutical promotion, especially in regard to the influence on patients’ health. Conclusions Pharmaceutical promotion in Egypt is intensely directed at prescribers and dispensers. Physicians, pharmacists and policymakers expressed little skepticism to the influence of promotion towards their individual prescribing. Raising awareness of the pitfalls of pharmaceutical promotion is necessary, especially among the less experienced physicians.

No one sees the fear: becoming diseased before becoming ill--being diagnosed with breast cancer.

Background: Breast cancer patients experience profound life changes that include feelings of fear years after concluding treatment. Objective: The aim of this article was to understand the nature and origin of the persistent worry women experience after breast cancer treatment. Methods: Materials from participant observation of an oncology ward and from interviews with 17 first-time breast cancer patients, 4 oncologists, and 10 nurses were analyzed. Interpretation of materials was guided by theoretical concepts such as embodiment and liminality to understand the phenomenological aspects and cultural shaping of the illness experience. Results: Interviewees felt healthy at the time of diagnosis. It was the physician’s word that initiated the illness process through the experience of shock. Nurses’ work and therapeutic emplotment were instrumental in guiding the women to overcome the shock and engage in treatment. Study participants’ lives were restructured under biomedical conditions. This included mistrust toward their bodies. Because of the mode of diagnosis and the initial shock, long-term fear can be seen as an integral part of the experience of having had breast cancer. Conclusions: The study participants’ sense of being in the world had changed in that their bodies had become objects unto themselves, dangerous objects. Fear became part of women’s lives. To control the fear, women relied on biomedical practices to interpret bodily sensations. Implications for Practice: Therapeutic interventions and practices of care that facilitate a reconnection of trust with the (physical) body should be included in the care of posttreatment patients.