Sheba George

Effects of Exam-Room Computing on Clinician–Patient Communication: A Longitudinal Qualitative Study

AbstractOBJECTIVE: To evaluate the impact of exam-room computers on communication between clinicians and patients. DESIGN AND METHODS: Longitudinal, qualitative study using video-tapes of regularly scheduled visits from 3 points in time: 1 month before, 1 month after, and 7 months after introduction of computers into the exam room. SETTING: Primary care medical clinic in a large integrated delivery system. PARTICIPANTS: Nine clinicians (6 physicians, 2 physician assistants, and 1 nurse practitioner) and 54 patients. RESULTS: The introduction of computers into the exam room affected the visual, verbal, and postural connection between clinicians and patients. There were variations across the visits in the magnitude and direction of the computer’s effect. We identified 4 domains in which exam-room computing affected clinician-patient communication: visit organization, verbal and nonverbal behavior, computer navigation and mastery, and spatial organization of the exam room. We observed a range of facilitating and inhibiting effects on clinician-patient communication in all 4 domains. For 2 domains, visit organization and verbal and nonverbal behavior, facilitating and inhibiting behaviors observed prior to the introduction of the computer appeared to be amplified when exam-room computing occurred. Likewise, exam-room computing involving navigation and mastery skills and spatial organization of the exam-room created communication challenges and opportunities. In all 4 domains, there was little change observed in exam-room computing behaviors from the point of introduction to 7-month follow-up. CONCLUSIONS: Effective use of computers in the outpatient exam room may be dependent upon clinicians’ baseline skills that are carried forward and are amplified, positively or negatively, in their effects on clinician-patient communication. Computer use behaviors do not appear to change much over the first 7 months. Administrators and educators interested in improving exam-room computer use by clinicians need to better understand clinician skills and previous work habits associated with electronic medical records. More study of the effects of new technologies on the clinical relationship is also needed.

Mobilizing collective identity to reduce HIV risk among sex workers in Sonagachi, India: The boundaries, consciousness, negotiation framework

The significantly low rate of HIV infection and high rate of condom use among sex workers in Kolkata, India is partially attributable to a community-led structural intervention called the Sonagachi Project which mobilizes sex workers to engage in HIV education, formation of community-based organizations and advocacy around sex work issues. This research examines how Sonagachi Project participants mobilize collective identity and the manner in which collective identity influences condom use. Using purposive sampling methods, 46 Sonagachi Project participants were selected in 2005 for in-depth qualitative interviews. Taylor and Whittiers (Taylor, V & Whittier, N (1992). Collective identities in social movement communities: lesbian feminist mobilization. In A. Morris & C. Mueller (Eds.) Frontiers in social movement theory. New Haven, CT: Yale University Press) model of identity-formation through boundaries, consciousness and negotiation was used to interpret results. Subjects mobilized collective identity by (1) building boundaries demarcating in-group sex workers from out-group members, (2) raising consciousness about sex work as legitimate labor and the transformative change that results from program participation, and (3) negotiating identity with out-group members. This research establishes a conceptual link between the boundaries, consciousness and negotiation framework of collective identity mobilization and condom use. Condom use among sex workers is motivated by each element of the boundaries, consciousness and negotiation model: condoms mark boundaries, enunciate the consciousness that sex with clients is legitimate labor, and help negotiate the identity of sex workers in interactions with clients.

Improving communication and social support for caregivers of high-risk infants through mobile technologies

Upon leaving the hospital, parents of high-risk infants experience a variety of challenges in providing care at home. In this work, we present results from a qualitative study to understand the role of social interaction and information-sharing surrounding high-risk infants among both home caregivers and health professionals. These results demonstrate challenges in communication and social support for caregivers of these infants. Based on these results, we present design guidelines for collaborative communication technologies for this population and a prototype system design that demonstrates how these design guidelines might be met in a mobile application. Finally, we discuss how collaborative technologies can serve to improve communication with professionals as well as provide much-needed social support.

The Role of Brothels in Reducing HIV Risk in Sonagachi, India

High rates of empowerment, HIV-related knowledge, and condom use among sex workers in Sonagachi, India have been attributed to a community-led intervention called the Sonagachi HIV/AIDS Intervention Program (SHIP). In this research we examined the crucial role of brothels in the success of the intervention. In-depth, semistructured interviews were conducted with 55 participants of SHIP. The results indicate that brothels help sex workers reduce HIV risk by (a) serving as targeted sites for SHIP’s HIV intervention efforts, (b) being operated by madams (women managers of brothels) who participate in SHIP’s intervention efforts and promote healthy regimes, (c) structuring the economic transactions and sexual performances related to sex work, thus standardizing sex-related behavior, and (d) promoting community empowerment among brothel residents. Implications of these results are discussed for future efforts to replicate SHIP’s success in other sex work communities.

Culture: The missing link in health research

Culture is essential for humans to exist. Yet surprisingly little attention has been paid to identifying how culture works or developing standards to guide the application of this concept in health research. This paper describes a multidisciplinary effort to find consensus on essential elements of a definition of culture to guide researchers in studying how cultural processes influence health and health behaviors. We first highlight the lack of progress made in the health sciences to explain differences between population groups, and then identify 10 key barriers in research impeding progress in more effectively and rapidly realizing equity in health outcomes. Second, we highlight the primarily mono-cultural lens through which health behavior is currently conceptualized, third, we present a consensus definition of culture as an integrating framework, and last, we provide guidelines to more effectively operationalize the concept of culture for health research. We hope this effort will be useful to researchers, reviewers, and funders alike.

Sex and condom use in a large jail unit for men who have sex with men (MSM) and male-to-female transgenders.

Few data are available on factors contributing to sexual activity and condom use in custody settings, particularly among self-identified sexual minority prisoners. To address this gap, we undertook a study of sexual behavior and condom use of 101 randomly-selected men who have sex with men (MSM) and male-to-female transgender inmates in a segregated Los Angeles jail unit that has weekly condom access. Most survey participants (53%) reported anal sex during custody. Although 65% of these reported using condoms, 75% also reported having sex without condoms. Qualitative interviews (n=17) indicate a wide range of reasons for participating in protected and unprotected sex during custody, the use of cues within the custody environment to assess potential partners’ HIV status, and support for increased condom availability. Findings also indicate that high-risk sex occurs frequently in this unit and that condom distribution likely prevents a substantial amount of related HIV/STD risk.

Sources and Types of Social Support that Influence Engagement in HIV Care among Latinos and African Americans

The change in HIV from acute to chronic disease due to the introduction of HAART in the mid-1990s increased the importance of its successful management and imposed substantial lifestyle adjustments on HIV-positive people and their support networks. Few studies have examined the sources and types of social support and the areas of care relevant for engagement in HIV treatment among HIV-positive Latinos and African Americans. This paper reports the results of 24 semi-structured in-depth interviews that were conducted with HIV-positive African American and Latino women and men who have sex with men. Formal networks were found to be more critical for engagement in HIV-specific medical care; specifically, study participants relied primarily on health care providers for support in accessing and maintaining illness-specific care. In contrast, informal networks (family and friends) were crucial for other general subsistence care, such as emotional, household-related, and financial support.

How do low-income urban African Americans and Latinos feel about telemedicine? a diffusion of innovation analysis

Introduction. Telemedicine is promoted as a means to increase access to specialty medical care among the urban underserved, yet little is known about its acceptability among these populations. We used components of a diffusion of innovation conceptual framework to analyze preexperience perceptions about telemedicine to assess its appeal among urban underserved African Americans and Latinos. Methods. Ten focus groups were conducted with African American (n = 43) and Latino participants (n = 44) in both English and Spanish and analyzed for key themes. Results. Both groups perceived increased and immediate access to multiple medical opinions and reduced wait time as relative advantages of telemedicine. However, African Americans expressed more concerns than Latinos about confidentiality, privacy, and the physical absence of the specialist. This difference may reflect lower levels of trust in new health care innovations among African Americans resulting from a legacy of past abuses in the US medical system as compared to immigrant Latinos who do not have this particular historical backdrop. Conclusions. These findings have implications for important issues such as adoption of telemedicine, patient satisfaction, doctor-patient interactions, and the development and tailoring of strategies targeted to each of these populations for the introduction, marketing, and implementation of telemedicine.

The Effect of Urban Street Gang Densities on Small Area Homicide Incidence in a Large Metropolitan County, 1994–2002

The presence of street gangs has been hypothesized as influencing overall levels of violence in urban communities through a process of gun–drug diffusion and cross-type homicide. This effect is said to act independently of other known correlates of violence, i.e., neighborhood poverty. To test this hypothesis, we independently assessed the impact of population exposure to local street gang densities on 8-year homicide rates in small areas of Los Angeles County, California. Homicide data from the Los Angeles County Coroners Office were analyzed with original field survey data on street gang locations, while controlling for the established covariates of community homicide rates. Bivariate and multivariate regression analyses explicated strong relationships between homicide rates, gang density, race/ethnicity, and socioeconomic structure. Street gang densities alone had cumulative effects on small area homicide rates. Local gang densities, along with high school dropout rates, high unemployment rates, racial and ethnic concentration, and higher population densities, together explained 90% of the variation in local 8-year homicide rates. Several other commonly considered covariates were insignificant in the model. Urban environments with higher densities of street gangs exhibited higher overall homicide rates, independent of other community covariates of homicide. The unique nature of street gang killings and their greater potential to influence future local rates of violence suggests that more direct public health interventions are needed alongside traditional criminal justice mechanisms to combat urban violence and homicides.

'Their type of drugs': perceptions of substance use, sex and social boundaries among young African American and Latino gay and bisexual men.

Studies of sexuality have increasingly shifted their attention towards understanding the social contexts that inform and organise sexual behaviour. Building on this work, we examine how substance use and sex are socially organised and meaningful activities for young African American and Latino gay and bisexual men who use substances with sex. Drawing on 30 qualitative interviews in Los Angeles and New York, we identify the ways in which social boundaries inform substance use among these young men. We find that many of them view the gay and racial/ethnic communities they belong to as differentiated by patterns of substance use. Further, they see these communities as actively constructing group boundaries through substance use, sanctioning the use of particular substances while simultaneously discouraging the use or discussion of others. For these young men, racial/ethnic and gay communities provide salient contexts in which the use of certain substances and not others is socially meaningful. Findings demonstrate the important and heretofore unrecognised ways that perceived social boundaries inform these young mens use of substances. As both protective and marginalising influences, perceptions of communities and social identities have real consequences for the sexual health of young African American and Latino gay and bisexual men.