A discussion of chain referral as a method of sampling hard-to-reach populations

"Stories of starting": Understanding the complex contexts of opioid misuse initiation

Background: The impacts of opioid use disorder and opioid-involved overdose are known, but less is known about the contexts in which people first misuse opioids, and the motivations for continued misuse. Methods: In-depth interviews with 26 individuals in Allegheny County, Pennsylvania with current or past histories of opioid misuse were conducted. Narratives were analyzed to understand the circumstances and influences contributing to initial and continued misuse of opioids. Results: Participants described social and familial contexts that normalized or accepted opioid misuse-this often included their own use of other illicit substances prior to initiating opioids. Participants also described initial use of opioids as related to efforts to cope with physical pain. They also described recognizing and then seeking psychological/emotional benefits from opioids. All three of these themes often overlapped and intersected in these stories of starting opioid misuse. Conclusions: Opioid misuse stemmed from complex interacting influences involving coping with physical and psychological pain, perception that opioids are needed to feel "normal", and acceptance or normalization of opioid use. This suggests a multi-pronged approach to both prevention and treatment are needed.

Withdrawn: How perceived threat of Covid-19 causes turnover intention among Pakistani nurses: A moderation and mediation analysis

Withdrawal: Muhammad Irshad, Sana Aroos Khattak, Muhammad Mubbashar Hassan, Mehwish Majeed, Sajid Bashir, 'How perceived threat of Covid-19 causes turnover intention among Pakistani nurses: A moderation and mediation analysis', International Journal of Mental Health Nursing, https://doi.org/10.1111/inm.12775. The above article, published online on 10 August 2020 in Wiley Online Library (wileyonlinelibrary.com), has been withdrawn by agreement between the journal Editor in Chief, Professor Kim Usher and John Wiley and Sons Ltd. The withdrawal has been agreed due to the article containing copyright material for which permission was not obtained for reuse of a questionnaire from the following article in Traumatology, "Fearing Future Terrorism: Development, Validation, and Psychometric Testing of the Terrorism Catastrophizing Scale (TCS)" by Samuel J. Sinclair and Alice LoCicero, 2007, Vol 13: 75-90.

Acceptability of psychologically-based pain management and online delivery for people living with HIV and chronic neuropathic pain: a qualitative study

OBJECTIVES

Chronic neuropathic pain is common in people living with HIV. Psychological treatments can improve quality of life for people with chronic pain in general, and online delivery can increase access to these treatments. However, the acceptability of psychological treatment and online delivery have not been investigated in-depth in people living with HIV and chronic neuropathic pain. Therefore, a qualitative study was undertaken to explore views about a psychological treatment for pain management in this population and to investigate the acceptability of online treatment delivery.

METHODS

Qualitative interviews were conducted and analysed using inductive thematic analysis, adopting a critical realist perspective. Twenty-six people living with HIV and chronic neuropathic pain completed semi-structured interviews. Their views about a psychological treatment for pain management and online delivery were explored in-depth.

RESULTS

Three themes and 12 subthemes were identified. Theme one represents a desire for a broader approach to pain management, including not wanting to take more pills and having multidimensional goals that were not just focussed on pain relief. Theme two includes barriers to online psychologically-based pain management, including concerns about using the Internet and confidentiality. Theme three describes treatment facilitators, including accessibility, therapist support, social connection, and experiencing success.

CONCLUSIONS

A psychological treatment for chronic neuropathic pain management appears acceptable for people living with HIV. Therapist-supported online delivery of cognitive-behavioural pain management may be acceptable for people living with HIV given appropriate development of the treatment to address identified barriers to engagement. These data can inform developments to enhance engagement in online psychologically-informed pain management in people living with HIV and more broadly in remote delivery of psychological treatments.

What Are the Core Competencies of a Mental Health Nurse? Protocol for a Concept Mapping Study

This study aims to identify and contrast key stakeholder perspectives about the core competencies of mental health nurses. Mental health nurses provide much of the direct care and treatment to patients with mental disorders. The perspectives of users of mental health services, mental health nurses, mental health nurse clinical leaders, psychiatrists, and mental health nurse academics regarding the core competencies of a mental health nurse are informative to improve the quality of care given to patients. We will use concept mapping to compare and contrast the views of different stakeholder groups (n = 50, 10 per group) about the core competencies (knowledge, skills, and attitudes) of mental health nurses. There are six stages in concept mapping: preparation, generation of statements, structuring of statements, representation of statements, interpretation of maps, and utilisation of maps. The Good Reporting of A Mixed Methods Study (GRAMMS) checklist will guide this study. The final output is a “concept map” that can be used and interpreted to understand core mental health nursing competencies. This study will provide insight into the perceived core competencies of mental health nurses from a variety of perspectives.

A participatory, farmer-led approach to changing practices around antimicrobial use on UK farms

Farmer-led, participatory approaches are being increasingly employed in agricultural research, with promising results. This study aimed to understand how a participatory approach based on the Danish stable schools could help to achieve practical, farmer-led changes that reduced reliance on antimicrobials in the UK. Five facilitated farmer action groups comprising 30 dairy farms across South West England met on farm at regular intervals between 2016 and 2018, and worked collaboratively within their groups to discuss how to reduce antimicrobial use. Qualitative data from group discussions and individual semi-structured interviews were collected and analyzed using thematic analysis to explore how the approach helped farmers address and deal with changes to their on-farm practices. Facilitator-guided reviews of antimicrobial use and benchmarking were carried out on each farm to assess any change in usage and help farmers review their practices. The pattern of antimicrobial use changed over the 2 yr of the study, with 21 participating farms reducing their use of highest-priority critically important antibiotics (6 farms were not using any of these critical medicines from the outset). Thirty practical action plans were co-developed by the groups with an average implementation rate of 54.3% within a year. All assessed farms implemented 1 recommendation, and many were still ongoing at the end of the study. Farmers particularly valued the peer-to-peer learning during farm walks. Farmers reported how facilitated discussions and action planning as a peer group had empowered them to change practices. Participants identified knowledge gaps during the project, particularly on highest-priority critically important antibiotics, where they were not getting information from their veterinarians. The study demonstrated that facilitation has a valuable role to play in participatory approaches beyond moderating discussion; facilitators encouraged knowledge mobilization within the groups and were participants in the research as well. Facilitated, farmer-led, participatory approaches that mobilize different forms of knowledge and encourage peer learning are a promising way of helping farmers to adapt and develop responsible practices.

Perspectives and Experiences of Transgender and Non-binary Individuals on Seeking Urological Care

OBJECTIVE

To describe perspectives and experiences related to urology care-seeking of transgender and non-binary (TGNB) individuals assigned male at birth.

MATERIALS AND METHODS

This HIPAA-compliant study was IRB approved and followed Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines. Through semistructured interviews, perspectives, and experiences of individuals related to urology care-seeking were explored. Open-ended questions were designed to elicit a range of responses rather than quantifiable data. Thematic codes were developed and explicitly defined. Codes pertaining to patient experiences were assessed and described.

RESULTS

Twenty-five TGNB individuals assigned male at birth were interviewed. Participants reported an array of factors that informed and inhibited care-seeking, factors that framed individual urologic care experiences, and their overall impression of the healthcare system's ability to effectively and respectfully serve the TGNB population. Specifically, participants reported that prior negative healthcare experiences dissuaded them from seeking care such as feeling discriminated against and having a lack of trust in providers. Additionally, participants reported feeling a need and responsibility to "educate" providers on both their medical needs and psychosocial experiences. Participants were also unclear how best to identify "trans-friendly" urologists who are culturally competent and have appropriate medical knowledge.

CONCLUSION

TGNB individuals face significant barriers to care for unique healthcare needs. TGNB participants described care avoidance and reported experiences of healthcare discrimination. These data highlight the importance for urologists to understand the perspectives and historical experiences of these individuals who may seek urological care.

Assessing care trajectories of adolescent females seeking early induced abortion in New South Wales: multistage, mixed-methods study protocol

INTRODUCTION

In Australia, New South Wales (NSW), abortion has recently been removed from the criminal code. Previous research from Australia and other high-income countries has focused on adult women's access to abortion services. This protocol describes a five-stage mixed-methods study to determine the care trajectories and experiences of adolescent females, aged 16-19 years, seeking an early induced abortion in NSW. The aims are to (1) explore the needs and perspectives of adolescent females seeking sexual and reproductive health services in NSW and (2) develop a framework for abortion service provision for adolescents in NSW.

METHODS AND ANALYSIS

This study comprises: (1) semistructured qualitative interviews with key informants, individuals with diverse, in-depth experience of providing and/or supporting abortion care in NSW; (2) a cross-sectional online survey of adolescent females residing in NSW; (3) case study interviews with adolescents females who have accessed an abortion service in NSW; (4) a co-design workshop with adolescents who took part in stage 3 to develop relevant knowledge and recommendations and (5) a knowledge dissemination forum with key stakeholders.

ETHICS AND DISSEMINATION

Ethics approval has been received from the University of Technology Sydney Human Research Ethics Committee for this study. Data collection commenced in March 2019 and will continue until the end of 2020. This study aims to develop a deep understanding of adolescent abortion care trajectories and experiences of abortion services in NSW. The study will deliver co-produced recommendations to improve adolescent access to abortion information and services.

Nutritional and social contribution of meat in diets: Interplays among young urban and rural men

Considering the recent increase in the demand for meat and its subsequent implications for health and food security, there is an increasing need to explore its nutritional and social importance among young men in settings experiencing nutrition transition. A better understanding of meat in the diets of this group could contribute to the design of socio-culturally appropriate interventions to improve healthy eating, as these men are key decision makers in family food choices. This mixed-methods study aimed to assess the nutritional and social contribution of meat in the diet of young adult men in urban and rural Zambia. A food frequency questionnaire, multiple pass 24-h dietary recall, anthropometric measurements and a socio-demographic questionnaire were utilized while qualitative interviews explored the socio-cultural importance of meat consumption. Rural and urban participants had an isocaloric diet. All macronutrient intakes except carbohydrates were significantly higher in the urban population than the rural population (p < 0.01). Zinc intake was significantly greater in the urban than the rural sample (χ² (39) = 40, p-value = 0.04). Except for vitamin A, calcium and folate, participants met the recommendations for all micronutrients. Regardless of being rural or urban, the higher the participant's level of education, the weaker the socio-cultural importance of meat. In both settings, increased consumption of meat was associated with prosperity, authority and respect within society. There are strong social and cultural beliefs among participants about meat consumption, reflecting the symbolic meaning in their customs. These findings could help improve the design and implementation of dietary interventions, incorporating specific cultural beliefs and socio-economic factors in the targeted population, to achieve healthy eating practices.

Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia

AIMS

To examine perceptions of extended-release (XR) buprenorphine injections among people who regularly use opioids in Australia.

DESIGN

Cross-sectional survey prior to implementation. XR-buprenorphine was registered in Australia in November 2018.

SETTING

Sydney, Melbourne and Hobart. Participants A total of 402 people who regularly use opioids interviewed December 2017 to March 2018.

MEASUREMENTS

Primary outcome concerned the proportion of participants who believed XR-buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR-buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication-type, dose, prescriber/dosing setting, unsupervised doses, out-of-pocket expenses and travel distance).

FINDINGS

Sixty-eight per cent [95% confidence interval (CI) = 63-73%] believed XR-buprenorphine was a good treatment option for them. They were more likely to report being younger [26-35 versus > 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12-8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04-2.69; P = 0.034), < 10 years school education (OR = 1.87, 95% CI = 1.12-3.12; P = 0.016) and past-month heroin (OR = 1.81, 95% CI = 1.15-2.85; P = 0.006) and methamphetamine use (OR = 1.90, 95% CI = 1.20-3.01; P = 0.006). Fifty-four per cent reported no preference for weekly versus monthly injections, 7% preferred weekly and 39% preferred monthly. Among OAT recipients (n = 255), believing XR-buprenorphine was a good treatment option was associated with shorter treatment episodes (1-2 versus ≥ 2 years; OR = 3.93, 95% CI = 1.26-12.22; P = 0.018), fewer unsupervised doses (≤ 8 doses past-month versus no take-aways; OR = 0.50; 95% CI = 0.27-0.93; P = 0.028) and longer travel distance (≥ 5 versus < 5 km; OR = 2.10, 95% CI = 1.20-3.65; P = 0.009). Sixty-nine per cent reported 'no problems or concerns' with potential differences in availability, flexibility and location of XR-buprenorphine.

CONCLUSIONS

Among regular opioid users in Australia, perceptions of extended-release buprenorphine as a good treatment option are associated with being female, recent illicit drug use and factors relating to the (in)convenience of current opioid agonist treatment.

Social networks and their influences on nutrient intake, nutritional status and physical function in community-dwelling ethnically diverse older adults: a mixed-methods longitudinal study

Background

The United Kingdom population is ageing and becoming increasingly diverse; thus, it is vital to develop and implement interventions supporting this population shift. Social networks (SN) significantly impact health outcomes in later life, however relatively little is known about SN of community-dwelling ethnically diverse older adults. This study aimed to: 1) profile SN and changes in SN in this population over 8 months; 2) examine associations between SN, dietary intake, nutritional status, and physical function.

Methods

SN were assessed using the Wenger Practitioner Assessment of Network Type. Energy and nutrient intakes were measured using multiple-pass 24-h recalls. The Mini Nutritional Assessment-Short Form (MNA-SF) assessed nutritional status. Physical function was measured using the Short Physical Performance Battery (SPPB) and handgrip strength. Data were collected at baseline and 8-months. Correlation and regression analyses examined relationships between SN, physical function, nutrient intake and nutritional status. Semi-structured interviews were conducted at baseline (n = 92) and follow-up (n = 81) to identify potential influences of SN. Interviews were transcribed verbatim and analysed using directed content analysis.

Results

Quantitative data were obtained from 100 participants at baseline and 81 at follow-up. Mean (SD) age was 70.8 (8.1) years (59% male), comprising African/Caribbean (60%), South Asian (34%), and other ethnicities (6%). Five SN typologies were identified under two broad areas: integrated-SN consisting of locally integrated (44%) and wider community (8%); and non-integrated-SN consisting of family dependent (25%), local self-contained (17%), and private restricted (6%). At follow-up, 37% remained in non-integrated networks, 19% transitioned to non-integrated networks, 11% transitioned to, and 33% remained in, integrated networks. Participants within integrated networks at baseline had higher SPPB scores at follow-up. Compared to the private restricted, local self-contained SN significantly predicted zinc, riboflavin and vitamin B6 intakes. Participants remaining in, or transitioning to, non-integrated networks had low MNA-SF scores. Qualitative findings indicate that participants with reductions in SN perceived it as causing poorer physical function and eating behaviours.

Conclusion

In the present study, integrated SN were associated with higher physical function and nutritional status at 8-month’s follow-up. These results can inform the design of interventions to improve social networks, physical function and healthy nutrition within this population.

"Midwives do not appreciate pregnant women who come to the maternity with torn and dirty clothing": institutional delivery and postnatal care in Torit County, South Sudan: a mixed method study

Background

South Sudan has one of the highest maternal mortality ratios in the world, at 789 deaths per 100,000 live births. The majority of these deaths are due to complications during labor and delivery. Institutional delivery under the care of skilled attendants is a proven, effective intervention to avert some deaths. The aim was to determine the prevalence and explore the factors that affect utilization of health facilities for routine delivery and postnatal care in Torit County, South Sudan.

Methods

A convergent parallel mixed method design combined a community survey among women who had delivered in the previous 12 months selected through a multistage sampling technique (n = 418) with an exploratory descriptive qualitative study. Interviews (n = 19) were conducted with policymakers, staff from non-governmental organizations and health workers. Focus group discussions (n = 12) were conducted among men and women within the communities. Bivariate and multivariate logistic regression were conducted to determine independent factors associated with institutional delivery. Thematic analysis was undertaken for the qualitative data.

Results

Of 418 participants who had delivered in the previous 12 months, 27.7% had institutional deliveries and 22.5% attended postnatal care at least once within 42 days following delivery. Four or more antenatal care visits increased institutional delivery 5 times (p < 0.001). The participants who had an institutional delivery were younger (mean age 23.3 years old) than those who had home deliveries (mean age 25.6 years). Any previous payments made for delivery in the health facility doubled the risk of home delivery (p = 0.021). Women were more likely to plan and prepare for home delivery than for institutional delivery and sought institutional delivery when complications arose. Perceived poor quality of care due to absence of health staff and lack of supplies was reported as a major barrier to institutional delivery. Women emphasized fear of discrimination based on social and economic status. Unofficial payments such as soap and sweets were reported as routine expectations and another major barrier to institutional delivery.

Conclusion

Interventions to stop unofficial payments and discrimination based on socio-economic status and to increase access to ANC, delivery services and PNC are needed.

Occupational noise induced hearing loss in the mining sector in South Africa: Perspectives from occupational health practitioners on how mineworkers are trained

Background

Historically, occupational health concerns associated with mining, particularly occupational noise-induced hearing loss (ONIHL), were ignored by the mining sector, policy-makers and academic researchers. As such, there is a dearth of literature related to ONIHL, especially in low- and middle-income countries such as South Africa. Consequently, mineworkers were not aware of the latent effects of excessive exposure to hazardous noise and the resultant hearing loss thereof.

Objectives

The aim of this study was to explore the perspectives of occupational health practitioners (OHPs) regarding education and training of mineworkers on occupational noise-induced hearing loss (ONIHL) and its impact on mineworkers’ health.

Method

Qualitative, in-depth telephonic and face-to-face interviews were conducted with 16 OHPs. Purposive and snowball sampling methods were utilised to recruit participants. Data were analysed using inductive thematic analysis.

Results

Three themes emerged from the data: ‘seeing is believing’, ‘not my department!’ and ‘barriers and facilitators to raising awareness’ with two subthemes: ‘blame it on the language and level of education’ and ‘compensation pay-outs’. Superficially, OHPs believe that mineworkers are aware of the impact of noise on health; however, the OHPs are not aware on how the mineworkers are educated on ONIHL and its latent consequences. Furthermore, language, low levels of education and literacy, as well as financial constraints, are the factors found to affect education and training of the mineworkers about the risks of ONIHL.

Conclusion

If the mining industry is committed in eliminating ONIHL, they should prioritise health literacy, and mines need to have an effective awareness-raising plan in place to eliminate ONIHL from every mine. This plan must consider diversity of workforce, including linguistic, as well as educational level diversity.

Contraceptive Beliefs, Decision Making and Care Experiences Among Transmasculine Young Adults: A Qualitative Analysis

CONTEXT

Transmasculine people-that is, individuals who were assigned female at birth and have a male or masculine gender identity-can experience unintended pregnancy. Yet research on contraception among transmasculine individuals is extremely limited.

METHODS

Participants were recruited online; from community-based organizations, health centers and student groups; and by chain referral. From purposive sampling, 21 transmasculine individuals aged 18-29 who resided in the greater Boston area and had had, in the last five years, a sexual partner who was assigned male at birth were selected for in-depth interviews. All interviews were conducted in person between February and May 2018 in Boston, and transcripts were analyzed using a thematic analysis approach involving inductive and deductive coding to identify themes and subthemes.

RESULTS

Most participants believed that contraceptive use was necessary to effectively prevent pregnancy among transmasculine individuals. Their beliefs and decisions regarding contraception occurred in the context of a lack of information about contraception among transmasculine people, especially those using testosterone. Many individuals chose a contraceptive method on the basis of whether it mitigated their gender dysphoria or stopped menstruation, and said they preferred condoms and implants because these methods provided fewer reminders of their natal anatomy and were not perceived as interfering with testosterone use. Gender bias, discrimination and stigma in patient-provider interactions and health care settings negatively influenced participants' contraceptive care experiences.

CONCLUSIONS

Health care providers and facilities should provide transmasculine people with tailored contraceptive information and care that address their specific gender-affirmation needs and contraceptive preferences in safe, inclusive and supportive clinical settings.

Understanding the Experiences and Needs of Migrant Women Affected by Female Genital Mutilation Using Maternity Services in Australia

Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for non-therapeutic reasons. Changing patterns of migration in Australia and other high-income countries has meant that maternity care providers and health systems are caring for more pregnant women affected by this practice. The aim of the study was to identify strategies to inform culturally safe and quality woman-centred maternity care for women affected by FGM who have migrated to Australia. An Appreciative Inquiry approach was used to engage women with FGM. We conducted 23 semi-structured interviews and three focus group discussions. There were four themes identified: (1) appreciating the best in their experiences; (2) achieving their dreams; (3) planning together; and (4) acting, modifying, improving and sustaining. Women could articulate their health and cultural needs, but they were not engaged in all aspects of their maternity care or considered active partners. Partnering and involving women in the design and delivery of their maternity care would improve quality care. A conceptual model, underpinned by women’s cultural values and physical, emotional needs, is presented as a framework to guide maternity services.

Promoting access to health information

Purpose

Describe the design of a health information and technology educational intervention that promotes health information sharing and technology use for older adult African Americans to support access to health information. The paper aims to discuss this issue.

Design/methodology/approach

The study team developed a novel method to design the intervention. It drew upon three approaches: intergenerational technology transfer, participatory design and community-based participatory research.

Findings

Older adult African Americans (55+) with diabetes and young adults (18–54) connected to them via familial or naturally occurring social networks designed the intervention, which was conducted in the two study sites in Michigan, USA. In total, 29 participants helped design the intervention. Four themes emerged concerning factors that promote intergenerational information exchange in the context of technology and health. First, focus on one technology skill. Second, working together in small groups is preferred. Third, patience is essential. Last, physical capabilities (i.e., eyesight, operating on relatively small screens) and literacy levels should be considered.

Originality/value

This novel method of having participants from the sample population select the health information materials and technology exercises serves as a guide for implementing health information and education interventions aimed at technology use to support self-management for vulnerable patient populations.

Pathways From Sexual Stigma to Inconsistent Condom Use and Condom Breakage and Slippage Among MSM in Jamaica

BACKGROUND

HIV prevalence among men who have sex with men (MSM) in Jamaica, where same sex practices are criminalized, is among the Caribbean's highest. Sexual stigma, the devaluation, mistreatment, and reduced power afforded to sexual minorities, is a distal driver of HIV vulnerabilities. The mechanisms accounting for associations between sexual stigma and condom use outcomes are underexplored. We examined pathways from sexual stigma to condom use and condom breakage and/or slippage among MSM in Jamaica.

METHODS

We conducted a cross-sectional survey with a chain-referral sample of MSM (n = 556) in Kingston, Montego Bay, and Ocho Rios. Structural equation modeling using weighted least squares estimation methods was conducted to test the direct effects of sexual stigma on inconsistent condom use and condom breakage/slippage, and the indirect effects through depression, sexual abuse history, and condom use self-efficacy, adjusting for sociodemographic factors.

RESULTS

One-fifth of participants (21%; 90/422) who had engaged in anal sex reported inconsistent condom use, and 38% (155/410) reported condom breakage/slippage during the previous 4 weeks. The relationship between sexual stigma and inconsistent condom use was mediated by the combination effect of sexual abuse history, condom use self-efficacy, and depression. The relationship between sexual stigma and condom breakage and slippage was mediated by the combination effect of condom use self-efficacy and sexual abuse history.

CONCLUSIONS

Sexual stigma is associated with negative condom use outcomes in Jamaican MSM, mediated by psychosocial factors. Multilevel social ecological approaches to the HIV prevention cascade can inform interventions at individual, interpersonal, community, and systemic levels.

Transformational leadership behaviours of women in a socially dynamic environment

Purpose

This paper aims to provide insights into the female transformational leadership behaviours within a socially dynamic environment. Research was conducted in the State of Qatar, a country that is going through a rapid social change.

Design/methodology/approach

The research framework was based on the transformational leadership framework (TLF) initially proposed by Burns (1978) and further developed by Bass (1985). A respondent set, consisting of 25 Qatari female managers, was taken from the largest public university in the State of Qatar. In-depth interviews were the main source of collected data. The data were analysed using NVivo 11.

Findings

Predominantly, Qatari female leadership behaviours were reflective of transformational leadership. In their dealings, Qatari female managers displayed motherly instincts, encouraged open communication, used relationship adaptations and used trust. From time to time, Qatari female managers displayed non-transformational leadership behaviours. This occasional leadership style switch was part of behavioural flexibility that was required in a mixed age, mixed gender, mixed experience and mixed nationalities work environment. The key reason for the change in transformational leadership approach came as a reaction to subordinates’ attitude. In particular, the male-dominated work environment required behavioural adjustments (such as being more assertive and autocratic) to deal with masculine subordinates.

Research limitations/implications

A range of respondent perceptions were related to defining leadership. There was some overlapping between the tested determinants. For example, idealised influence and individualised consideration shared a degree of similarity in terms of how they were perceived.

Social implications

Socially dynamic environment should be seen as an opportunity for female transformational leadership development. Social dynamism may result in an evolved TLF that could be more appropriate for Qatari organisations. Hence, experience and problem sharing between Qatari female managers may help in developing a socially and culturally fitting transformational leadership model.

Originality/value

The study presented a perspective of a socially dynamic environment where women were practicing transformational leadership primarily through behavioural flexibility and change management. The study suggests an extended version of TLF that would be more suitable for female leadership within a socially dynamic environment.

Syndemic Experiences, Protective Factors, and HIV Vulnerabilities Among Lesbian, Gay, Bisexual and Transgender Persons in Jamaica

Syndemics approaches explore the convergence of psychosocial factors that elevate HIV vulnerabilities. Less research has explored syndemics among lesbian, gay, bisexual and transgender (LGBT) persons in contexts where criminalization has downstream impacts on LGBT discrimination, such as Jamaica. We implemented a cross-sectional survey with LGBT persons (n = 911) in Jamaica. We conducted structural equation modeling to examine direct and indirect effects of a latent syndemics construct (binge drinking, depressive symptoms, childhood/adult abuse) on HIV vulnerabilities (lifetime sex partners, perceived HIV risk, condom self-efficacy) and the mediating role of protective factors (social support, resilient coping). Direct paths from syndemics to lifetime sex partners, perceived HIV risk, and condom self-efficacy were significant. Resilient coping and social support partially mediated the association between syndemics and condom use self-efficacy. Resilient coping partially mediated the relationship between syndemics and lifetime sex partners. Interventions can target syndemic issues to reduce HIV vulnerabilities among Jamaican LGBT persons.

Perceptions and Factors Influencing Eating Behaviours and Physical Function in Community-Dwelling Ethnically Diverse Older Adults: A Longitudinal Qualitative Study

Ethnic minorities have a high prevalence of non-communicable diseases relating to unhealthy lifestyle practices. Several factors have been identified as influencing unhealthy lifestyle practices among this population; however, there is little evidence about how these factors differ among a heterogeneous sample living in a super-diverse city. This study aimed to: (1) identify and compare factors influencing eating behaviours and physical function among ethnic older minorities living in Birmingham, United Kingdom; and (2) understand how these factors and their association with healthy eating and physical function changed over 8-months. An in-depth interviewing approach was used at baseline (n = 92) and after 8-months (n = 81). Interviews were transcribed verbatim and analysed using directed content analysis. Healthy eating was viewed as more important than, and unrelated to, physical function. Personal, social and cultural/environmental factors were identified as the main factors influencing eating behaviours and physical function, which differed by ethnicity, age, and sex. At 8-month interviews, more men than women reported adverse changes. The study provides unique and useful insights regarding perceived eating behaviours and physical function in a relatively large and diverse sample of older adults that can be used to design new, and adapt existing, culturally-tailored community interventions to support healthy ageing.

Evaluating Cost-Effective Methods for Rapid and Repeatable National Scale Detection and Mapping of Invasive Species Spread

Invasive species can spread rapidly at local and national scales, creating significant environmental and economic impacts. A central problem in mitigation efforts is identifying methods that can rapidly detect invasive species in a cost-effective and repeatable manner. This challenge is particularly acute for species that can spread over large areas (>1 million km²). Wild pigs (Sus scrofa) are one of the most prolific invasive mammals on Earth and cause extensive damage to agricultural crops, native ecosystems, and livestock, and are reservoirs of disease. They have spread from their native range in Eurasia and North Africa into large areas of Australia, Africa, South America, and North America. We show that the range of invasive wild pigs has increased exponentially in Canada over the last 27 years following initial and ongoing releases and escapes from domestic wild boar farms. The cumulative range of wild pigs across Canada is 777,783 km², with the majority of wild pig distribution occurring in the Prairie Provinces. We evaluate eight different data collection and evaluation/validation methods for mapping invasive species over large areas, and assess their benefits and limitations. Our findings effectively map the spread of a highly invasive large mammal and demonstrate that management efforts should ideally rely on a set of complementary independent monitoring methods. Mapping and evaluating resulting species occurrences provide baseline maps against which future changes can be rapidly evaluated.

The confirmation of treatment effects in Japanese acupuncture

BACKGROUND

Japanese acupuncture is gaining international recognition. However, previous research has failed to comprehensively describe the characteristics of Japanese acupuncture by not investigating it within the Japanese clinical environment. This qualitative ethnographic study aimed to identify unique and routine elements of Japanese acupuncture, describe these in detail and examine how they related to treatment principles.

METHODS

Between August 2012 and December 2016, ethnographic fieldwork was conducted in Japan. Participants were recruited by chain referral and emergent sampling. Data were collected through participant observation and interviews as well as by analyzing documents. A total of 38 participants were recruited. A total of 22 agreed to clinical observation; 221 treatments were observed with 172 patients. Seventeen participants consented to participate in formal interviews and 28 to informal interviews. Thematic analysis was used to evaluate data.

RESULTS

That practitioners tended to confirm perceived effects of interventions during treatment, was a major theme interpreted from the data. Confirmation was performed continually throughout treatment and at three different levels of timing and anatomical areas (micro, meso and macro). Many markers signified treatment effects which were in general, perceived by observing and/or palpating body tissue. Belief in the instantaneous effects of treatment and the value of effect through technique exemplify the philosophical foundations of confirmation. Continually monitoring treatment results at a range of time and body location increments is an important element of Japanese acupuncture.

CONCLUSION

This effect confirmation practice model promotes a system of constant feedback gained by repeated intervention and confirmation. This may be a unique feature of Japanese acupuncture.

"Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania

BACKGROUND

The World Health Organization advocates that health workforce development is a continuum of three stages of entry, available workforce and exit. However, many studies have focused on addressing the shortage of numbers and the retention of doctors in rural and remote areas. The latter has left the contribution of the entry stage in particularly the deployment process on the shortage of health workforce less understood. This study therefore explored the experiences of medical doctors (MDs) on the deployment process after the internship period in Tanzania's health sector.

METHODS

A qualitative case study that adopted chain referral sampling was used to conduct 20 key informant interviews with MDs who graduated between 2003 and 2009 from two Medical Universities in Tanzania between February and April 2016. These MDs were working in hospitals at different levels and Medical Universities in eight regions and five geo-political zones in the country. Information gathered was analysed using a qualitative content analysis approach.

RESULTS

Experiences on the deployment process fall into three categories. First, "uncertainties around the first appointment" attributed to lack of effective strategies for identification of the pool of available MDs, indecision and limited vacancies for employment in the public sector and private sector and non-transparent and lengthy bureaucratic procedures in offering government employment. Second, "failure to respect individuals' preferences of work location" which were based on the influence of family ties, fear of the unknown rural environment among urbanized MDs and concern for career prospects. Third, "feelings of insecurity about being placed at a regional and district level" partly due to local government authorities being unprepared to receive and accommodate MDs and territorial protectionism among assistant medical officers.

CONCLUSIONS

Experiences of MDs on the deployment process in Tanzania reveal many challenges that need to be addressed for the deployment to contribute better in availability of equitably distributed health workforce in the country. Short-term, mid-term and long-term strategies are needed to address these challenges. These strategies should focus on linking of the internship with the first appointment, work place preferences, defining and supporting career paths to health workers working under the local government authorities, improving the working relationships and team building at the work places and fostering rural attachment to medical students during medical training.

Researching health behaviour in ‘real time’: Methodological insights from a prospective study on Olympic hopefuls

In this article, we share our experience of navigating qualitative longitudinal research with a ‘hard to recruit’ population. To detail design conception, methodological challenges and insights, we draw on the case of a 1-year-long study on health behaviour in Olympic hopefuls. In order to accompany 12 athletes who aimed to qualify for either an Olympic Games (n = 10) or a World Championship (n = 2), we developed and implemented a career background questionnaire; semi-structured interviews; weekly web surveys; a training observation and a compilation of competition results. Based on the longitudinal research experience, we present project management and project data of the Paths-to-Rio study to discuss the challenges we faced, including gaining access to an elite population, their retention and anonymity. We further outline insights the prospective study gave us on the value of missing data as data and on the benefits participants described in terms of learning through research involvement. We conclude with recommendations for future qualitative longitudinal research.

Battling the Tides of Climate Change: The Power of Intangible Cultural Resource Values to Bind Place Meanings in Vulnerable Historic Districts

Climate change increases not only the vulnerability of cultural resources, but also the cultural values that are deeply embedded in cultural resources and landscapes. As such, heritage managers are faced with imminent preservation challenges that necessitate the consideration of place meanings during adaptation planning. This study explores how stakeholders perceive the vulnerability of the tangible aspects of cultural heritage, and how climate change impacts and adaptation strategies may alter the meanings and values that are held within those resources. We conducted semi-structured interviews with individuals with known connections to the historic buildings located within cultural landscapes on the barrier islands of Cape Lookout National Seashore in the United States (US). Our findings revealed that community members hold deep place connections, and that their cultural resource values are heavily tied to the concepts of place attachment (place identity and place dependence). Interviews revealed a general acceptance of the inevitability of climate impacts and a transition of heritage meanings from tangible resources to intangible values. Our findings suggest that in the context of climate change, it is important to consider place meanings alongside physical considerations for the planning and management of vulnerable cultural resources, affirming the need to involve community members and their intangible values into the adaptive planning for cultural resources.

A DETERMINANTS OF HEALTH CONCEPTUAL MODEL FOR FISH AND WILDLIFE HEALTH

Our objectives were to establish if the determinant of health model used in the fields of human population and public health could be adapted to wildlife health; if it was applicable to more than one species; and if it reflected how fish and wildlife managers conceptualized health in practice. A conceptual model was developed using a scoping review on fish and wildlife health and resilience coupled with a participatory process with experts on barren ground caribou ( Rangifer tarandus groenlandicus) and sockeye salmon ( Oncorhynchus nerka) health. Both the literature and experts supported the concept of wildlife health as a cumulative effect involving multiple factors that extend beyond the disease and pathogen focus of many wildlife health studies and legislation. Six themes were associated with fish and wildlife health: 1) the biologic endowment of the individual and population; 2) the animal's social environment; 3) the quality and abundance of the animal's needs for daily living; 4) the abiotic environment in which the animal lives; 5) sources of direct mortality; and 6) changing human expectations. These themes were shared between salmon and caribou and conformed to expert perceptions of health. Determinants of health used in human public health are used for planning, development of policy, and guiding of research. The model we produced may also have use as a wildlife health planning tool to help managers identify health protection priorities and to promote actions across the determinants of health.

Management of occupational noise induced hearing loss in the mining sector in South Africa: Where are the audiologists?

OBJECTIVE

This study was conducted to explore the scope of practice for occupational audiologists in the mining industry and the audiologists' involvement in hearing conservation programmes in South African mines. Additionally, this study investigated the mining industry's role in the audiologists' involvement, and assessed the audiologists' levels of preparedness for working in occupational audiology.

METHODS

In-depth, qualitative telephone and face-to face interviews were conducted with seven occupational audiologists involved in the management of occupational, noise-induced hearing loss (ONIHL) in the South African mining sector. Snowball sampling was utilized to recruit possible participants for this study. Data were analysed using inductive thematic analysis.

RESULTS

The following themes were identified: scope-context misalignment, juniorization of the experts, audiologists are important... but for what?, and limited training in occupational audiology.

CONCLUSIONS

Our evidence highlights important gaps in HCPs in South Africa. The fact that the audiologists responsible for the management of ONIHL are only minimally and peripherally involved may play a significant role in the lack of progress reported in the management of ONIHL in the South African mining sector.

Enhancing the sample diversity of snowball samples: Recommendations from a research project on anti-dam movements in Southeast Asia

Snowball sampling is a commonly employed sampling method in qualitative research; however, the diversity of samples generated via this method has repeatedly been questioned. Scholars have posited several anecdotally based recommendations for enhancing the diversity of snowball samples. In this study, we performed the first quantitative, medium-N analysis of snowball sampling to identify pathways to sample diversity, analysing 211 reach-outs conducted via snowball sampling, resulting in 81 interviews; these interviews were administered between April and August 2015 for a research project on anti-dam movements in Southeast Asia. Based upon this analysis, we were able to refine and enhance the previous recommendations (e.g., showcasing novel evidence on the value of multiple seeds or face-to-face interviews). This paper may thus be of particular interest to scholars employing or intending to employ snowball sampling.

Teachers' and Parents' Perspectives on a Curricular Subject of "Religion and Spirituality" for Indian Schools: A Pilot Study Toward School Mental Health Program

Religious-spiritual (R/S) education helps medical students cope with caregiving stress and gain skills in interpersonal empathy needed for clinical care. Such R/S education has been introduced into K-12 and college curricula in some developed nations and has been found to positively impact student's mental health. Such a move has not yet been seen in the Indian education system. This paper aimed to examine perspectives of teachers and parents in India on appropriateness, benefits, and challenges of including R/S education into the school curriculum and also to gather their impressions on how a R/S curriculum might promote students' health. A cross-sectional study of religiously stratified sample of teachers and parents was initiated in three preselected schools in India and the required sample size (N = 300) was reached through snowballing technique. A semi-structured questionnaire, with questions crafted from "Religion and Spirituality in Medicine, Physicians Perspective" (RSMPP) and "American Academy of Religion's (AAR) Guidelines for Religious Literacy," was used to determine participants' perspectives. Findings revealed that teachers' and parents' "comfort in integrating R/S into school curriculum" was associated with their gender (OR 1.68), education status (OR 1.05), and intrinsic religiosity (OR 1.05). Intrinsic religiosity was significantly (p = 0.025) high among parents while "intrinsic spirituality" was high (p = 0.020) among teachers. How participants' R/S characteristics influence their support of R/S education in school is discussed. In conclusion, participants believe R/S education will fosters students' emotional health and interpersonal skills needed for social leadership. A curriculum that incorporates R/S education, which is based on AAR guidelines and clinically validated interpersonal spiritual care tools would be acceptable to both teachers and parents.

Moral injury in relation to public debates: The role of societal misrecognition in moral conflict-colored trauma among soldiers

The last decade has witnessed fast-growing scholarly interest in the concept of moral injury, which addresses the link between the ethics of military intervention and deployment-related suffering. However, current research on moral injury, predominantly psychological in nature, tends to approach the phenomenon as an internally contained disorder. Consequently, it medicalizes moral injury and de-contextualizes it from the people who send soldiers to conflict zones and 'welcome' them back. This article addresses the ways in which the experience of moral injury is embedded in and shaped by public debates on military intervention, drawing on relevant literature from the fields of psychology, philosophy, and social sciences, and on in-depth qualitative interviews collected in 2016 and 2017 with 80 Dutch veterans. The article examines the explicit public condemnation experienced by Dutch veterans deployed to Bosnia as peacekeepers, and the more subtle public misunderstanding experienced by Dutch veterans deployed to Afghanistan as combat soldiers. It demonstrates that public criticism and admiration may both be experienced as misrecognition, and, in turn, societal misrecognition may directly or indirectly contribute to moral injury. Moreover, not only soldiers and veterans may struggle with the moral significance of military intervention, but society as well.

The Cultural Importance of Plants in Western African Religions

This paper explores the importance of elements of the natural world, and particularly plants, among people of different religious affiliations in western Africa. Plants play an overriding role in African folk religions, which in turn are closely associated with health practices and influence management decisions concerning natural resources. In spite of the extensive literature documenting ritual plant use, the cultural importance of plants in this context has not been systematically assessed. Our objective was to see whether the importance of plants was reflected in people's conceptions of global (i.e., Christianity, Islam) and folk religions (i.e., Vodoun and Bwiti) in Benin (West Africa) and Gabon (Central Africa). By performing a cultural domain analysis (CDA) with 96 individuals, we found that, regardless of the religious affiliation of informants, plants and other elements of the natural world were more present in people's notions of folk religions than in global religions. We conclude by reflecting on the potentials and limitations of the data presented here as a starting point to explore the topic of cultural keystone species.

Exploring the lived experience of gay men with prostate cancer: A phenomenological study

PURPOSE

Gay men with prostate cancer are an 'invisible species' in the research literature despite concerns that the impact of treatment may be more profound and in some ways unique compared to heterosexual men. The aim of this research is to explore the lived experience of gay men with prostate cancer.

METHOD

In-depth interviews were recorded and transcribed verbatim from a purposive sample of eight gay men treated for prostate cancer in Ireland. A qualitative methodological approach employing Giorgi's descriptive phenomenological method was used to collect and analyse data.

FINDINGS

Three key aspects emerged representing the essence of the participants lived experience; The experience of diagnosis, treatment decision making, and the impact of treatment, with sub-themes of shock of diagnosis, the generalist nature of information, sexual side effects and incontinence, and masculinity and gay identity. Secondly, the experience of the healthcare service with sub-themes of sexual orientation disclosure and communication with the healthcare team; and thirdly, sources of support and means of coping which included significant others, family & friends, cancer support groups, and gay resources and support services.

CONCLUSION

Gay men with prostate cancer have unmet information and supportive care needs throughout their prostate cancer journey, especially related to the impact of sexual dysfunction and associated rehabilitation, negatively impacting their quality of life. Issues associated with heteronormativity, minority stress, and stigma may influence how gay men interact with the health service, or how they perceive the delivery of care. Healthcare education providers should update prostate cancer education programmes accordingly.

Contact Tools in Japanese Acupuncture: An Ethnography of Acupuncture Practitioners in Japan

This study aimed to identify procedural elements of Japanese acupuncture, describe these elements in detail, and explain them in terms of the key thematic category of treatment principles. Between August 2012 and December 2016, ethnographic fieldwork was conducted in Japan. In total, 38 participants were recruited by chain referral and emergent sampling. Data was collected through participant observation, interviews, and by analyzing documents. A total of 22 participants agreed to clinical observation; 221 treatments were observed with 172 patients. Seventeen consented to formal interviews and 28 to informal interviews. Thematic analysis was used to critically evaluate data. One especially interesting theme was interpreted from the data: a variety of contact tools were applied in treatment and these were manipulated by adjusting elements of form, speed, repetition, and pressure. Tapping, holding, pressing/pushing, and stroking were the most important ways contact tools were used on patients. Contact tools are noninvasive, painless, can be applied in almost any environment, and may be easily accepted by patients worldwide. Contact tool theory and practice may be successfully integrated into acupuncture curricula outside of Japan, used to inform clinical trials, and contribute to an expanded repertoire of methods for practitioners to benefit individual patients in international contexts.

"But the moment they find out that you are MSM…": a qualitative investigation of HIV prevention experiences among men who have sex with men (MSM) in Ghana's health care system

Background

The prevalence of HIV in Ghana is 1.3%, compared to 17% among men who have sex with men (MSM). There is limited empirical data on the current health care climate and its impact on HIV prevention services for Ghanaian MSM. The purposes of this study were to investigate (1) MSM’s experiences using HIV prevention resources, (2) what factors, including health care climate factors, influenced MSM’s use of prevention resources and (3) MSM self-identified strategies for improving HIV/sexually transmitted infection (STI) prevention among MSM in Ghanaian communities.

Methods

We conducted 22 focus groups (n = 137) with peer social networks of MSM drawn from three geographic communities in Ghana (Accra, Kumasi, Manya Krobo). The data were examined using qualitative content analysis. Interviews with individual health care providers were also conducted to supplement the analysis of focus group findings to provide more nuanced illuminations of the experiences reported by MSM.

Results

There were four major findings related to MSM experiences using HIV prevention resources: (1) condom quality is low, condom access is poor, and condom use is disruptive, (2) inaccurate information undermines HIV testing (3), stigma undermines HIV testing, and (4) positive attitudes towards HIV prevention exist among MSM. The main healthcare climate factors that affected prevention were that MSM were not free to be themselves, MSM were not understood by healthcare providers, and that MSM did not feel that healthcare providers cared about them. To improve HIV prevention MSM suggested increased education tailored to MSM should be provided to enable self-advocacy and that education and awareness are needed to protect human rights of MSM in Ghana.

Conclusion

MSM in Ghana are exposed to negative health care climates. Health care spaces that are unsupportive of MSM’s autonomy undermine the uptake of prevention measures such as condoms, HIV testing, and accurate sexual health education. These findings contribute to knowledge to inform development of HIV prevention interventions for MSM in Ghana, such as culturally appropriate sexual health education, and digital technology to connect individuals with resources supportive of MSM.

Meaning making after a near-death experience: The relevance of intrapsychic and interpersonal dynamics

This study aims to investigate the processes used by individuals to integrate a near-death experience (NDE) and to discuss the use of a meaning-making component to help people who have had such experiences. A psychotherapist interviewed six individuals who reported having had a NDE. Transcripts of the interviews were coded using an interpretative phenomenological analysis. The authors identified intrapsychic and interpersonal dynamics implicated in the individuals' meaning-making processes, and the problems encountered during their integration of the experience. Meaning-based approaches are a feasible theoretical framework for shedding light on the NDE and providing support for people who have lived through them.

Beliefs and values in Japanese acupuncture: an ethnography of Japanese trained acupuncture practitioners in Japan

BACKGROUND

Japanese acupuncture is gaining international recognition. However, previous research has failed to comprehensively describe the characteristics of Japanese acupuncture by not investigating it within the Japanese clinical environment. This study aimed to identify unique and routine elements of Japanese acupuncture, describe these elements in detail, and examine how the current beliefs and attitudes of Japanese acupuncture practitioners related to philosophical concepts in their practice.

METHODS

Between August 2012 and December 2016, ethnographic fieldwork was conducted in Japan. Japanese trained acupuncture practitioners were recruited by chain referral and emergent sampling. Data were collected through participant observation, interviews, and by analyzing documents. Thematic analysis was used to critically evaluate the data.

RESULTS

Thirty-eight participants were recruited. Of these participants, 22 agreed to clinical observation; 221 treatments were observed with 172 patients. Additionally, 17 participants consented to participate in formal semistructured interviews and 28 to informal unstructured interviews (fieldwork discussion). Besides "knowledge," "beliefs and values" was a major theme interpreted from the data. Subthemes-including Zen Buddhism, effect through technique, instant effects of treatment, anatomical areas of significance, resolution of abnormalities, minimal stimulation, and patient comfort and customer service-were identified.

CONCLUSION

Beliefs and values are an underrepresented, yet extremely important aspect of philosophical concepts influencing acupuncture practice in Japan. Uniquely Japanese beliefs and values that do not rely on a commitment to any spiritual or religious affiliations or proprietary knowledge of traditional or biomedicine may be successfully exported from Japan to advance acupuncture education, research and practice in international contexts.

Social venue range and referral chain impact: Implications for the sampling of hidden communities

Background

It has been argued that the success of respondent-driven sampling (RDS) in generating unbiased estimates for epidemiologic outcomes depends on participants’ abilities to generate long referral chains. While this is thought to depend on the number of people participants know in the target population, this idea is rarely tested. Furthermore, little attention has been paid to the role of other aspects of social connectedness in recruitment, such as participants’ involvement in local clubs and venues.

Methods

We examine whether the recruitment potential of young Black men who have sex with men (YBMSM) depends on (1) their social network size and (2) their affiliations with a variety of sex venues across geographic areas. We analyze data from a 2014 RDS study of 598 YBMSM on the south side of Chicago.

Results

Both a participant’s personal network size and the number of different types of sex venues with which he was affiliated were significantly positively associated with (1) the total number of recruits in the participant’s prospective referral chains and (2) the lengths of those chains. However, only venue affiliation remain significantly associated with recruitment potential in the multivariate model.

Conclusions

The success of RDS in generating valid samples may depend more on recruiting participants who are involved in multiple venues within the community (i.e., their affiliation networks) than on recruiting those who have large personal social networks.

Integrative Governance of Environmental Water in Australia's Murray-Darling Basin: Evolving Challenges and Emerging Pathways

Integration, a widely promoted response to the multi-scale complexities of social-environmental sustainability, is diversely and sometimes poorly conceptualized. In this paper we explore integrative governance, which we define as an iterative and contextual process for negotiating and advancing the common interest. We ground this definition in a discussion of institutional factors conditioning integrative governance of environmental water in Australia's Murray-Darling Basin. The Murray-Darling Basin is an iconic system of social-ecological complexity, evocative of large-scale conservation challenges in other developed arid river basins. Our critical assessment of integrative governance practices in that context emerges through analysis of interviews with policy participants and documents pertaining to environmental water management in the tri-state area of southwestern New South Wales, northwestern Victoria, and the South Australian Riverland. We identify four linked challenges: (i) decision support for developing socially robust environmental water management goals, (ii) resource constraints on adaptive practice, (iii) inter-state differences in participatory decision-making and devolution of authority, and (iv) representative inclusion in decision-making. Our appraisal demonstrates these as pivotal challenges for integrative governance in the common interest. We conclude by offering a perspective on the potential for supporting integrative governance through the bridging capacity of Australia's Commonwealth Environmental Water Holder.

Recruiting African American Children for Research: An Ecological Systems Theory Approach

With health disparities still pervasive and persistent in the United States, medical researchers and social scientists continue to develop recruitment strategies to increase the inclusion of racial/ethnic minority groups in research and interventions. Effective methods for recruiting samples of African American participants for pediatric research may be best understood when situated within an overarching conceptual model-one that serves to organize and explain effective recruitment strategies. A theoretical framework well suited for this purpose is Bronfenbrenner's ecological systems theory, which views individuals as influencing and being influenced by (both directly and indirectly) a series of interconnected social systems. Based on the ecological systems theory and on previous research from multiple domains (e.g., medicine, psychology, public health, social work), in the current article, we review strategies for effective recruitment of African American children and adolescents for research.

Factors associated with HIV testing among men who have sex with men in Western Kenya: a cross-sectional study

HIV diagnosis is an important step in the HIV cascade of prevention and treatment. However, men who have sex with men in low- and middle-income countries have limited access to HIV care services. We examined factors associated with prior HIV testing among men who have sex with men in western Kenya. We recruited 95 men who have sex with men aged 18 years and older, and who reported at least one sexual contact with a man in the past 6 months; however, this analysis is restricted to 89 participants who completed questions on HIV testing. Logistic regression model was used to determine factors associated with HIV testing in the past one year. Results indicate that 23 (26%) had not been tested in the past 12 months. Bivariate analyses demonstrated that condomless anal sex (odds ratio = 3.29, 95% confidence interval = 1.18-9.17) and comfort with healthcare providers (odds ratio = 1.15, 95 % CI = 1.05-1.26) were associated with higher odds of HIV testing in the past 12 months. Experiencing social stigma was associated with lower odds of HIV testing in the last 12 months (odds ratio = 0.91, 95% confidence interval = 0.84-0.94). In multivariable models, social stigma remained significantly associated with lower odds of HIV testing in the last 12 months odds ratio = 0.90, 95% confidence interval = 0.82-0.99) after inclusion of sexual risk and individual level variables. Development of men who have sex with men-sensitive HIV-testing services, addressing stigma, and training healthcare workers to provide culturally sensitive services may assist in effectively engaging men who have sex with men in the HIV treatment cascade.

Low Nutrient Intake and Frailty Among Overweight and Obese Migrant Women From Ethnically Diverse Backgrounds Ages 60 Years and Older: A Mixed-Methods Study

OBJECTIVE

To examine associations between energy/nutrient intakes and frailty in older migrant women, and to explore perceptions of body weight, dietary intake, and physical function.

DESIGN

Cross-sectional, mixed-methods study.

SETTING

Birmingham, United Kingdom.

PARTICIPANTS

Seventy-six first-generation migrant women ≥ 60 years of age.

MAIN OUTCOME MEASURES

Energy/nutrient intakes (assessed by 24-hour dietary recall), frailty (using the frailty phenotype), and links between perceptions of body weight, dietary intake, and physical function (via semi-structured interviews).

ANALYSIS

Bivariate and logistic regression analyses examined associations between frailty and low energy/nutrient intakes. Interviews were analyzed using inductive thematic analysis.

RESULTS

Seventy-six women completed a 24-hour dietary recall; 46 participated in a semi-structured interview. Low energy intake was associated with frailty (odds ratio [OR], 11.71; 95% confidence interval [CI], 2.36-57.97). After adjusting for energy and other confounders, a low intake of > 3 nutrients was associated with frailty (OR, 6.58; 95% CI, 1.01-43.08). Qualitative data suggest that dietary intake was influenced by concerns about body weight and perceptions that unhealthy foods reduce mobility.

CONCLUSIONS AND IMPLICATIONS

Among older migrant women with high prevalence of overweight/obesity, an inadequate dietary intake may be a stronger predictor of frailty than weight loss. Dietary interventions should focus on healthy weight maintenance and optimization of nutritional adequacy and physical function.

An exploratory study of the experience of fibromyalgia diagnosis in South Africa

Within the conceptual framework of 'medically-ill-defined' conditions, this article focuses on the experiences of 'diagnosis' through a narrative analysis of fibromyalgia (a chronic musculoskeletal pain disorder) in South Africa. In-depth interviews were used to collect narratives from 15 participants. The findings show how the contested and confusing experience of fibromyalgia diagnosis can be understood, by viewing the interactions that patients have with their practitioners, families, peers and colleagues. The currency of fibromyalgia as a diagnosis and the inequalities present in the South African health care system characterise the experiences of symptom recognition, diagnosis and treatment. The analysis reveals how those living with fibromyalgia search for diagnosis, and struggle to maintain legitimacy for their experience in the complex constellation of porous symptoms that appear infrequently. The findings of this study confirm the existing evidence that shows fibromyalgia to be a challenging illness experience, which is attributed to the lack of clarity and legitimacy, and high contestation that surrounds the condition. Additionally, this study presents the ways that limited access to diagnosis and treatment for fibromyalgia in the South African context shapes this specific illness experience, and the value of using narrative approaches to gain insight into how people live with hidden and poorly understood conditions in this environment.