Marilyn Swinton

Women's Care-Seeking Experiences After Referral for Postpartum Depression

This qualitative descriptive study explored womens care-seeking experiences after referral for postpartum depression. Interviews with 18 participants revealed individual-, social network—, and health system—related factors that hindered and facilitated care seeking. Womens normalizing of symptoms, limited understanding of postpartum depression, waiting for symptom improvement, discomfort discussing mental health concerns, and fears deterred care seeking; symptom awareness and not feeling like oneself were facilitating influences. Family and friends sometimes hindered care seeking because they, too, normalized symptoms or had limited understanding of postpartum depression. Care seeking was facilitated when women encouraged a health professional visit or expressed worry and concern. Health system barriers included normalizing of symptoms, offering of unacceptable interventions, and disconnected care pathways. Care seeking was facilitated by having established and supportive relationships, outreach and follow-up, legitimization of postpartum depression, and timeliness of care. These findings can be used to guide clinical practice and service provision.

Alternatives to Project-specific Consent for Access to Personal Information for Health Research: What Is the Opinion of the Canadian Public?

OBJECTIVES This study sought to determine public opinion on alternatives to project-specific consent for use of their personal information for health research. DESIGN The authors conducted a fixed-response random-digit dialed telephone survey of 1,230 adults across Canada. MEASUREMENTS We measured attitudes toward privacy and health research; trust in different institutions to keep information confidential; and consent choice for research use of ones own health information involving medical record review, automated abstraction of information from the electronic medical record, and linking education or income with health data. RESULTS Support was strong for both health research and privacy protection. Studying communicable diseases and quality of health care had greatest support (85% to 89%). Trust was highest for data institutes, university researchers, hospitals, and disease foundations (78% to 80%). Four percent of respondents thought information from their paper medical record should not be used at all for research, 32% thought permission should be obtained for each use, 29% supported broad consent, 24% supported notification and opt out, and 11% felt no need for notification or consent. Opinions were more polarized for automated abstraction of data from the electronic medical record. Respondents were more willing to link education with health data than income. CONCLUSIONS Most of the public supported alternatives to study-specific consent, but few supported use without any notification or consent. Consent choices for research use of ones health information should be documented in the medical record. The challenge remains how best to elicit those choices and ensure that they are up-to-date.

Prophylactic antibiotic regimens in tumour surgery (PARITY): protocol for a multicentre randomised controlled study

Introduction Limb salvage with endoprosthetic reconstruction is the standard of care for the management of lower-extremity bone tumours in skeletally mature patients. The risk of deep postoperative infection in these procedures is high and the outcomes can be devastating. The most effective prophylactic antibiotic regimen remains unknown, and current clinical practice is highly varied. This trial will evaluate the effect of varying postoperative prophylactic antibiotic regimens on the incidence of deep infection following surgical excision and endoprosthetic reconstruction of lower-extremity bone tumours. Methods and analysis This is a multicentre, blinded, randomised controlled trial, using a parallel two-arm design. 920 patients 15 years of age or older from 12 tertiary care centres across Canada and the USA who are undergoing surgical excision and endoprosthetic reconstruction of a primary bone tumour will receive either short (24 h) or long (5 days) duration postoperative antibiotics. Exclusion criteria include prior surgery or infection within the planned operative field, known colonisation with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus at enrolment, or allergy to the study antibiotics. The primary outcome will be rates of deep postoperative infections in each arm. Secondary outcomes will include type and frequency of antibiotic-related adverse events, patient functional outcomes and quality-of-life scores, reoperation and mortality. Randomisation will be blocked, with block sizes known only to the methods centre responsible for randomisation, and stratified by location of tumour and study centre. Patients, care givers and a Central Adjudication Committee will be blinded to treatment allocation. The analysis to compare groups will be performed using Cox regression and log-rank tests to compare survival functions at α=0.05. Ethics and dissemination This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB# 12-009). Successful completion will significantly impact on clinical practice and enhance patients’ lives. More broadly, this trial will develop a network of collaboration from which further high-quality trials in Orthopaedic Oncology will follow.

Use of a daily goals checklist for morning ICU rounds: a mixed-methods study.

Objective:To understand the perspectives and attitudes of ICU clinicians about use of a daily goals checklist on rounds. Design:Our three data collection methods were as follows: 1) Field observations: two investigators conducted field observations to understand how and by whom the daily goals checklist was used for 80 ICU patient rounds over 6 days. 2) Document analysis: The 72 completed daily goals checklists from observed rounds were analyzed using mixed methods. 3) Interviews: With 56 clinicians, we conducted semistructured individual and focus-group interviews, analyzing transcripts using a qualitative descriptive approach and content analysis. Triangulation was achieved by a multidisciplinary investigative team using two research methods and three data sources. Setting:Fifteen bed closed ICU in a tertiary care, university-affiliated hospital. Patients:Medical-surgical ICU patients. Interventions:None. Measurements and Main Results:Field observations: The daily goals checklist was completed for 93% of observed rounds, largely by residents (86%). The champion of the verbal review was commonly a resident (83%) or medical student (9%). Document analysis: Domains with high completion rates included ventilation, sedation, central venous access, nutrition, and various prophylactic interventions. Interviews: The daily goals checklist enhanced communication, patient care, and education. Nurses, physicians, and pharmacists endorsed its enhancement of interdisciplinary communication. It facilitated a structured, thorough, and individualized approach to patient care. The daily goals checklist helped to identify new patient care issues and sparked management discussions, especially for sedation, weaning, and medications. Residents were prominent users, finding served as a multipurpose teaching tool. Conclusions:The daily goals checklist was perceived to improve the management of critically ill patients by creating a systematic, comprehensive approach to patient care and by setting individualized daily goals. Reportedly improving interprofessional communication and practice, the daily goals checklist also enhanced patient safety and daily progress, encouraging momentum in recovery from critical illness. Daily goals checklist review prompted teaching opportunities for multidisciplinary learners on morning rounds.

Sensibility assessment of the HIV Disability Questionnaire

Purpose: Our purpose was to assess the sensibility of the human immunodeficiency virus (HIV) Disability Questionnaire (HDQ), the first HIV-specific disability questionnaire. Methods: We administered the HDQ, a sensibility questionnaire and a structured qualitative interview to 22 adults living with HIV and five experienced clinicians. We considered the HDQ sensible if median scores on the sensibility questionnaire were ≥5 for adults living with HIV and ≥4 for clinicians for at least 80% of the items. We analyzed the interview data using directed qualitative content analytical techniques. Results: Questionnaire scores were ≥5 for 88% (15/17) of the items and ≥4 for 100% (17/17) of the items for adults living with HIV and clinicians, respectively. The interview analysis indicated participants felt the HDQ possessed face and content validity in all disability dimensions, had adequate response options, was easy to complete, and adequately captured the episodic nature of disability. Participants had mixed responses about the questionnaire title and provided recommendations to refine item wording and response options. Conclusions: The HDQ appears sensible for use with adults living with HIV. Next steps include further measurement property assessment. The HDQ may be used by rehabilitation clinicians and researchers to assess disability experienced by adults living with HIV. Implications for Rehabilitation As people with HIV infection live longer, individuals may face a range of health-related challenges due to the disease, concurrent health conditions and the potential adverse effects of treatment. Together, these health-related challenges may be termed disability. The HIV Disability Questionnaire (HDQ) is the first HIV-specific instrument developed to describe the presence, severity and episodic nature of the disability experienced by adults living with HIV. The HDQ is comprised of four domains including symptoms and impairments, uncertainty about future health, difficulties carrying out day-to-day activities, and challenges to social inclusion. The HDQ appears sensible for use with adults living with HIV, possessing face and content validity and ease of use in all four domains as well as describing the daily episodic nature of disability. The HDQ may be used by rehabilitation clinicians and researchers to assess disability experienced by adults living with HIV.

The Ontario Mother and Infant Study (TOMIS) III: a multi-site cohort study of the impact of delivery method on health, service use, and costs of care in the first postpartum year.

BackgroundThe caesarean section rate continues to rise globally. A caesarean section is inarguably the preferred method of delivery when there is good evidence that a vaginal delivery may unduly risk the health of a woman or her infant. Any decisions about delivery method in the absence of clear medical indication should be based on knowledge of outcomes associated with different childbirth methods. However, there is lack of sold evidence of the short-term and long-term risks and benefits of a planned caesarean delivery compared to a planned vaginal delivery. It also is important to consider the economic aspects of caesarean sections, but very little attention has been given to health care system costs that take into account services used by women for themselves and their infants following hospital discharge.Methods and designThe Ontario Mother and Infant Study III is a prospective cohort study to examine relationships between method of delivery and maternal and infant health, service utilization, and cost of care at three time points during the year following postpartum hospital discharge. Over 2500 women were recruited from 11 hospitals across the province of Ontario, Canada, with data collection occurring between April 2006 and October 2008. Participants completed a self-report questionnaire in hospital and structured telephone interviews at 6 weeks, 6 months, and 12 months after discharge. Data will be analyzed using generalized estimating equation, a special generalized linear models technique. A qualitative descriptive component supplements the survey approach, with the goal of assisting in interpretation of data and providing explanations for trends in the findings.DiscussionThe findings can be incorporated into patient counselling and discussions about the advantages and disadvantages of different delivery methods, potentially leading to changes in preferences and practices. In addition, the findings will be useful to hospital- and community-based postpartum care providers, managers, and administrators in guiding risk assessment and early intervention strategies. Finally, the research findings can provide the basis for policy modification and implementation strategies to improve outcomes and reduce costs of care.

Barriers to and facilitators for screening women for intimate partner violence in surgical fracture clinics: a qualitative descriptive approach

BackgroundIntimate Partner Violence (IPV) is a major health issue that involves any physical, sexual or psychological harm inflicted by a current or former partner. Musculoskeletal injuries represent the second most prevalent clinical manifestation of IPV. Health care professionals, however, rarely screen women for IPV. Using qualitative methods, this study aimed to explore the perceived barriers to IPV screening and potential facilitators for overcoming these barriers among orthopaedic surgeons and surgical trainees.MethodsWe conducted three focus groups with orthopaedic surgeons, senior surgical trainees, and junior surgical trainees. A semi-structured focus group guide was used to structure the discussions. Transcripts and field notes from the focus groups were analyzed using the qualitative software program N’Vivo (version 10.0; QSR International, Melbourne, Australia). To further inform our focus group findings and discuss policy changes, we conducted interviews with two opinion leaders in the field of orthopaedics. Similar to the focus groups, the interviews were digitally recorded and transcribed, and then analyzed.ResultsIn the analysis, four categories of barriers were identified: surgeon perception barriers; perceived patient barriers; fracture clinic barriers and orthopaedic health care professional barriers. Some of the facilitators identified included availability of a crisis team; development of a screening form; presence of IPV posters or buttons in the fracture clinic; and the need for established policy or government support for IPV screening. The interviewees identified the need for: the introduction of evidence-based policy aiming to increase awareness about IPV among health care professionals working within the fracture clinic setting, fostering local and national champions for IPV screening, and the need to generate change on a local level.ConclusionsThere are a number of perceived barriers to screening women in the fracture clinic for IPV, many of which can be addressed through increased education and training, and additional resources in the fracture clinic. Orthopaedic health care professionals are supportive of implementing an IPV screening program in the orthopaedic fracture clinic.

Experiences and Expressions of Spirituality at the End of Life in the Intensive Care Unit

Rationale: The austere setting of the intensive care unit (ICU) can suppress expressions of spirituality. Objectives: To describe how family members and clinicians experience and express spirituality during the dying process in a 21‐bed medical‐surgical ICU. Methods: Reflecting the care of 70 dying patients, we conducted 208 semistructured qualitative interviews with 76 family members and 150 clinicians participating in the Three Wishes Project. Interviews were recorded and transcribed verbatim. Data were analyzed by three investigators using qualitative interpretive description. Measurements and Main Results: Participants characterize dying as a spiritual event. Spirituality is an integral part of the life narrative of the patient before, during, and after death. Experiences and expressions of spirituality for patients, families, and clinicians during end‐of‐life care in the ICU are supported by eliciting and implementing wishes in several ways. Eliciting wishes stimulates conversations for people of diverse spiritual orientations to respond to death in personally meaningful ways that facilitate continuity and closure, and ease emotional trauma. Soliciting wishes identifies positive aspirations, which provide comfort in the face of death. The act of soliciting wishes brings clinician humanity to the fore. Wishing makes individual spiritual preferences and practices more accessible. Wishes may be grounded in spiritual goals, such as peace, comfort, connections, and tributes; they may seek a spiritually enhanced environment or represent specific spiritual interventions. Conclusions: Family members and clinicians consider spirituality an important dimension of end‐of‐life care. The Three Wishes Project invites and supports the expression of myriad forms of spirituality during the dying process in the ICU.

Prophylactic antibiotic regimens in tumour surgery (PARITY): a pilot multicentre randomised controlled trial

Objective Clinical studies of patients with bone sarcomas have been challenged by insufficient numbers at individual centres to draw valid conclusions. Our objective was to assess the feasibility of conducting a definitive multi-centre randomised controlled trial (RCT) to determine whether a five-day regimen of post-operative antibiotics, in comparison to a 24-hour regimen, decreases surgical site infections in patients undergoing endoprosthetic reconstruction for lower extremity primary bone tumours. Methods We performed a pilot international multi-centre RCT. We used central randomisation to conceal treatment allocation and sham antibiotics to blind participants, surgeons, and data collectors. We determined feasibility by measuring patient enrolment, completeness of follow-up, and protocol deviations for the antibiotic regimens. Results We screened 96 patients and enrolled 60 participants (44 men and 16 women) across 21 sites from four countries over 24 months (mean 2.13 participants per site per year, standard deviation 2.14). One participant was lost to follow-up and one withdrew consent. Complete data were obtained for 98% of eligible patients at two weeks, 83% at six months, and 73% at one year (the remainder with partial data or pending queries). In total, 18 participants missed at least one dose of antibiotics or placebo post-operatively, but 93% of all post-operative doses were administered per protocol. Conclusions It is feasible to conduct a definitive multi-centre RCT of post-operative antibiotic regimens in patients with bone sarcomas, but further expansion of our collaborative network will be critical. We have demonstrated an ability to coordinate in multiple countries, enrol participants, maintain protocol adherence, and minimise losses to follow-up. Cite this article: Bone Joint Res;4:154–162

Using Qualitative Methods to Assess the Measurement Property of a New HIV Disability Questionnaire

The purpose of this article is to describe our experience using a qualitative team approach and predetermined theoretical framework to assess sensibility of a newly developed HIV disability questionnaire. Two interviewers conducted structured qualitative interviews with 22 adults living with HIV, asking participants how well the questionnaire characterized the disability they experienced living with HIV. Data collection and analysis occurred over six stages with four analysts who met throughout. Strengths of our approach included the ability to assess the sensibility of the questionnaire from the perspective of adults living with HIV, collect and analyze data across multiple sites, establish a systematic team analytical process, and enhance rigour through multiple coding, team reflexivity, and interviewer and analyst triangulation. Challenges included increased resources required to coordinate and implement this approach, differential recruitment rates, initial divergent analytical styles, and the potential to miss emerging codes given the structured nature of the analysis. This article offers a methodological process for researchers to use a qualitative team approach with directed content analysis to assess the sensibility of a new health status questionnaire.