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

A Novel Strategy to Increase Identification of African-Born People With Chronic Hepatitis B Virus Infection in the Chicago Metropolitan Area, 2012-2014

INTRODUCTION

Most research on hepatitis B virus (HBV) infection in the United States is limited to Asian populations, despite an equally high prevalence among African immigrants. The purpose of this study was to determine testing and detection rates of HBV infection among African-born people residing in the Chicago metropolitan area.

METHODS

A hepatitis education and prevention program was developed in collaboration with academic, clinical, and community partners for immigrant and refugee populations at risk for HBV infection. Community health workers implemented chain referral sampling, a novel strategy for recruiting hard-to-reach participants, targeting African-born participants. Participants were tested in both clinical and nonclinical settings. To assess infection status, blood samples were obtained for hepatitis B surface antigen (HBsAg), core antibody, and surface antibody testing. Demographic information was collected on age, sex, health insurance status, country of origin, and years residing in the United States. Participants were notified of testing results, and HBsAg-positive participants were referred for follow-up medical care.

RESULTS

Of 1,000 African-born people who received education, 445 (45%) agreed to participate in HBV screening. There were 386 (87%) participants tested in clinical and 59 (13%) tested in nonclinical sites. Compared with participants who were tested in clinical settings, participants tested in nonclinical settings were older, were less likely to have health insurance, and had lived in the United States longer (P < .005 for each). Of these, most were from the Democratic Republic of the Congo (14%), Nigeria (13%), Ghana (11%), Somalia (11%), or Ethiopia (10%). There were 35 (8%) HBsAg-positive people, 37% had evidence of past infection, and 29% were immune.

CONCLUSIONS

Chain referral sampling identified many at-risk African-born people with chronic HBV infection. The large proportion of HBsAg-positive people in this sample reinforces the need for health promotion programs that are culturally appropriate and community-driven.

Prevalence and Patterns of Prescription Drug Misuse among Young Ketamine Injectors

In recent years, epidemiological monitoring data has indicated sharp increases in prescription drug misuse. Despite these increases, little is known about the context or patterns associated with prescription drug misuse, particularly among youth or young injection drug users (IDUs). A three-city study of 213 young IDUs found prescription drug misuse to be pervasive, specifically the use of opioids and benzodiazepines. Particular practices not commonly associated with prescription drugs were reported, such as sniffing, smoking, and injection. Associated health risks included initiation into injection drug use, polydrug use, drug overdose, and drug dependency. A greater awareness of the potential health risks associated with prescription drug misuse should be incorporated into services that target IDUs, including street outreach, syringe exchanges, and drug treatment.

'And so I took up residence': The experiences of family members of people with dementia during admission to an acute hospital unit

It is estimated that a quarter of acute hospital beds are in use by older people with dementia at any one time. Little empirical research has been carried out that has specifically examined the day-to-day input of family members into the care of people with dementia during an acute hospital admission. In this article, we present the results of analysis of interviews with 26 family members of people with dementia about their experiences of supporting an admission of a person with dementia to an acute hospital unit in New Zealand. For all family members, the desire to support the person with dementia during their admission was at the forefront and was their primary focus. The theme, ‘And so I took up residence’, exemplifies fully the experiences of all of the family member participants. This study provides evidence that family members are a resource that may be unrecognised, untapped and unsupported in the event of hospitalisation of people with dementia.

A Practical Guide to Using the Positive Deviance Method in Health Services Research

OBJECTIVE

To provide practical tips for health services researchers considering the use of positive deviance (PD) methods to help explain variations in quality of care or other meaningful parameters.

DATA SOURCES

Published literature and personal experience.

STUDY DESIGN

Narrative review.

PRINCIPAL FINDINGS

This review includes a discussion of possible applications of PD to health services research, some methodological choices applicable to PD, and some brief tips regarding publishing the results and incorporating them into future interventions.

CONCLUSIONS

It is hoped that this article will help health services researchers to use this valuable research method more effectively, especially those who have not done so before.

The Emotional Experience of Motherhood in Planned Lesbian Families in the South African Context: "… Look How Good a Job I'm Doing, Look How Amazing We Are"

This article focuses on lesbian mothers' emotional experience of motherhood. It forms part of a larger qualitative and exploratory study with 10 lesbian couples in South Africa on their lived experience of planned motherhood. The study is located in a feminist phenomenological framework. Semi-structured interviews were conducted and interview transcripts were analyzed using thematic analysis. Participants described many different emotions associated with new motherhood: hope, joy, love, anxiety, helplessness, exhaustion, and feeling companionship and togetherness as well as feeling compromised and deprived. Mothers described these emotions but also focused on the development of a new identity, that of being a mother.

A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England

OBJECTIVES

To explore how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England. We explored women's perceptions of deinfibulation, caesarean section and vaginal delivery; their experiences of care during pregnancy and labour; and factors that affect ability to access these services, in order to make recommendations about future practice.

DESIGN

A descriptive, exploratory qualitative study using face-to-face semistructured interviews. Interviews were audio-recorded, transcribed and data were analysed using a thematic approach. An interpreter was used when required (n=3).

SETTING

Participants recruited from 2 community centres in Birmingham, England.

PARTICIPANTS

Convenience and snowball sample of 10 Somali women resident in Birmingham, who had accessed antenatal care services in England within the past 5 years.

RESULTS

3 core themes were interpreted: (1) Experiences of female genital mutilation during life, pregnancy and labour: Female genital mutilation had a significant physical and psychological impact, influencing decisions to undergo deinfibulation or caesarean section. Women delayed deinfibulation until labour to avoid undergoing multiple operations if an episiotomy was anticipated. (2) Experience of care from midwives: Awareness of female genital mutilation from midwives led to open communication and stronger relationships with women, resulting in more positive experiences. (3) Adaptation to English life: Good language skills and social support networks enabled women to access these services, while unfavourable social factors (eg, inability to drive) impeded.

CONCLUSIONS

Female genital mutilation impacts Somali women's experiences of antenatal and intrapartum care. This study suggests that midwives should routinely ask Somali women about female genital mutilation to encourage open communication and facilitate more positive experiences. As antenatal deinfibulation is unpopular, we should consider developing strategies to promote deinfibulation to non-pregnant women, to align with current guidelines. Women with unfavourable social factors may require additional support to improve access to English antenatal care services.

Percepção de risco: um campo de interesse para a interface ambiente, saúde e sustentabilidade

Neste artigo, os autores discutem o complexo campo da percepção, em particular da percepção de risco, a partir de um ensaio de natureza teórica e metodológica que busca destacar a sua relevância em pesquisas que dialogam com a interface ambiente, saúde e sustentabilidade. Reconhecendo que fatores sociais e culturais influenciam direta e indiretamente as percepções que os indivíduos têm sobre diferentes riscos, os autores sinalizam que estudos nesse campo podem evidenciar os interesses, os valores e os pontos de conflitos existentes nas arenas e oferecer insights que ajudariam os tomadores de decisão a aperfeiçoar processos decisórios com maior envolvimento da sociedade. Para além da percepção de risco, o artigo discute também exemplos de investigações conduzidas pelos autores com enfoque sobre percepção ambiental. Buscando uma perspectiva crítica para tratar o tema, reconhecem a necessidade de compreender nos processos ambientais e em contextos sociais a configuração dos riscos socioambientais e suas percepções.

First Year Open Enrollment Findings: Health Insurance Coverage for Asian Americans and the Role of Navigators

The health insurance coverage established by the Patient Protection and Affordable Care Act has created an opportunity to reduce racial/ethnic disparities in healthcare. It is expected that of the 24 million individuals projected to join, nearly one-half will be non-white and one-fourth will speak a language other than English at home. Asian Americans are one of the fastest growing racial/ethnic groups in the USA. The majority are foreign born and experience limited English proficiency. The role of navigators has been shown to increase enrollment rates of public insurance programs. They are trusted for their shared traditions and sense of community. By conducting culturally-targeted outreach, Cambodian, Chinese, Vietnamese, Korean, and Laotian community-based organizations were able to reach individuals for whom the percentage of uninsured is disproportionately high. They enrolled eligible Asians immigrants in coverage despite language barriers and limited health knowledge. Through a collaborative network, a community-level intervention was implemented that was associated with increases in first year marketplace enrollment and greater likelihood of obtaining a primary care physician. Preventable illnesses, lost productivity, and inadequate healthcare are major hardships in immigrant communities that bear similar burdens to society. Bringing primary care to the underserved helps to contain these costs.

House to house, shelter to shelter: experiences of black women seeking housing after leaving abusive relationships

Locating safe and affordable housing is a vital step for women who decide to leave their abuser. Without housing, many women, particularly those who live in poverty, are forced to remain in abusive relationships, accept inadequate or unsafe housing, or become homeless (Menard, 2001; Moses, 2010). Women who choose to leave their abusers are faced with multiple barriers in establishing their independence such as limited financial resources, mental illness, and the lack of affordable housing (Botein & Hetling, 2010), putting them at risk of revictimization. This pilot study explores the narratives of Black mothers currently residing at an emergency intimate partner violence shelter to discover their experiences in seeking housing after leaving abusive relationships with a focus on housing instability and mental health. Utilizing a qualitative descriptive design, four major themes emerged: (a) unstable/insecure housing over time, (b) limited support,

Impact of biogas digesters on cookhouse volatile organic compound exposure for rural Kenyan farmwomen

Women living on rural Kenyan smallholder dairy farms burn wood as biofuel in family cookhouses. Unventilated biofuel combustion produces harmful levels of respirable particles and volatile organic compound (VOC) emissions in indoor environments. Biogas digesters, which can generate high methane-content biogas from livestock manure composting were recently installed on 31 farms. The study objectives were to compare VOC exposure profiles for women cooking on farms with and without biogas digesters, and to compare seasonal variations in VOC exposures for those women cooking with biogas. Participants (n=31 biogas farms, n=31 referent farms) wore passive thermal desorption VOC sampling tubes and recorded cookhouse fuel use on time activity sheets for 7 days. Women using biogas spent significantly less time (mean=509 min/week) exposed to cookhouse wood smoke compared with the referent group (mean=1122 min/week) (P<0.01). Total VOC exposure did not differ between farm groups (P=0.14), though concentrations of trans-1,3-dichloropropene, bromoform, and 1,4-dichlorobenzene in biogas cookhouses were significantly lower than in referent cookhouses, even after Bonferroni correction. The composition of VOC species was also significantly different, reflecting the different fuel sources. Biogas digester technologies have great potential for reducing exposure to wood smoke VOCs in low-income countries.

Employment, Social Networks and Undocumented Migrants: The Employer Perspective

This article draws on data from qualitative interviews with ethnic enclave and ethnic economy business entrepreneurs from Chinese, Bangladeshi and Turkish-speaking communities in London. Routes into business and worker recruitment practices are explored, demonstrating the centrality of social capital in the form of family and other social networks within these processes. The article investigates what employers consider the desirable characteristics of workers: trust, kinship, gender, social networks, language compatibility and the needs of the business intersect with racialised notions of workers' strengths and characteristics. Finally, we consider changing practices in relation to the employment of undocumented migrants, in the context of an increasingly punitive legislative regime. The complex and variable impact of policy alongside the ways in which other obligations and positions outweigh the fear and risks of sanctions associated with non-compliance is revealed.

The Role of Identity Integration in Hedonic Adaptation to a Beneficial Life Change: The Example of "Coming Out" for Lesbians and Gay Men

After apparently beneficial life changes, people are expected to experience elevated well-being. However, research suggests that some individuals adapt quickly to change, so their well-being increases little in the long-term. We propose this phenomenon is explained by the integration of the changes into identity, in interaction with perceived valence of the changes. We hypothesized that higher integration would be associated with smaller increases in well-being for changes perceived as positive. For changes perceived as negative, higher integration would be associated with larger increases in well-being. Lesbians and gay men (N = 80) completed a questionnaire on well-being, perceived valence of coming out and its integration into identity. Moderated regressions supported the hypotheses, revealing the importance of considering identity integration and perceived valence in research on adaptation to changes. The results question the merits of interventions promoting identity integration.

Evidence of a link between taboos and sacrifices and resource scarcity of ritual plants

BACKGROUND

One of the main obstacles for the mainstreaming of religious traditions as tools for the conservation of nature is the limited applicability of research results in this field. We documented two different restrictions implemented by local people (taboos and sacrifices) related to the use of ritual plants in Benin (West Africa) and Gabon (Central Africa).

METHODS

To see whether these restrictions reflected plant scarcity from an etic perspective (official threat status) and an emic viewpoint (perceived scarcity by local people), we conducted 102 interviews with traditional healers and adepts of traditional faiths.

RESULTS

We documented a total of 618 ritual plants, from which 52 species were used in both countries. In Benin, the use of 63 of the 414 ritual plant species was restricted; while in Gabon 23 of the 256 ritual plants were associated with taboos and sacrifices. In Benin, restricted plants were significantly more often officially threatened, perceived as scarce, and actively protected than non-restricted plants. In the more forested and less densely populated Gabon, plants that were perceived as scarce were more often associated to local restrictions than officially threatened species.

CONCLUSIONS

These results prove the presence of a form of adaptive management where restrictions are related to resource scarcity and protection of ritual plant species. By providing baseline data on possibly endangered species, we demonstrate how plant use in the context of religious traditions can yield important information for conservation planning.

Occupational risks and pregnancy and infant health outcomes in Florida farmworkers

The agricultural industry has some of the highest incidence rates and numbers of occupational injuries and illnesses in the United States. Injuries and illnesses in agriculture result from accidents, falls, excessive heat, repetitive motion and adverse pesticide exposure. Women working in agriculture are exposed to the same hazards and risks as their male counterparts, but can face additional adverse impacts on their reproductive health. Yet, few occupational risk assessment studies have considered the reproductive health of female farmworkers. The objective of this community-based participatory research study was to conduct a retrospective, cross-sectional survey to collect information on workplace conditions and behaviors and maternal, pregnancy and infant health outcomes among a sample of female nursery and fernery farmworkers in Central Florida. Survey results showed that nursery workers were more likely to report health symptoms during their pregnancy than fernery workers. We also observed a self-reported increased risk of respiratory illness in the first year of life for infants whose mothers worked in ferneries. Our findings confirm that agricultural work presents potential reproductive hazards for women of childbearing age.

Our bodies are our own: resistance to ABC-based HIV-prevention programmes in northern Tanzanian conservation organisations

ABC-based HIV-prevention programmes have been widely employed in northern Tanzanian wildlife conservation settings in an attempt to (re)shape the sexual behaviours of conservation actors. Utilising findings from 66 semi-structured interviews conducted in 2009-2010, this paper examines ABC prevention as a form of Foucauldian governmentality--circulating technologies of power that mobilise disciplinary technologies and attempt to transform such efforts into technologies of the self--and explores how individuals understand and respond to attempts to govern their behaviour. ABC regimes attempt to rework subjectivity, positioning HIV-related behaviours within a risk-based neoliberal rationality. However, efforts to use ABC as a technology to govern populations and individual bodies are largely incommensurate with existing Tanzanian sociocultural formations, including economic and gendered inequalities, and local understandings of sexuality. The language research participants used to talk about ABC and the justifications they offered for non-compliance illuminate this discrepancy. Data reveal that the recipients of ABC campaigns are active producers of understandings that work for them in their lives, but may not produce the behavioural shifts envisioned by programme goals. These findings corroborate previous research, which questions the continued plausibility of ABC as a stand-alone HIV- prevention framework.

Associations of diet quality with dairy group membership, membership duration and non-membership for Kenyan farm women and children: a comparative study

OBJECTIVE

To examine associations among diet quality and dairy group membership, membership duration and non-member status for women and school-aged children in rural Kenya.

DESIGN

A cross-sectional survey, using chain referral sampling, was conducted and diet quality indices and prevalence of inadequate intake (PII) were estimated using the 'estimated average requirement' cut-off point method from single 24 h recalls, using a Kenyan nutrient database. PII was compared among members and non-members and among membership-duration groups.

SUBJECTS

Women and children of dairy group members (n 88), across membership-duration groups (1-3, 4-6, 7-9 and 10+ years), and non-members (n 23) living among members.

SETTING

Small farms in central Kenya.

RESULTS

Members had higher energy, percentage of energy from animal-source foods and dietary diversity. Member women and children had lower PII for respectively seven and three of eleven micronutrients. Reduced PII for milk-source micronutrients was associated with membership duration for women. Many member women (38%) had inadequate vitamin A intake and 39% of member children had inadequate Zn intake. Members' PII was also high (>45%) for Fe, Ca and vitamin B12. A higher prevalence of being overweight among member women compared with non-member women suggested nutrition transition effects of higher farm productivity.

CONCLUSIONS

Dairy group membership was positively associated with adequate quantity and quality of diets for women and children. Long-term membership was insufficient to address micronutrient deficiencies. Understanding and addressing barriers to better diet quality and strategies to mitigate negative nutrition transition effects are needed to optimize nutritional outcomes of dairy group membership.

Using risk model judgements to better understand perceptions of synergistic risks

Numerous scientific studies show that risk factors can interact to synergistically increase the likelihood of certain adverse and life-threatening outcomes. Yet, the extent to which individuals know that specific risk factor combinations present 'synergistic risks' is unclear and little is known about the determinants of such knowledge. This is largely because epistemological progress concerning this topic has been frustrated by a reliance on metrics that have latterly been judged to be of questionable validity. To address this issue, this paper presents two studies that assess an alternative approach (i.e., risk model judgements) which requires respondents to judge the risk for a factor combination relative to, rather than in isolation from, the risk attributable to each constituent factor. Results from both studies indicate that risk model judgements overcome the drawbacks of traditional metrics. More importantly, the results provide epistemological insights into what can determine whether an individual understands that a factor combination presents a synergistic risk; these determinants include experiential and intuitive insights into the effects of combining specific risk factors, domain-specific judgemental experience and exposure to effective learning opportunities. These findings can be utilized in interventions aimed at helping individuals to make better decisions concerning multiple risk factors.

The other side of the bridge: exploring the sexual relationships of men who have sex with men and their female partners in Mumbai, India

Behaviourally bisexual men have been identified as a 'bridge' population of HIV transmission to heterosexual women in India. Little is known about the sexual relationships that these men have with their female sex partners. The primary objective of this study was to explore the sexual practices and relationship dynamics between married and unmarried behaviourally bisexual men and their female sex partners in Mumbai, India. In 2009, semi-structured qualitative interviews were conducted with 32 men who reported sex with men and women. Participants discussed a variety of sexual practices and arrangements with female sex partners. Irrespective of marital status and sexual identity, many said that they had satisfying sexual experiences and feelings of affection for female sex partners. However, sexual incompatibility between married partners was also reported. Explanations of bisexual concurrency were discussed in terms of both sexual satisfaction and sexual preference. Self-perceived HIV risk related to same-sex sexual behaviour motivated many men to use condoms with female partners. Expectations of unprotected marital sex and perceptions of partner risk were barriers to condom use. HIV-prevention programmes for this population may benefit from tailored risk-reduction counselling that attends to the variations of these sexual and social relationship dynamics.

Sexual practices, identities and health among women who have sex with women in Lesotho - a mixed-methods study

Despite the high prevalence of HIV and STIs among women in Africa and the growing literature on HIV and STIs among women who have sex with women, research on the sexual health of women who have sex with women in Africa is scant. This study used mixed methods to describe sexual identity, practices and health among women who have sex with women in Lesotho. Most respondents (48%) described themselves as lesbian, 29% as bisexual and 23% as heterosexual. Almost half (45%) had disclosed their same-sex attraction to family, but only 25% had done so with healthcare workers. A total of 8% reported having HIV. Self-reported HIV was associated with having three or more male partners, having male and female partners at the same time and having a history of STIs. Gender norms, the criminalisation of homosexuality, varied knowledge of, and access to, safer-sex strategies, and mixed experiences of HIV/STI testing and sexual healthcare provided social and structural contexts for HIV- and STI-related vulnerability.

Healthcare professionals' perspectives on environmental sustainability

Background:

Human health is dependent upon environmental sustainability. Many have argued that environmental sustainability advocacy and environmentally responsible healthcare practice are imperative healthcare actions.

Research questions:

What are the key obstacles to healthcare professionals supporting environmental sustainability? How may these obstacles be overcome?

Research design:

Data-driven thematic qualitative analysis of semi-structured interviews identified common and pertinent themes, and differences between specific healthcare disciplines.

Participants:

A total of 64 healthcare professionals and academics from all states and territories of Australia, and multiple healthcare disciplines were recruited.

Ethical considerations:

Institutional ethics approval was obtained for data collection. Participants gave informed consent. All data were de-identified to protect participant anonymity.

Findings:

Qualitative analysis indicated that Australian healthcare professionals often take more action in their personal than professional lives to protect the environment, particularly those with strong professional identities. The healthcare sector’s focus on economic rationalism was a substantial barrier to environmentally responsible behaviour. Professionals also feared conflict and professional ostracism, and often did not feel qualified to take action. This led to healthcare professionals making inconsistent moral judgements, and feeling silenced and powerless. Constraints on non-clinical employees within and beyond the sector exacerbated these difficulties.

Discussion:

The findings are consistent with the literature reporting that organisational constraints, and strong social identification, can inhibit actions that align with personal values. This disparity can cause moral distress and residue, leading to feelings of powerlessness, resulting in less ethical behaviour.

Conclusion:

The data highlight a disparity between personal and professional actions to address environmental sustainability. Given the constraints Australian healthcare professionals encounter, they are unlikely to shift to environmentally responsible practice without support from institutions and professional associations. Professional development is required to support this endeavour. The poor transference of pro-ecological behaviour from one setting to another is likely to have international implications for healthcare practice.

Perceived Drug Use Functions and Risk Reduction Practices Among High-Risk Nonmedical Users of Prescription Drugs

Nonmedical use of prescription drugs has become the fastest growing drug problem in the United States, particularly among young adults. This study examines the reasons young polydrug users misuse prescription drugs, and explores how young users employ risk reduction strategies to minimize adverse consequences. The sample was recruited during 2008 and 2009 in Los Angeles and New York, and comprised 45 nonmedical users of prescription drugs, aged 16 to 25. Data from a semistructured interview were analyzed quantitatively and qualitatively. Participants reported nonmedical use of prescription drugs to change mood, to facilitate activity, and to monitor the intake of other substances. Commonly employed risk reduction strategies included calculating pill timing, dosage, and access, and monitoring frequency of use, particularly when combining different substances. Most study participants often planned drug use to occur within socially acceptable parameters, such that prescription drug misuse was a normalized feature of their everyday lives.

Control over drug acquisition, preparation and injection: Implications for HIV and HCV risk among young female injection drug users

Young female injection drug users (IDUs) are at risk for HIV/HCV, and initiating the use of a new drug may confer additional and unexpected risks. While gender differences in the social context of injection drug use have been identified, it is unknown whether those differences persist during the initiation of a new drug. This mixed-methods study examined the accounts of 30 young female IDUs in Los Angeles, CA, USA from 2004 to 2006, who described the social context of initiating injection drug use and initiating ketamine injection. The analysis aimed to understand how the social context of young women's injection events contributes to HIV/HCV risk. Women's initiation into ketamine injection occurred approximately 2 years after their first injection of any drug. Over that time, women experienced changes in some aspects of the social context of drug injection, including the size and composition of the using group. A significant proportion of women described injection events characterized by a lack of control over the acquisition, preparation, and injection of drugs, as well as reliance on friends and sexual partners. Findings suggest that lack of control over drug acquisition, preparation, and injection may elevate women's risk; these phenomena should be considered as a behavioral risk factor when designing interventions.

Deafness among physicians and trainees: a national survey

PURPOSE

To describe the characteristics of and accommodations used by the deaf and hard-of-hearing (DHoH) physician and trainee population and examine whether these individuals are more likely to care for DHoH patients.

METHOD

Multipronged snowball sampling identified 86 potential DHoH physician and trainee participants. In July to September 2010, a Web-based survey investigated accommodations used by survey respondents. The authors analyzed participants' demographics, accommodation and career satisfaction, sense of institutional support, likelihood of recommending medicine as a career, and current/anticipated DHoH patient population size.

RESULTS

The response rate was 65% (56 respondents; 31 trainees and 25 practicing physicians). Modified stethoscopes were the most frequently used accommodation (n = 50; 89%); other accommodations included auditory equipment, note-taking, computer-assisted real-time captioning, signed interpretation, and oral interpretation. Most respondents reported that their accommodations met their needs well, although 2 spent up to 10 hours weekly arranging accommodations. Of 25 physicians, 17 reported primary care specialties; 7 of 31 trainees planned to enter primary care specialties. Over 20% of trainees anticipated working with DHoH patients, whereas physicians on average spent 10% of their time with DHoH patients. Physicians' accommodation satisfaction was positively associated with career satisfaction and recommending medicine as a career.

CONCLUSIONS

DHoH physicians and trainees seemed satisfied with frequent, multimodal accommodations from employers and educators. These results may assist organizations in planning accommodation provisions. Because DHoH physicians and trainees seem interested in primary care and serving DHoH patients, recruiting and training DHoH physicians has implications for the care of this underserved population.

Patterns of prescription drug misuse among young injection drug users

Misuse of prescription drugs and injection drug use has increased among young adults in the USA. Despite these upward trends, few studies have examined prescription drug misuse among young injection drug users (IDUs). A qualitative study was undertaken to describe current patterns of prescription drug misuse among young IDUs. Young IDUs aged 16-25 years who had misused a prescription drug, e.g., opioids, tranquilizers, or stimulants, at least three times in the past 3 months were recruited in 2008 and 2009 in Los Angeles (n = 25) and New York (n = 25). Informed by an ethno-epidemiological approach, descriptive data from a semi-structured interview guide were analyzed both quantitatively and qualitatively. Most IDUs sampled were both homeless and transient. Heroin, prescription opioids, and prescription tranquilizers were frequently misused in the past 30 days. Qualitative results indicated that young IDUs used prescription opioids and tranquilizers: as substitutes for heroin when it was unavailable; to boost a heroin high; to self-medicate for health conditions, including untreated pain and heroin withdrawal; to curb heroin use; and to reduce risks associated with injecting heroin. Polydrug use involving heroin and prescription drugs resulted in an overdose in multiple cases. Findings point to contrasting availability of heroin in North American cities while indicating broad availability of prescription opioids among street-based drug users. The results highlight a variety of unmet service needs among this sample of young IDUs, such as overdose prevention, drug treatment programs, primary care clinics, and mental health services.

The dual nature of medical enculturation in postgraduate medical training and practice

OBJECTIVES

Enculturation is a normal and continuing part of human development. This study examined how medical graduates perceive the process of enculturation after graduation.

METHODS

We conducted a qualitative study of the values of medical graduates associated with Sydney Medical School to identify processes that contribute to the ongoing process of enculturation.

RESULTS

Two processes contributing to the process of enculturation were identified. Participants were aware of having passively absorbed the explicit and implicit culture of medicine, and of having actively sought to assimilate (or to avoid assimilating) the medical culture. The processes of enculturation were particularly evident in relation to three major concerns: competence; patient-centredness, and self-care.

CONCLUSIONS

The participants in this study demonstrated the capacity to reflect on and differentiate between two types of enculturation: absorption and assimilation. They were aware of the impacts of enculturation with respect to three main sets of values that are, respectively, epistemic, interpersonal and personal. Faculty development programmes might benefit from paying explicit attention to the process of enculturation and its influence on learning and practice.

Pilot study on the impact of biogas as a fuel source on respiratory health of women on rural Kenyan smallholder dairy farms

Biomass burning in indoor environments has been highlighted as a major cause of respiratory morbidity for women and children in low-income countries. Inexpensive technological innovations which reduce such exposures are needed. This study evaluated the impact of low tech compost digesters, which generate biogas for cooking, versus traditional fuel sources on the respiratory health of nonsmoking Kenyan farmwomen. Women from 31 farms with biogas digesters were compared to age-matched women from 31 biomass-reliant farms, in June 2010. Only 43% of the biogas group reported any breathing problems, compared to 71% in the referent group (P = 0.03). Referent women self-reported higher rates of shortness of breath (52% versus 30%), difficulty breathing (42% versus 23%), and chest pain while breathing (35% versus 17%) during the last 6 months (P = 0.09 to 0.12) compared to biogas women. Biogas women demonstrated slightly better spirometry results but differences were not statistically significant, likely due to limited latency between biogas digester installation and spirometry testing. Most biogas women reported improved personal respiratory health (87%) and improved children's health (72%) since biogas digester installation. These findings suggest that using biogas in cookhouses improves respiratory symptoms but long-term impacts on lung function are unclear.

Denial of prescription opioids among young adults with histories of opioid misuse

OBJECTIVES

An exploratory study was undertaken to examine how being denied prescription opioids to treat pain impacted the drug-using careers of young adults with a history of misuse of prescription drugs.

DESIGN

Ethno-epidemiological methodology utilizing a cross-sectional design, semi-structured interviews, and qualitative/quantitative data analysis. Settings.  Non-clinical participants were recruited from natural settings, such as streets, parks, beaches, and college campuses, in New York City and Los Angeles during 2008 and 2009.

PARTICIPANTS

One hundred fifty participants aged 16 to 25 who had misused a prescription opioid, tranquilizer, or stimulant in the past 90 days. Outcome Measures.  Analyses focused on denial of opioids and associated consequences, including self-medication with prescription opioids and heroin.

RESULTS

Thirty-four participants (22.7%) described being denied prescription opioids for the treatment of a painful condition. Current opioid misuse and current pain problems were higher in this group compared to those who had never been denied prescription opioids. Reasons for denial included being identified as a drug user by a physician, lack of health insurance, and having medication withheld by a parent or authority figure. Approximately half reported self-medicating pain with either illegally obtained prescription opioids or heroin. Self-medication often coincided with initiation of new risk behaviors and more intensive drug use.

CONCLUSION

Being denied prescription opioids was an important moment in the drug using careers of many study participants. Results suggest that effective pain management techniques are needed to prevent high-risk young adults with pain problems from engaging in escalated opioid misuse and risk behaviors.

Cluster sampling with referral to improve the efficiency of estimating unmet needs among pregnant and postpartum women after disasters

INTRODUCTION AND BACKGROUND

Women of reproductive age, in particular women who are pregnant or fewer than 6 months postpartum, are uniquely vulnerable to the effects of natural disasters, which may create stressors for caregivers, limit access to prenatal/postpartum care, or interrupt contraception. Traditional approaches (e.g., newborn records, community surveys) to survey women of reproductive age about unmet needs may not be practical after disasters. Finding pregnant or postpartum women is especially challenging because fewer than 5% of women of reproductive age are pregnant or postpartum at any time.

METHODS

From 2009 to 2011, we conducted three pilots of a sampling strategy that aimed to increase the proportion of pregnant and postpartum women of reproductive age who were included in postdisaster reproductive health assessments in Johnston County, North Carolina, after tornadoes, Cobb/Douglas Counties, Georgia, after flooding, and Bertie County, North Carolina, after hurricane-related flooding.

RESULTS

Using this method, the percentage of pregnant and postpartum women interviewed in each pilot increased from 0.06% to 21%, 8% to 19%, and 9% to 17%, respectively.

CONCLUSION AND DISCUSSION

Two-stage cluster sampling with referral can be used to increase the proportion of pregnant and postpartum women included in a postdisaster assessment. This strategy may be a promising way to assess unmet needs of pregnant and postpartum women in disaster-affected communities.

Recruitment of a rural, southern, predominantly African-American population into a diabetes self-management trial

We are conducting a community-based cluster-randomized trial in rural Alabama, testing a peer-support intervention designed to improve diabetes self-care behaviors. We describe recruitment and data collection approaches used, focusing on strategies that created community partnerships and facilitated recruitment in underserved, rural, largely minority communities. Key recruitment and data collection strategies included early community engagement; pilot testing of procedures; inclusion of community members as study team members, recruiters, and data collectors; data collection at community venues to minimize participant travel requirements; and provision of a multi-disciplinary diabetes education program to both intervention and control participants. A total of 424 participants were recruited and enrolled (400 targeted). Of the 759 referrals received, 78.9% (n=599) successfully completed telephone screening. Of these, 78.8% (n=472) were eligible and scheduled for a local enrollment day, and 81.4% (n=384) attended and enrolled in the study. In addition, community members who walked in and expressed interest were screened, and 40 eligible and willing individuals were consented and enrolled. We exceeded recruitment goals in underserved, rural communities in Alabama. This success was due in large part to community partnerships that facilitated community involvement on several levels: engaging the community early in study proposal and design; hiring community members to fill various capacities as research team members, recruiters, and data collectors; conducting data collection within communities; and collecting additional contact information to maintain communication. Providing diabetes education to all participants, including intervention and control, helped ensure that everyone stood to benefit and likely enhanced overall participation.

U.K. parents' decision-making about measles-mumps-rubella (MMR) vaccine 10 years after the MMR-autism controversy: a qualitative analysis

BACKGROUND AND OBJECTIVES

Public concern about an unsubstantiated link between MMR vaccine and autism stemmed from a 1998 paper by Dr Andrew Wakefield and colleagues, and the substantial media coverage which that work attracted. Though the Wakefield paper is now discredited and an MMR-autism link has never been demonstrated empirically, this concern has manifested in over a decade of suboptimal MMR uptake. Few qualitative studies have explored parents' MMR decision-making since uptake began to improve in 2004. This study updates and adds methodological rigour to the evidence base.

METHODS

24 mothers planning to accept, postpone or decline the first MMR dose (MMR1) for their 11-36 month-old children, described their decision-making in semi-structured interviews. Mothers were recruited via General Practice, parents' groups/online forums, and chain referral. MMR1 status was obtained from General Practice records 6 months post-interview. Interview transcripts were coded and interpreted using a modified Grounded Theory approach.

RESULTS

Five themes were identified: MMR vaccine and controversy; Social and personal consequences of MMR decision; Health professionals and policy; Severity and prevalence of measles, mumps and rubella infections; Information about MMR and alternatives. Results indicated that MMR1 acceptors were sympathetic toward Wakefield as a person, but universally rejected his study which sparked the controversy; parents opting for single vaccines expressed the sense that immune overload is not a consideration but that not all three components of MMR are warranted by disease severity; and MMR1 rejectors openly criticised other parents' MMR decisions and decision-making.

CONCLUSIONS

This study corroborated some previous qualitative work but indicated that the shrinking group of parents now rejecting MMR comprises mainly those with more extreme and complex anti-immunisation views, whilst parents opting for single vaccines may use second-hand information about the controversy. In response, policymakers and practitioners should revise their expectations of today's MMR decision-makers, and their methods for supporting them.

Initiation into prescription opioid misuse amongst young injection drug users

BACKGROUND

Prescription opioids are the most frequently misused class of prescription drugs amongst young adults. Initiation into prescription opioid misuse is an important public health concern since opioids are increasingly associated with drug dependence and fatal overdose. Descriptive data about initiation into prescription opioid misuse amongst young injection drug users (IDUs) are scarce.

METHODS

An exploratory qualitative study was undertaken to describe patterns of initiation into prescription opioid misuse amongst IDUs aged 16-25 years. Those young IDUs who had misused a prescription drug at least three times in the past three months were recruited during 2008 and 2009 in Los Angeles (n=25) and New York (n=25). Informed by an ethno-epidemiological approach, descriptive data from a semi-structured interview guide were analysed both quantitatively and qualitatively.

RESULTS

Initiation into prescription opioid misuse was facilitated by easy access to opioids via participant's own prescription, family, or friends, and occurred earlier than misuse of other illicit drugs, such as heroin. Nearly all transitioned into sniffing opioids, most injected opioids, and many initiated injection drug use with an opioid. Motives for transitions to sniffing and injecting opioids included obtaining a more potent high and/or substituting for heroin; access to multiple sources of opioids was common amongst those who progressed to sniffing and injecting opioids.

CONCLUSION

Prescription opioid misuse was a key feature of trajectories into injection drug use and/or heroin use amongst this sample of young IDUs. A new pattern of drug use may be emerging whereby IDUs initiate prescription opioid misuse before using heroin.

Taxonomy of the psychosocial consequences caused by the violence of persecution of ETA's network

This paper delimits and analyzes the effects of the harassment perpetrated by ETA's terrorist network in the Basque Country. The aim was to provide a taxonomy of the consequences of psychological violence and to validate this taxonomy, by means of a content analysis of 37 testimonies of victims of terrorist violence. The taxonomy of consequences of psychological violence is made up by four components: 1. the effects on the context of the persons affected, 2. on their emotional state, 3. on cognition and 4. on behavior. Results show a predominance of contextual consequences and negative cognitions. Intra-observer and inter-observer reliability analysis showed high stability and reproducibility coefficients. This study shows that harassment and psychological violence have major consequences not only for victims but also for family members, threatened collectives and even the society as a whole.

Longitudinal trajectories of ketamine use among young injection drug users

BACKGROUND

Ketamine is a dissociative anaesthetic that became increasingly popular in the club and rave scene in the 1980s and 1990s. Reports surfaced in the late 1990s indicating that ketamine was being injected in several U.S. cities by young injection drug users (IDUs). Since all studies on ketamine injection were cross-sectional, a longitudinal study was undertaken in 2005 to determine: characteristics of young IDUs who continue to inject ketamine; frequency of ketamine injection over an extended time period; risks associated with ongoing ketamine injection; and environmental factors that impact patterns of ketamine use.

METHODS

Young IDUs aged 16-29 with a history of injecting ketamine (n=101) were recruited from public locations in Los Angeles and followed during a 2-year longitudinal study. A semi-structured instrument captured quantitative and qualitative data on patterns of ketamine injection and other drug use. A statistical model sorted IDUs who completed three or more interviews (n=66) into three groups based upon patterns of ketamine injection at baseline and follow-up. Qualitative analysis focused on detailed case studies within each group.

RESULTS

IDUs recruited at baseline were typically in their early 20s, male, heterosexual, white, and homeless. Longitudinal injection trajectories included: "Moderates," who injected ketamine several times per year (n=5); "Occasionals," who injected ketamine approximately once per year (n=21); and "Abstainers," who did not inject any ketamine during follow-up (n=40). Findings suggest that ketamine is infrequently injected compared to other drugs such as heroin, cocaine, and methamphetamine. Most IDUs who begin injecting ketamine will stop or curb use due to: negative or ambivalent experiences associated with ketamine; an inability to find the drug due to declining supply; or maturing out of injecting drugs more generally.

CONCLUSION

Reducing ketamine injection among young IDUs may best be accomplished by targeting particular groups of IDUs identified in this study, such as homeless youth and homeless travellers.

'Reaching the hard to reach'--lessons learned from the VCS (voluntary and community Sector). A qualitative study

Background

The notion 'hard to reach' is a contested and ambiguous term that is commonly used within the spheres of social care and health, especially in discourse around health and social inequalities. There is a need to address health inequalities and to engage in services the marginalized and socially excluded sectors of society.

Methods

This paper describes a pilot study involving interviews with representatives from eight Voluntary and Community Sector (VCS) organisations. The purpose of the study was to explore the notion of 'hard to reach' and perceptions of the barriers and facilitators to accessing services for 'hard to reach' groups from a voluntary and community sector perspective.

Results

The 'hard to reach' may include drug users, people living with HIV, people from sexual minority communities, asylum seekers, refugees, people from black and ethnic minority communities, and homeless people although defining the notion of the 'hard to reach' is not straight forward. It may be that certain groups resist engaging in treatment services and are deemed hard to reach by a particular service or from a societal stance. There are a number of potential barriers for people who may try and access services, including people having bad experiences in the past; location and opening times of services and how services are funded and managed. A number of areas of commonality are found in terms of how access to services for 'hard to reach' individuals and groups could be improved including: respectful treatment of service users, establishing trust with service users, offering service flexibility, partnership working with other organisations and harnessing service user involvement.

Conclusions

If health services are to engage with groups that are deemed 'hard to reach' and marginalised from mainstream health services, the experiences and practices for engagement from within the VCS may serve as useful lessons for service improvement for statutory health services.

Recruiting and retaining mobile young injection drug users in a longitudinal study

Longitudinal studies that research homeless persons or transient drug users face particular challenges in retaining subjects. Between 2005 and 2006, 101 mobile young injection drug users were recruited in Los Angeles into a 2-year longitudinal study. Several features of ethnographic methodology, including fieldwork and qualitative interviews, and modifications to the original design, such as toll-free calls routed directly to ethnographer cell phones and wiring incentive payments, resulted in retention of 78% of subjects for the first follow-up interview. Longitudinal studies that are flexible and based upon qualitative methodologies are more likely to retain mobile subjects while also uncovering emergent research findings.

THE FIRST INJECTION EVENT: DIFFERENCES AMONG HEROIN, METHAMPHETAMINE, COCAINE, AND KETAMINE INITIATES

This article describes how the drug type injected at the first injection event is related to characteristics of the initiate, risk behaviors at initiation, and future drug-using trajectories. A diverse sample (n=222) of young injection drug users (IDUs) were recruited from public settings in New York, New Orleans, and Los Angeles during 2004 and 2005. The sample was between 16 and 29 years old, and had injected ketamine at least once in the preceding two years. Interview data was analyzed both quantitatively and qualitatively. Young IDUs initiated with four primary drug types: heroin (48.6%), methamphetamine (20.3%), ketamine (17.1%), and cocaine (14%). Several variables evidenced statistically significant relationships with drug type: age at injection initiation, level of education, region of initiation, setting, mode of administration, patterns of self-injection, number of drugs ever injected, current housing status, and their hepatitis C virus (HCV) status. Qualitative analyses revealed that rationale for injection initiation and subjective experiences at first injection differed by drug type.

Multiple drug use and polydrug use amongst homeless traveling youth

Diverse forms of drug use are an emerging theme within research on young people and substance use. This manuscript, based on a three city study of health risks amongst young injection drug users, explores multiple drug use and polydrug use amongst a subset of homeless youth referred to as "travelers." In particular, we outline characteristics of homeless traveler youths and the various ways in which they practiced multiple drug use and polydrug use. From here, we discuss some theoretical and public health implications of multiple drug use and polydrug use amongst this particular population.

Lesbians' constructions of depression

Lesbians are a marginalized group of women living in a heteronormative society. This study describes lesbians' subjective experiences of depression, and identifies the ways that dominant and alternative discourses shaped their understandings of depression and sexuality. Twelve self-identified lesbians participated in up to three in-depth interviews conducted over a 9-month period. Thematic analysis led to themes that explicated their physical and emotional descriptions of depression; identified troubled interpersonal relationships as a primary source of depression; and discussed the means implemented to cope with depression, including taking medication, engaging in therapy, developing social support networks, and discovering their own spirituality. Depression and sexuality were understood within the framework of the dominant discourses of (1) medical model, (2) dysfunctional family, and (3) organized religion; and the alternative discourses of (1) lesbian identity, (2) alternative families, and (3) spirituality. Nurses in clinical practice can assist depressed lesbian clients by bolstering explorations of spirituality and the development of strong support networks within the lesbian and gay communities. Politically, institutionalized heteronormativity must be attacked at every level.

HIV risk behaviors among Mahuwahine (native Hawaiian transgender women)

This study explored HIV risk behaviors among Hawaiian and Polynesian- identified transgender women living in Hawai'i. The term transgender encompasses the experience of individuals who violate rigid binomial Western gender roles (Bockting, Robinson, & Rosser, 1998; Lombardi, Wilchins, Priesing, & Malouf, 2001; Yep & Pietri, 1999, pp. 199-200). Although traditional Polynesian cultures tolerate more gender role variations than Western culture, postcolonial acculturation has resulted in notable stigma for transgender individuals in Hawaiì today (Kameèleihiwa, 1999; Kanuha, 2000). Mahu is a cross-Polynesian term originally describing transgender women or female-acting males (Link, 2004; Nanda, 2000; Odo & Hawelu, 2001; Souza, 1976). Mahuwahine is a newly coined term of empowerment among Hawaiì's transgender community signifying male-to-female (MTF) transgender identity in varying, personally chosen, forms and coincides with the Hawaiian cultural renaissance (Odo & Hawelu, 2001). Although most of the participants in this study identified as mahu or Mahuwahine there was a significant range in self-identifying terminology. Because of this range and intended audience this article will use the term transgender women in referring to individuals described in the findings.

"Research chemicals": tryptamine and phenethylamine use among high-risk youth

Tryptamines and phenethylamines are two broad categories of psychoactive substances with a long history of licit and illicit use. Profiles of users of recently emerging tryptamines and phenethylamines are nonexistent, however, since surveillance studies do not query the use of these substances. This manuscript describes the types, modes of administration, onset of use, and context of use of a variety of lesser known tryptamines and phenethylamines among a sample of high-risk youth. Findings are based upon in-depth interviews with 42 youth recruited in public settings in Los Angles during 2005 and 2006 as part of larger study examining health risks associated with injecting ketamine. Youth reported that their use of tryptamines and phenethylamines was infrequent, spontaneous, and predominately occurred at music venues, such as festivals, concerts, or raves. Several purchased a variety of these "research chemicals" from the Internet and used them in private locations. While many described positive experiences, reports of short-term negative health outcomes included nausea, vomiting, diarrhea, disorientations, and frightening hallucinations. These findings, based upon pilot study data, move toward an epidemiology of tryptamine and phenethylamine use among high-risk youth.

Towards an Explanation of Subjective Ketamine Experiences among Young Injection Drug Users

Ketamine is a dissociative anesthetic with powerful sedative and hallucinogenic properties. Despite the wide variability in reported subjective experiences, no study has attempted to describe the particular factors that shape these experiences. This manuscript is based upon a sample of 213 young injection drug users recruited in New York, New Orleans, and Los Angeles with histories of ketamine use. Qualitative interviews focused on specific ketamine events, such as first injection of ketamine, most recent injection of ketamine, and most recent experience sniffing ketamine. Findings indicate that six factors impacted both positive and negative ketamine experiences: polydrug use, drug using history, mode of administration, quantity and quality of ketamine, user group, and setting. Most subjective experiences during any given ketamine event were shaped by a combination of these factors. Additionally, subjective ketamine experiences were particularly influenced by a lifestyle characterized by homelessness and traveling.

The utility of non-proportional quota sampling for recruiting at-risk women for microbicide research

In the context of a measurement development study designed to contextualize microbicide acceptability, a sample that represented a range of at-risk women and maintained the statistical power needed for validity analyses was required. A non-proportional quota sampling strategy focused on race/ethnicity and number of sexual partners was utilized. This strategy resulted in enrollment of approximately equal proportions of Latina (31%), Black (36%), and White (32%) women, and an approximately 1:2 ratio of single-partnered (29%) and multi-partnered (71%) women. About 17% of women screened were ineligible based on eligibility criteria; an additional 16% were ineligible based on quota closures. Most participants were recruited through word of mouth (39%), community-based organizations (19%), or media sources (19%). Women recruited through word of mouth had the highest screen-to-interview completion percentage (67%). Non-proportional quota sampling is a feasible option for ensuring adequate representation of sample characteristics in microbicide research, but this goal should be weighed against cost and staff burden.