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Table of Contents for Health. List of articles from both the latest and ahead of print issues.
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A new kind of gatekeeper: The increasing prevalence of Advanced Practice Nurses as case managers in US hospitals

mer, 12/16/2020 - 08:35
Health, Ahead of Print.
Case management is a representation of managed care, cost-containment organizational practices in healthcare, where managed care and its constitutive parts are situated against physician autonomy and decision-making. As a professional field, case management has evolved considerably, with the role recently taken up increasingly by Advanced Practice Nurses in various health care settings. We look at this evolution of a relatively new work task for Advanced Practice Nurses using a countervailing powers perspective, which allows us to move beyond discussions of case management effectiveness and best practices, and draw connections to trends in the social organization of healthcare, especially hospitals. We evaluated organizational (hospital-level) and environmental (county and state-level) characteristics associated with hospitals’ use of Advanced Practice Nurses as case managers, using data from U.S. community acute care hospitals for 2016–2018, collected from three data sources: American Hospital Association annual survey (AHA), Centers for Medicare and Medicaid Services (CMS), and Area Resource File. Among organizational characteristics, we found that hospitals that are a part of established Accountable Care Organizations (OR = 2.55, p = 0.009; 95% CI = 1.26–5.14) and those that serve higher acuity patients, as indicated by possessing a higher Case Mix Index (OR = 1.32, p = 0.001; 95% CI = 1.13–1.55), were more likely to use Advanced Practice Nurses as case managers. Among environmental characteristics, having higher local Advanced Practice Nurses concentrations (OR = 1.24, p < 0.001; 95% CI = 1.11–1.39) was associated with hospital Advanced Practice Nurses case management service provision. Beyond the health impacts of Covid-19, its associated recession is placing families, governments and insurers under unprecedented financial stress. Governments and insurers alike are looking to reduce costs anywhere possible. This will inevitably result in increasing amounts of managed care, and decreasing reimbursements to hospitals, likely resulting in higher demand for APRN patient navigators.
Catégories: Santé Publique

‘To more than I can be’: A phenomenological meta-ethnography of singing groups for people with chronic obstructive pulmonary disease

mar, 12/15/2020 - 09:56
Health, Ahead of Print.
Anecdotal experience and qualitative accounts suggest that singing groups, classes or choirs specifically for people with COPD (henceforth referred to as COPD-SGs) are effective in improving health. However, this is not reflected in the quantitative evidence. This meta-ethnography deployed phenomenological methods to explore this discrepancy. Analysis identified the phenomena of being together, being uplifted and being involved as central benefits of COPD-SGs. When viewed through the phenomenological lens of body-social as distinct from body-subject and body-object, findings demonstrated that the qualitative effectiveness of COPD-SGs is greatest on a collective basis. Qualitative research into the effectiveness of COPD-SGs offers more favourable results because phenomenological approaches can identify collective benefits that quantitative methods cannot. COPD-SGs should seek to maximise these collective benefits by rediscovering their cultural and artistic heritage within the national and global Arts in Health (AiH) movement, which has long emphasised the radical creative and healing power of group activity.
Catégories: Santé Publique

Medicalisation, suffering and control at the end of life: The interplay of deep continuous palliative sedation and assisted dying

sam, 12/12/2020 - 08:06
Health, Ahead of Print.
Medicalisation is a pervasive feature of contemporary end of life and dying in Western Europe and North America. In this article, we focus on the relationship between two specific aspects of the medicalisation of dying: deep continuous palliative sedation until death and assisted dying. We draw upon a qualitative interview study with 29 health professionals from three jurisdictions where assisted dying is lawful: Flanders, Belgium; Oregon, USA; and Quebec, Canada. Our findings demonstrate that the relationship between palliative sedation and assisted dying is often perceived as fluid and complex. This is inconsistent with current laws as well as with ethical and clinical guidelines according to which the two are categorically distinct. The article contributes to the literature examining health professionals’ opinions and experiences. Moreover, our findings inform a discussion about emergent themes: suffering, timing, autonomy and control – which appear central in the wider discourse in which both palliative sedation and assisted dying are situated, and which in turn relate to the wider ideas about what constitutes a ‘good death’.
Catégories: Santé Publique

The patient as a policy problem: Ambiguous perceptions of a critical interface in healthcare

mer, 12/09/2020 - 07:07
Health, Ahead of Print.
The interface between the patient and the health service has changed, which constitutes a potential problem for various policy-makers. Using a critical policy perspective and drawing on the theory of problem framing, this paper explores how actor groups with different responsibilities perceive the patient as a constructed policy problem. This is a qualitative study where data consists of single episode interviews with healthcare politicians, senior administrators, service strategists, and unit mangers from one regional health authority in Sweden. A thematic content analysis of the interviews was carried out in accordance with “the framework approach”. The study illustrates how the actors interpret their reality using diverse problem frames. This becomes more visible when the framing is disentangled with regard to what perspective they employ in relation to different accounts: society or the individual, or the (healthcare) system or the (healthcare) professional. The actor groups are part of the same institutional context, which explains certain tendencies of similarities in terms of the accounts being used, but still they approach the constructed problem differently which is visible as shifts—scaling up and down—between different accounts. By analyzing and structuring the various problem frames (including its policy styles) we can enhance our knowledge about how those responsible for the governance of healthcare approach the patient as a policy problem, as something that concerns only the patient and/or the provider, or as something that needs to be addressed in broader strategic terms.
Catégories: Santé Publique

Psychosocial challenges and concerns of COVID-19: A qualitative study in Iran

mar, 12/08/2020 - 07:44
Health, Ahead of Print.
As the world struggles to cope with the COVID-19 pandemic, it is critical that the psychosocial aspects related to health are attended to in addition to biological aspects. To this end, the present study aimed to explore the challenges and concerns facing people affected by COVID-19. This qualitative study was conducted using the content analysis method. A total of 25 people affected by COVID-19 were selected purposefully and administered semi-structured interviews. The sampling continued until data saturation. Coding and analysis of data were performed simultaneously using the Granheim method. After reviewing codes, checking the consistency and comparing categories, 5 categories, and 15 subcategories were explored. The most important psychosocial challenges of COVID-19 included the lack of accurate and timely dissemination of information, the intensification of economic problems, psychological instability, weakness in social prevention, and the suspension of social rituals. Identifying the psychosocial challenges and problems of people who faced by pandemic diseases such as COVID-19, and developing appropriate and timely planning for managing them can lead to designing effective strategies for prevention, treatment, and recovery of affected communities.
Catégories: Santé Publique

Enacting objects and subjects in a children’s rehabilitation clinic: Default and shifting ontological politics of muscular dystrophy care

lun, 11/02/2020 - 12:19
Health, Ahead of Print.
In health care clinics, problems are constructed through interactions, a choreography of human and non-human actors together enacting matters of concern. Studying the ways in which a body, person, family, or environment is objectified for clinical purposes opens discussion about advantages and disadvantages of different objectification practices, and exploration of creative ways to handle the diversity and tensions that exist. In this analysis, we explored objectifications in a Canadian neuromuscular clinic with young people with muscular dystrophy. This involved a close examination of clinical objectification practices across a series of 27 observed appointments. We identified the routinised clinical assessments, and argue these embed a default orientation to how to intervene in people’s lives. In this setting, the routine focused on meeting demands of daily activities while protecting the at-risk-body, and working toward an abstract sense of an independent future for the person/body with muscular dystrophy. But the default could be disrupted; through our analysis of the routine and disruptions, we highlight how contesting visions for the present and future were consequential in ways that might be more than what is anticipated within rehabilitation practice.
Catégories: Santé Publique

“This is what the truth is”: Provider-patient interactions serving as barriers to contraception

ven, 10/30/2020 - 13:00
Health, Ahead of Print.
Contraception is a vital component of women’s reproductive health, but not all women use it consistently and effectively. Many studies explore individual-level barriers to contraceptive use, yet interactional barriers are important to understand since contraception is primarily obtained through provider-patient interactions. Thus, through interviews with 86 women and 51 providers in the United States, we employ a framework of biomedicalization to study how such interactions, including the knowledge bases that inform them, shape women’s contraceptive decision-making. We find that when women’s embodied knowledge and providers’ biomedical knowledge differ, providers’ preferences supersede women’s. Providers, however, overlook this hierarchy, instead viewing their relationships with patients as empowering equal partnerships. This pattern precludes women from achieving their desired contraceptive method and highlights the process through which women’s concerns become barriers to contraceptive use. Moreover, these findings reflect how provider-patient hierarchies continue to thrive despite purported patient-centered care models.
Catégories: Santé Publique

Disciplining empathy: Differences in empathy with U.S. medical students by college major

mar, 10/20/2020 - 08:43
Health, Ahead of Print.
Citing their students’ low levels of empathy, medical educators have scrambled to implement curricula with the hopes of buffering against the corrosive effects of biomedical and clinical experiences in medical school. The assumption undergirding these studies by social scientists and medical educators alike is that immersion in biomedical education and clinical experience erodes students’ empathic capacities, and that exposure to humanities and social sciences content will amend these losses. But we do not know if this assumption is correct. In this project, we empirically assess this assumption by utilizing a unique data set constructed from student applicant and survey data from the American Medical College Application Service (AMCAS) and the Association of American Medical Colleges (AAMC). We test whether medical school students (N = 8255) from the United States (U.S.) with different academic backgrounds represented by their college major have different levels of empathy, net of demographic control variables. We report two findings. First, we find that students who majored in humanities or interpretive social sciences disciplines have higher empathy scores than their peers who majored in the positivistic social sciences and STEM (science, technology, engineering, and mathematics) disciplines. Second, we find that the relationship between empathy and time in medical school is more nuanced than we would expect from the existing literature.
Catégories: Santé Publique

Examining the language demands of informed consent documents in patient recruitment to cancer trials using tools from corpus and computational linguistics

mar, 10/13/2020 - 10:59
Health, Ahead of Print.
Obtaining informed consent (IC) is an ethical imperative, signifying participants’ understanding of the conditions and implications of research participation. One setting where the stakes for understanding are high is randomized controlled trials (RCTs), which test the effectiveness and safety of medical interventions. However, the use of legalese and medicalese in ethical forms coupled with the need to explain RCT-related concepts (e.g. randomization) can increase patients’ cognitive load when reading text. There is a need to systematically examine the language demands of IC documents, including whether the processes intended to safeguard patients by providing clear information might do the opposite through complex, inaccessible language. Therefore, the goal of this study is to build an open-access corpus of patient information sheets (PIS) and consent forms (CF) and analyze each genre using an interdisciplinary approach to capture multidimensional measures of language quality beyond traditional readability measures. A search of publicly-available online IC documents for UK-based cancer RCTs (2000-17) yielded corpora of 27 PIS and 23 CF. Textual analysis using the computational tool, Coh-Metrix, revealed different linguistic dimensions relating to the complexity of IC documents, particularly low word concreteness for PIS and low referential and deep cohesion for CF, although both had high narrativity. Key part-of-speech analyses using Wmatrix corpus software revealed a contrast between the overrepresentation of the pronoun ‘you’ plus modal verbs in PIS and ‘I’ in CF, exposing the contradiction inherent in conveying uncertainty to patients using tentative language in PIS while making them affirm certainty in their understanding in CF.
Catégories: Santé Publique

The transdisciplinary health research apparatus: A Baradian account of knowledge boundaries and beyond

sam, 10/03/2020 - 09:20
Health, Ahead of Print.
This paper engages with new materialist theory to reimagine transdisciplinary health research. In particular, we draw upon Karen Barad’s theory of agential realism and concept of apparatus to rethink the processes of doing transdisciplinary research. A Baradian inspired approach to transdisciplinarity encourages us to not only explore ways of knowing health phenomena differently by working across disciplines, but also to pay close attention to the politics and practices in such research. We offer a case study based on a two-year transdisciplinary research project focused on the health condition known as Low Energy Availability (LEA) in sportswomen. Through this case we highlight three key ways that Barad’s concept of apparatus helped us know transdisciplinarity differently: (1) Reading disciplines through each other, (2) Intra-actions and the everyday performativity of disciplinary boundaries, and (3) Troubling the boundaries of the apparatus. Ultimately this paper illustrates the value in feminist new materialist conceptual tools for encouraging different questions of transdisciplinary research as ethico-onto-epistemological practices, processes, and politics of knowledge production.
Catégories: Santé Publique

Exiting Alcoholics Anonymous disappointed: A qualitative analyses of the experiences of ex-members of AA

mer, 09/30/2020 - 09:38
Health, Ahead of Print.
Alcoholics Anonymous (AA) is an NGO designed to support anyone who identifies as alcoholic to stop drinking alcohol. Existing qualitative research in this field has primarily reflected the experiences of those who have conformed to AA ideology and had positive experiences in AA. To address this, the current study aimed to explore the perspectives and experiences of individuals who have left AA with some degree of disappointment. The study involved semi-structured interviews with 11 ex-members of AA from America, Australia, and England, who were recruited from several private social media platforms. The study used an interactionist conception of social career involving conversion and deconversion, and data were analyzed thematically. Findings included that while participants experienced some genuinely positive aspects of AA, they retrospectively believed that they remained in AA because they had been indoctrinated into a particular way of understanding themselves. Moreover, findings highlighted participants’ concerns with the people, ideology and practices within AA that ultimately led to their dissociation from the community. Our findings demonstrate a disparity between the idealistic principles in AA and the actual experiences of participants, and this is discussed in relation to the breadth of possible experiences across varying groups and AA’s unregulated peer-to-peer framework.
Catégories: Santé Publique

Mass media and communication interventions to increase HIV testing among gay and other men who have sex with men: Social marketing and visual design component analysis

sam, 09/19/2020 - 12:58
Health, Ahead of Print.
Mass media and communication interventions can play a role in increasing HIV testing among gay, bisexual and other men who have sex with men (GBMSM). Despite the key role of social marketing principles and visual design within intervention development of this type, evidence is limited regarding interventions’ social marketing mix or visual design. As part of a systematic review, intervention content was assessed using social marketing theory and social semiotics. Data were extracted on the nature of the intervention, mode of delivery, use of imagery, content and tone and the eight key characteristics of social marketing. Data were synthesised narratively. Across the 19 included studies, reference to social marketing principles was often superficial. Common design features were identified across the interventions, regardless of effectiveness, including: the use of actors inferred to be GBMSM; use of ‘naked’ and sexually explicit imagery; and the use of text framed as statements or instructions. Our results suggest that effective interventions tended to use multiple modes of delivery, indicating high social marketing complexity. However, this is only part of intervention development, and social marketing principles are key to driving the development process. We identified consistent aspects of intervention design, but were unable to determine whether this is based on evidence of effectiveness or a lack of originality in intervention design. An openness to novel ideas in design and delivery is key to ensuring that evidence-informed interventions are effective for target populations.
Catégories: Santé Publique