Acupuncture for menopausal hot flashes: a qualitative study about patient experiences

OBJECTIVE

The aim of this study was to describe any changes in health experienced by postmenopausal women after having acupuncture treatment for hot flashes.

MATERIALS AND METHODS

Our sample was drawn from women participating in a randomized controlled trial (ACUFLASH) investigating the effect of acupuncture on menopausal hot flashes. One hundred and twenty-seven (127) women from the intervention group who had received a course of 10 acupuncture treatments were asked to make a written statement about any kind of change they had perceived that they considered could be related to the acupuncture treatment. Qualitative data were analyzed using systematic text condensation.

RESULTS

Many women reported a substantial impact from the treatment with respect to a reduction in frequency and intensity of hot flashes both by night and by day. Changes related to improved sleep pattern were also reported, and a variety of different bodily and mental changes were described (i.e., feeling in a good mood, not so run down, and calmer). Several women were uncertain whether any changes had occurred. A few reported feeling worse.

CONCLUSIONS

Our results describe a variety of health changes that may not be revealed by limited outcome measures in acupuncture studies. Further analysis of the relationship between such bodily experiences could lead to the development of hypotheses or models for how the acupuncture effect is mediated in complex bodily systems, and also contribute to development of outcome measures relevant for acupuncture studies.

"Norwegians fear fatness more than anything else"--a qualitative study of normative newspaper messages on obesity and health

OBJECTIVE

To explore normative aspects of the Norwegian discourse on obesity.

METHODS

We conducted a qualitative study with data from five Norwegian newspapers, focusing normative entries about body weight. Discourse analysis provided a focus on the cultural attitudes when systematic text condensation was conducted. Data comprised 26 normative messages (prescriptions or comments on how obese people are or should be, messages mediating or discussing values prescribing a 'good' body).

RESULTS

Two main normative domains within the obesity discourse were identified. One group of entries warned about obesity from an aesthetic point of view, notifying the reader that beauty would suffer when weight increases, due to reduced attractiveness. These texts appealed to bodily conformity, linking leanness with attractiveness and delight, suggesting that fat people are ugly and unhappy. The other group referred to lack of control in the obese person, linking greediness to lack of responsibility and bad health. Fat people were displayed as undisciplined and greedy individuals who should be ashamed.

CONCLUSIONS

Cultural messages of blame and shame are associated with obesity, but also spreading from body weight to the very scene of life. People with obesity cannot escape this cultural context, only find a way of coping with it.

PRACTICE IMPLICATIONS

Quality care for people with obesity implies that public health and clinical medicine acknowledge the burden of cultural stigma. Developing awareness for cultural prejudices on body weight, doctors could counteract stigmatization and contribute to empowerment and health.

[Lesbian women's health-promoting experiences]

BACKGROUND

For lesbian women, we know more about causes of health problems than health-promoting factors. The aim of this study was to explore what lesbian women have perceived as health-promoting experiences.

MATERIAL AND METHODS

Focus group study with two group interviews (with nine lesbian women aged 40-55 years). Participants were required to be "out of the closet" regarding sexual orientation and to feel comfortable with their lives as lesbians. The interviews were audiotaped, transcribed, and analyzed with systematic text condensation supported by a salutogenic frame of reference.

RESULTS

The women told about how a perception of being different could translate into opportunities and a positive strength. A good "coming-out process" could lead to companionship and strategies for coping with challenges. Furthermore, feelings of exemption from expectations of a narrow gender role had a positive impact on identity and sexuality. Finally, the liberating consequences of being able to organize personal relationships and family according to own priorities opened up new possibilities, especially regarding choosing to have children or not.

INTERPRETATION

Health promoting strategies and initiatives must be grounded in what individuals consider to be important in their own lives. Knowledge about lesbians' health-promoting experiences may contribute to a positive focus on coping with minority stress and challenge an established understanding of pathology in a marginalized group.

Toward an agenda for evaluation of qualitative research

Evaluation is essential for research quality and development, but the diversity of traditions that characterize qualitative research suggests that general checklists or shared criteria for evaluation are problematic. We propose an approach to research evaluation that encourages reflexive dialogue through use of an evaluation agenda. In proposing an evaluation agenda we shift attention from rule-based judgment to reflexive dialogue. Unlike criteria, an agenda may embrace pluralism, and does not request consensus on ontological, epistemological, and methodological issues, only consensus on what themes warrant discussion. We suggest an evaluation agenda-EPICURE-with two dimensions communicated through use of two acronyms.The first, EPIC, refers to the challenge of producing rich and substantive accounts based on engagement, processing, interpretation, and (self-)critique. The second-CURE-refers to the challenge of dealing with preconditions and consequences of research, with a focus on (social) critique, usefulness, relevance, and ethics. The seven items of the composite agenda EPICURE are presented and exemplified. Features and implications of the agenda approach to research evaluation are then discussed.

Preventing obesity: challenges and pitfalls for health promotion

OBJECTIVE

To explore challenges to health promotion strategies against obesity, with special attention to the Scandinavian context.

METHODS

Analytic induction, a procedure for verifying theories and propositions, based on purposefully selected literature references, with subsequent critical reflection.

RESULTS

Health promotion efforts against obesity face challenges related to the unequal distribution of vulnerability to weight gain within the population, and to the complex neuroregulatory determinants that explain why obesity is not just a simple matter of lifestyle. Cultural understandings of identity and morality may create victim blaming and disempowerment, thus obstructing clinical health promotion strategies for weight control. Finally, the conceptual validity of obesity measurements and their predictive power deserves attention.

CONCLUSION

Preventing obesity is difficult. Awareness of individual vulnerability and neurobiological mechanisms that lead to weight gain must be taken into account when strategies for health promotion are developed. These strategies must transcend a simplistic energy balance view.

PRACTICE IMPLICATIONS

Clinical health promotion needs to be highly individualized and tailored. Preventing weight gain requires attention to the person's sociodemographic, cultural and genetic characteristics. Cultural trends such as sedentary lifestyles and the nutrition transition should be counteracted without turning body weight control into a question of morality and inferior identity.

Can sustained arousal explain the Chronic Fatigue Syndrome?

We present an integrative model of disease mechanisms in the Chronic Fatigue Syndrome (CFS), unifying empirical findings from different research traditions. Based upon the Cognitive activation theory of stress (CATS), we argue that new data on cardiovascular and thermoregulatory regulation indicate a state of permanent arousal responses - sustained arousal - in this condition. We suggest that sustained arousal can originate from different precipitating factors (infections, psychosocial challenges) interacting with predisposing factors (genetic traits, personality) and learned expectancies (classical and operant conditioning). Furthermore, sustained arousal may explain documented alterations by establishing vicious circles within immunology (Th2 (humoral) vs Th1 (cellular) predominance), endocrinology (attenuated HPA axis), skeletal muscle function (attenuated cortical activation, increased oxidative stress) and cognition (impaired memory and information processing). Finally, we propose a causal link between sustained arousal and the experience of fatigue. The model of sustained arousal embraces all main findings concerning CFS disease mechanisms within one theoretical framework.

Gender in medicine — does it matter?

Aims: A broad range of socio-cultural issues have been recognized as determinants for health and disease. A notion of gender neutrality is still alive in the medical culture, suggesting that gender issues are not relevant within this field. Methods: We have explored the claim that doctors encounter their patients as human beings, not as men or women, and discuss causes and consequences of such a claim. Results: Empirical evidence does not support such a claim — gender seems to have a strong impact on medical knowledge and practice. The concept andronormativity signifies a state of affairs where male values are regarded as normal to the extent that female values disappear or need to be blatantly highlighted in order to be recognized. We have applied this frame of reference to understand how the idea of gender neutrality has been established in medicine. The average medical practitioner, teacher, or researcher is a man. We suggest that notions of normality subtly construct gender in medicine in ways where men become normal, while women become deviant. Finally, we discuss strengths and pitfalls of three different strategies which have been used by gender researchers in health to challenge andronormativity: demonstrating gender differences, revealing the consequences of gendered power inequalities, and deconstructing the meaning of gender. Conclusions: We conclude that gender still matters in medicine.

"Couldn't you have done just as well without the screening?". A qualitative study of benefits from screening as perceived by people without a high cardiovascular risk score

OBJECTIVE

To explore how individuals whose health screening does not reveal a high cardiovascular risk score (CRS) interpret and respond to this result.

DESIGN

Qualitative semi-structured interviews. Purposeful sampling reflected variations in age, gender, and self-rated health within the sample. Analysis and interpretation were informed by the Health Belief Model concerning individuals' cues to act when told there is a health threat, and by Hollnagel and Malterud's theories about personal self-assessed health resources.

SETTING

Participants were recruited among participants without a high cardiovascular risk score in a Danish health-screening project.

SUBJECTS

Seven men and 15 women aged 36-50 years with a low or moderate cardiovascular risk score.

RESULTS

The screening confirmed the participants' feeling of being in good health and they put emphasis on this acquired peace of mind. Participants used the results to eliminate worries and confirm their lifestyle up to now but were aware that the results gave no guarantee that there was nothing the matter elsewhere. Some paid a price for the reassurance since they had to undergo further examinations, had unfulfilled expectations, or were irritated at not being left in peace with their reassurance.

CONCLUSION

Screened individuals who were shown not to have a high risk score appear to be reassured and confirmed in their own feeling of being healthy, and to be aware of the limitations of the screening. Consideration should be given to the possible risk of creating either insecurity or over-complacency through population screening.

Lesbian women's experiences with health care: a qualitative study

BACKGROUND

Although the social situation for gay, lesbian, and bisexual people has improved over the last decades, lesbian women still face unique challenges when seeking healthcare services.

OBJECTIVES

To explore lesbian women's healthcare experiences specifically related to sexual orientation to achieve knowledge which can contribute to increased quality of healthcare for lesbian women.

METHODS

Qualitative study based on written stories, with recruitment, information, and data sampling over the internet. Data consisted of 128 anonymously written answers to a web-based, open-ended questionnaire from a convenience sample of self-identified lesbian women. Data were analysed with systematic text condensation. Interpretation of findings was supported by theories of heteronormativity. Main outcome measures. Patients' histories of experiences where a lesbian orientation was significant, when seeing a doctor or another healthcare professional.

RESULTS

Analysis presented three different aspects of healthcare professionals' abilities, regarded as essential by our lesbian participants. First, the perspective of awareness was addressed--is the healthcare professional able to think of and facilitate the disclosure of a lesbian orientation? Second, histories pointed to the attitudes towards homosexuality--does the healthcare professional acknowledge and respect the lesbian orientation? Third, the impact of specific and adequate medical knowledge was emphasized--does the healthcare professional know enough about the specific health concerns of lesbian women?

CONCLUSION

To obtain quality care for lesbian women, the healthcare professional needs a persistent awareness that not all patients are heterosexual, an open attitude towards a lesbian orientation, and specific knowledge of lesbian health issues. The dimensions of awareness, attitude, and knowledge are interconnected, and a positive direction on all three dimensions appears to be a necessary prerequisite.

When doctors experience their vulnerability as beneficial for the patients: a focus-group study from general practice

OBJECTIVE

To describe events where doctors have experienced that their own sense of vulnerability might have been beneficial for the patient.

DESIGN

Qualitative focus group study with data drawn from two group sessions. Analysis was conducted with systematic text condensation.

SUBJECTS

A total of 12 GPs (five men and seven women) aged 30-68 participated. Their clinical experience ranged from one to 39 years.

MAIN OUTCOME MEASURES

Analysis presented different aspects of participants' experiences of vulnerability experienced as beneficial.

RESULTS

The participants generously shared stories about personal and professional vulnerability which they had perceived and sometimes disclosed to the patient. One cluster of stories dealt with situations where the doctors in some way or other had identified with the patient and his or her problem. They felt that their awareness and capacity for interpretation, creative solutions, and compassion had been enhanced through recognition. Another cluster of stories covered events where uncomfortable feelings due to uncertainty or inconsiderate behaviour sharpened the doctors' reflexivity towards their own roles in the interaction. Presenting an excuse or sharing the doubt could break the ice and make a difference.

IMPLICATIONS

Vulnerability may bring strength, but must be used with caution. Our study opens towards further awareness of the vulnerability of the doctor and how it can benefit the patient in some situations.

"If you cannot tolerate that risk, you should never become a physician": a qualitative study about existential experiences among physicians

BACKGROUND AND OBJECTIVES

Physicians are exposed to matters of existential character at work, but little is known about the personal impact of such issues.

METHODS

To explore how physicians experience and cope with existential aspects of their clinical work and how such experiences affect their professional identities, a qualitative study using individual semistructured interviews has analysed accounts of their experiences related to coping with such challenges. Analysis was by systematic text condensation. The purposeful sample comprised 10 physicians (including three women), aged 33-66 years, residents or specialists in cardiology or cardiothoracic surgery, working in a university hospital with 24-hour emergency service and one general practitioner.

RESULTS

Participants described a process by which they were able to develop a capacity for coping with the existential challenges at work. After episodes perceived as shocking or horrible earlier in their career, they at present said that they could deal with death and mostly keep it at a distance. Vulnerability was closely linked to professional responsibility and identity, perceived as a burden to be handled. These demands were balanced by an experience of meaning related to their job, connected to making a difference in their patients' lives. Belonging to a community of their fellows was a presupposition for coping with the loneliness and powerlessness related to their vulnerable professional position.

CONCLUSIONS

Physicians' vulnerability facing life and death has been underestimated. Belonging to caring communities may assist growth and coping on exposure to existential aspects of clinical work and developing a professional identity.

Obstructions for quality care experienced by patients with chronic fatigue syndrome (CFS)--a case study

OBJECTIVE

To explore obstructions for quality care from experiences by patients suffering from chronic fatigue syndrome (CFS).

METHODS

Qualitative case study with data drawn from a group meeting, written answers to a questionnaire and a follow-up meeting. Purposeful sample of 10 women and 2 men of various ages, recruited from a local patient organization, assumed to have a special awareness for quality care.

RESULTS

CFS patients said that lack of acknowledgement could be even worse than the symptoms. They wanted their doctors to ask questions, listen to them and take them seriously, instead of behaving degrading. Many participants felt that the doctors psychologized too much, or trivialized the symptoms. Participants described how doctors' lack of knowledge about the condition would lead to long-term uncertainty or maltreatment. Even with doctors who were supportive, it would usually take months and sometimes years until a medical conclusion would be reached, or other disorders were ruled out. Increased physical activity had been recommend, but most of the informants experienced that this made them worse.

CONCLUSION

Current medical scepticism and ignorance regarding CFS shapes the context of medical care and the illness experiences of CFS patients, who may feel they neither get a proper assessment nor management.

PRACTICE IMPLICATIONS

CFS patients' reports about patronizing attitudes and ignorance among doctors call for development of evidence based strategies and empowerment of patients, acknowledging the patients' understanding of symptoms and the complex nature of the disease. The NICE guidelines emphasize the need of patient participation and shared decision-making.

[How did health personnel perceive supervision of obstetric institutions?]

BACKGROUND

Through audits, the Norwegian Board of Health supervises and ensures that health institutions adhere to rules and regulations that apply to them. Conduct of such supervision should be predictable and the basis for decisions should be documented and challengeable. Those in charge of the supervision must have the necessary professional competence and be able to integrate and understand the collected information so they can draw the right conclusions. The audit team should demonstrate consideration and respect to those they meet during audits. We therefore wanted to study the experience of being audited among health care providers and leaders of institutions and subsequent adjustments after the audit.

MATERIAL AND METHODS

We used a questionnaire to evaluate the national audit of 26 (of 60 totally) Norwegian obstetric institutions in 2004. A questionnaire was sent to leaders and health care providers in all institutions that had been inspected (208 persons). Data from semi-structured interviews were used to validate and explore the quantitative findings.

RESULTS

89% responded to the questionnaire. The supervision was well received by leaders and health care providers at the obstetric institutions. The respondents confirmed that the audit team's approach and conduct in principle adhered to the rules within the examined domains. The conclusions presented by the audit teams were accepted as correct by most of the respondents. A large number of adjustments were reported after the audits.

INTERPRETATION

We conclude that auditing can lead to improvements and that the described programme probably contributed to improving obstetric services in Norway. The audit team's conduct seems to have an effect on acceptance of the supervision. The performance of the teams may have an impact of the acceptance of auditing, but not on reporting of the adjustments carried out.

When the helper humiliates the patient: A qualitative study about unintended intimidations

Aims: To explore experiences of intimidating patients/clients from the perspective of the professional. Methods: This was a qualitative study based on memory work, a procedure whereby memories are converted into written stories. The setting was a workshop about oppression and empowerment in a rehabilitation conference. Participants were 48 health and social professionals in six groups. Thirty-seven of the participants provided their written stories. The main outcome measures were descriptions of intimidation episodes according to the level of passivity/activity in the professional responsible for the act. Results: The participants were able to recall episodes where they later realized that they had been involved in events perceived as intimidations by the patient/client. The memory stories described events that were not isolated events, but represented issues that might occur now and then. The first type of intimidation included events where the professional intimidated the patient/client by neglecting various basic needs, such as bodily functions, information, regard, time, and patience. The second type included events where the professional patronized and overruled the patient/client by pursuing the professional's agenda, ridiculing, or only partially acknowledging, the person. Remembering and presenting these events created ideas for alternative modes of action for the professionals. Conclusions: Systems for health and social care suffer from lack of resources, time, and proximity — issues that facilitate the occurrence of intimidation of patients/clients. Yet, the professional remains responsible for his or her moral conduct. High moral awareness and systems with a better balance between reason and emotion are needed to stop vulnerable people being subjected to disempowering practices.

Stories about bodies: a narrative study on self-understanding and chronic pain

OBJECTIVE

To explore experiences from a process of change for women with chronic pain.

DESIGN, SETTING, AND SUBJECTS

A group-based treatment programme was intended to increase the awareness of how attitudes, habits and bodily practices are established, developed, and can be transformed, and thereby probably reduce pain. A single case story from this treatment programme is presented. A semi-structured interview was conducted with all participants about their experiences after completion of the programme. All eight women reported that they had benefited from participation. From these interviews a single case was chosen to represent the study's findings. A narrative analysis was conducted, focusing this patient's story from a phenomenological understanding of the body.

RESULTS

The patient's story illuminates how events and experiences can be connected, and how she interprets her contemporary situation in the light of previous experiences. In this way, she alters her understanding and develops a new approach to her situation. Her story demonstrated how symptoms can be understood as the result of stressful habits that the body has developed as a reaction to demands from the surroundings.

CONCLUSIONS

Reflection on how the body functions may lead to a new realization of how phenomena are interconnected, thus making changes possible.

Diagnostic interaction: the patient as a source of knowledge?

OBJECTIVE

To explore diagnostic interaction to understand more about why some problems appear medically unexplained.

DESIGN

A qualitative discourse analysis case study.

SETTING

Encounters between women patients and general practitioners in primary healthcare.

SUBJECTS

Microanalysis of two audiotaped consultations without a clear-cut diagnosis and opposing levels of mutuality between doctor and patient.

MAIN OUTCOME MEASURES

Descriptions of linguistic patterns in diagnostic interaction.

RESULTS

Two patterns were identified demonstrating how different ways of speech acts contribute or obstruct diagnostic interaction and common ground for understanding. To invite or reject the patient into/from the diagnostic process, and to recognize or stereotype the patient may impose on how illness stories are perceived as medically unexplained.

CONCLUSION

Making sense of illness can be enhanced by inviting and recognizing the patient's story.

Identity and coping experiences in Chronic Fatigue Syndrome: a synthesis of qualitative studies

OBJECTIVE

To provide insight into patients' and doctors' experiences with CFS.

METHODS

We compiled available qualitative studies and applied meta-ethnography to identify and translate across the studies. Analysis provided second-order interpretation of the original findings and developed third-order constructs from a line of arguments.

RESULTS

Twenty qualitative studies on CFS experiences were identified. Symptom experiences and the responses from significant others could jeopardise the patients' senses of identity. They felt severely ill, yet blamed and dismissed. Patients' beliefs and causal attributions oppose the doctor's understanding of the condition. For the patient, getting a diagnosis and knowing more was necessary for recovery. Doctors were reluctant towards the diagnosis, and struggle to maintain professional authority. For patients, experience of discreditation could lead to withdrawal and behavioural disengagement.

CONCLUSION

The identities of CFS patients are challenged when the legitimacy of their illness is questioned. This significant burden adds to a loss of previously established identity and makes the patient more vulnerable than just suffering from the symptoms. CFS patients work hard to cope with their condition by knowing more, keeping a distance to protect themselves and learning more about their limits.

PRACTICE IMPLICATIONS

Doctors can support patients' coping by supporting the strong sides of the patients instead of casting doubt upon them.

Experiences of guilt and shame in patients with familial hypercholesterolemia: a qualitative interview study

OBJECTIVE

To explore patients' experiences of guilt and shame with regard to how they manage familial hypercholesterolemia.

METHODS

We interviewed 40 men and women diagnosed with heterozygous familial hypercholesterolemia. Data were analyzed by systematic text condensation inspired by Giorgi's phenomenological method.

RESULTS

Participants disclosed their condition as inherited and not caused by an unhealthy lifestyle. They could experience guilt or shame if they violated their own standards for dietary management, or if a cholesterol test was not favorable. Participants had experienced health professionals who they felt had a moralizing attitude when counseling on lifestyle and diets. One group took this as a sign of care. Another group conveyed experiences of being humiliated in consultations.

CONCLUSION

Patients with familial hypercholesterolemia may experience guilt and shame related to how they manage their condition. Health professionals' counseling about lifestyle and diet may induce guilt and shame in patients.

PRACTICE IMPLICATIONS

Health professionals should be sensitive to a patient's readiness for counseling in order to diminish the risk of unintentionally inducing guilt and shame in patients.

The fibromyalgia diagnosis: hardly helpful for the patients? A qualitative focus group study

OBJECTIVE

To explore experiences and consequences of the process of being diagnosed with fibromyalgia.

DESIGN

Qualitative focus-group study.

SETTING

Two local self-help groups.

SUBJECTS

Eleven women diagnosed with fibromyalgia.

MAIN OUTCOME MEASURES

Descriptions of experiences and consequences of the process of being diagnosed with fibromyalgia.

RESULTS

Many participants had been suffering for years, and initial response of relief was common. For some, the diagnosis legitimized the symptoms as a disease, for others it felt better to suffer from fibromyalgia rather than more serious conditions. Nevertheless sadness and despair emerged when they discovered limitations in treatment options, respect, and understanding. Some patients keep the diagnosis to themselves since people seem to pay no attention to the name, or blatantly regard them as too cheerful or healthy looking. The initial blessing of the fibromyalgia diagnosis seems to be limited in the long run. The process of adapting to this diagnosis can be lonely and strenuous.

CONCLUSION

A diagnosis may be significant when it provides the road to relief or legitimizes the patient's problems. The social and medical meaning of the fibromyalgia diagnosis appears to be more complex. Our findings propose that the diagnosis was hardly helpful for these patients.

[Preventing failures and malfunction in general practice]

BACKGROUND

According to governmental regulations, general practitioners are responsible for identifying domains within their office procedures where failures may happen, or where rules are broken.

MATERIAL AND METHODS

Fjellsiden Health Centre has developed a simple system for prevention of professional failures, based on identification, recording and review of cases representing routine malfunction. Presuppositions, procedures, development, experiences and current functioning are described.

RESULTS AND INTERPRETATION

The annual number of reported cases varied between 12 and 52. Most cases are related to lab tests, social interaction, or confidentiality. The typical case was not a serious flaw, but could--under less fortunate conditions - have had an unacceptable lapse. We have found that this system helps us to identify weak points in our procedures. Local quality assurance can be conducted by simple methods.