Women's decision-making about their health care: views over the life cycle

Women's decision making about antidepressant use during pregnancy: A narrative review

BACKGROUND

Depression is common, particularly among women of childbearing age, and can have far-reaching negative consequences if untreated. Efficacious treatments are available, but little is known about how women make depression treatment decisions during pregnancy. The purpose of this narrative review is to interpretively synthesize literature on women's decision making (DM) regarding antidepressant use during pregnancy.

METHODS

The databases PubMed, CINAHL, and PsycINFO were searched between May 2015 and August 2017 for peer-reviewed, English-language papers using terms such as "depression," "pregnancy," and "DM." The literature matrix abstraction method was used to systematically abstract data from full articles that met criteria for inclusion.

RESULTS

Of the articles abstracted (N = 10), half did not cite a DM theory on which the work was based. Key aspects of DM for this population were need for information and decision support, desire for active participation in DM, reflection on beliefs and values, evaluation of treatment option sequelae, and societal expectations. Treatment DM for depression during pregnancy is particularly impacted by the stigma associated with depression and societal expectations of pregnant women related to medication use during pregnancy. These findings, however, were based on studies of predominantly Caucasian and well-educated women.

CONCLUSIONS

Women require a nonjudgmental environment, in which shared DM feels safe, to foster positive DM experiences and outcomes. Future research is needed to define how to best support women to make depression treatment decisions in pregnancy, with particular attention to DM in the second and third trimesters of pregnancy.

Involvement of Family Members and Professionals in Older Women's Post-Fall Decision Making

This exploratory, descriptive study examined involvement of family members and professionals in older women's post-fall decision making. We conducted semistructured interviews with 17 older women who had recently fallen and 11 individuals these women identified as being engaged in their post-fall decision-making processes. Qualitative data analysis involved open and axial coding and development of themes. After experiencing a fall, these older women's openness to others' opinions and advice; their assessments of types and credibility of potential information sources; and the communication practices they established with these sources influenced how they accessed, accepted, or rejected information from family members and professionals. Increased awareness of the involvement of others in post-fall decision making could enhance communication with older women who fall. Developing and implementing practical strategies to help family members and professionals initiate and engage in conversations about falls and their consequences could lead to more open decision making and improved post-fall quality of life among older women.

Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making

BACKGROUND

In recent years, compounded bioidentical hormone therapy (CBHT) has emerged as a popular alternative to manufactured, FDA approved hormone therapy (HT)-despite concerns within the medical community and the availability of new FDA approved "bioidentical" products. This study aims to characterize the motivations for using CBHT in a U.S. sample of ordinary midlife women.

METHODS

We analyze data collected from 21 current and former users of CBHT who participated in a larger qualitative study of menopausal decision-making among U.S. women. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed thematically using an iterative inductive and deductive process.

RESULTS

Although women's individual motivations varied, two overarching themes emerged: "push motivations" that drove women away from conventional HT and from alternative therapies, and "pull motivations" that attracted women to CBHT. Push motivations focused on (1) fear and uncertainty about the safety of conventional HT, (2) an aversion to conjugated estrogens in particular, and (3) and overarching distrust of a medical system perceived as dismissive of their concerns and overly reliant on pharmaceuticals. Participants also voiced dissatisfaction with the effectiveness of herbal and soy supplements. Participants were attracted to CBHT because they perceive it to be (1) effective in managing menopausal symptoms, (2) safer than conventional HT, (3) tailored to their individual bodies and needs, and (4) accompanied by enhanced clinical care and attention.

CONCLUSIONS

This study finds that women draw upon a range of "push" and "pull" motivations in their decision to use CBHT. Importantly, we find that women are not only seeking alternatives to conventional pharmaceuticals, but alternatives to conventional care where their menopausal experience is solicited, their treatment goals are heard, and they are engaged as agents in managing their own menopause. The significance of this finding goes beyond understanding why women choose CBHT. Women making menopause treatment decisions of all kinds would benefit from greater shared decision-making in the clinical context in which they are explicitly invited to share their experiences, priorities, and preferences. This would also provide an opportunity for clinicians to discuss the pros and cons of conventional HT, CBHT, and other approaches to managing menopause.

An Exploratory Survey of Older Women's Post-Fall Decisions

This research examined factors influencing older women's post-fall decision making. We surveyed 130 independent older women from continuing care retirement communities and non-institutional homes. We categorized women's post-fall decisions as medical, corrective, and social decisions, and examined the associations between post-fall decision categories, decisional conflict, number of post-fall changes, self-rated health, frequency of falls, severity of falls, health literacy, awareness and openness to long-term care institutional options, and demographics. Older women experienced greater decisional conflict when making medical decisions versus social ( p = .012) and corrective ( p = .047) decisions. Significant predictors of post-fall decisional conflict were awareness of institutional care options ( p = .001) and health literacy ( p = .001). Future educational interventions should address knowledge deficits and provide resources to enhance collaborative efforts to lower women's post-fall decisional conflict and increase satisfaction in the decisions they make after a fall.

How Do Qataris Source Health Information?

BACKGROUND

Qatar is experiencing rapid population expansion with increasing demands on healthcare services for both acute and chronic conditions. Sourcing accurate information about health conditions is crucial, yet the methods used for sourcing health information in Qatar are currently unknown. Gaining a better understanding of the sources the Qatari population use to recognize and manage health and/or disease will help to develop strategies to educate individuals about existing and emerging health problems.

OBJECTIVE

To investigate the methods used by the Qatari population to source health information. We hypothesized that the Internet would be a key service used to access health information by the Qatari population.

METHODS

A researcher-led questionnaire was used to collect information from Qatari adults, aged 18-85 years. Participants were approached in shopping centers and public places in Doha, the capital city of Qatar. The questionnaire was used to ascertain information concerning demographics, health status, and utilization of health care services during the past year as well as sources of health information used.

RESULTS

Data from a total of 394 eligible participants were included. The Internet was widely used for seeking health information among the Qatari population (71.1%). A greater proportion of Qatari females (78.7%) reported searching for health-related information using the Internet compared to Qatari males (60.8%). Other commonly used sources were family and friends (37.8%) and Primary Health Care Centers (31.2%). Google was the most commonly used search engine (94.8%). Gender, age and education levels were all significant predictors of Internet use for heath information (P<0.001 for all predictors). Females were 2.9 times more likely than males (P<0.001) and people educated to university or college level were 3.03 times more likely (P<0.001) to use the Internet for heath information.

CONCLUSIONS

The Internet is a widely used source to obtain health-related information by the Qatari population. Internet search engines can be utilized to guide users to websites, developed and monitored by healthcare providers, to help convey reliable and accurate health information to Qatar's growing population.

Identifying families' shared disease experiences through a qualitative analysis of online twin-to-twin transfusion syndrome stories

Background

Twin-to-twin transfusion syndrome (TTTS) affects 10–20 % of monochorionic diamniotic (MCDA) births and accounts for 50 % of fetal loss in MCDA pregnancies. This exploratory qualitative study identified shared experiences, including potential emotional and psychosocial impacts, of this serious disease.

Methods

Forty-five publicly accessible, online stories posted by families who experienced TTTS were analyzed using grounded theory.

Results

Shared TTTS experiences included a common trajectory: early pregnancy experiences, diagnostic experiences, making decisions, interventions and variable outcomes. Families vacillated between emotional highs such as joy, excitement and relief, and lows including depression, anxiety, anger and grief.

Conclusions

TTTS disease experience can be considered an “emotional roller coaster” exacerbated by TTTS’s unpredictable and quickly changing nature with the potential for emotional and psychosocial effects. Increased TTTS awareness and research about its corresponding impacts can ensure appropriate patient and family support at all phases of the TTTS experience.

Young breast cancer patients' involvement in treatment decisions: the major role played by decision-making about surgery

OBJECTIVE

The objective of this study is to investigate young breast cancer patients' preferred and actual involvement in decision-making about surgery, chemotherapy, and adjuvant endocrine therapy (AET).

METHODS

A total of 442 women aged 18-40 years at the time of the diagnosis participated in the region-wide ELIPPSE40 cohort study (southeastern France). Logistic regression analyses were performed on various factors possibly affecting patients' preferred and perceived involvement in the decisions about their cancer treatment.

RESULTS

The women's mean age was 36.8 years at enrollment. Preference for a fully passive role in decision-making was stated by 20.7% of them. It was favored by regular breast surveillance (p = 0.04) and positive experience of being informed about cancer diagnosis (p = 0.02). Patients' preferences were independently associated with their reported involvement in decision-making about surgery (p = 0.01). A fully passive role in decision-making about chemotherapy and AET was more likely to be reported by patients who perceived their involvement in decision-making about surgery as having been fully passive (adjusted odds ratio = 4.8, CI95% [2.7-8.7], and adjusted odds ratio = 9.8, CI95% [3.3-29.2], respectively). This study shows a significant relationship between the use of antidepressants and involvement in decision-making about surgery, and confirms the relationship between impaired quality of life (in the psychological domain) and a fully passive role in decisions about cancer treatment.

CONCLUSIONS

Patients' involvement in decision-making about chemotherapy and AET was strongly influenced by their experience of decision-making about surgery, regardless of their tumor stage and history of breast or ovarian cancer. When decisions are being made about surgery, special attention should be paid to facilitating breast cancer patients' involvement in the decision-making.

Social Positioning Theory as a lens for exploring health information seeking and decision making

In this article I use Social Positioning Theory to explore the experiences of women as they interact with and make sense of evolving health information mediated by formal and informal sources. I investigate how women position themselves within their accounts of information seeking, and the influence of positioning on interactions with health professionals (HPs). Interviewed women gathered and valued information from a range of sources, and were likely to position themselves as autonomous, rather than collaborative or dependent. Faced with evolving health information, women felt responsible not only for information seeking, but also for making sense of gathered and encountered information. Participants did, however, value information provided by HPs and were likely to view decision making as collaborative when HPs fostered information exchange, appeared to appreciate different types of knowledge and cognitive authority, and supported women in their quests for information. Implications for shared decision making are discussed.

Women's prelabour preference for epidural analgesia: a cross-sectional study among women from the Netherlands and Belgium

BACKGROUND

This study describes variables related to women's prelabour preference for epidural analgesia (PEA) in two neighbouring countries with a comparable socio-economic and cultural background.

METHODS

Dutch women in midwifery (n = 164) or obstetrical care (n = 162), and Belgian women (n = 188) of ≥36 weeks gestation with a singleton in cephalic presentation completed questionnaires on demographic factors, received labour analgesia information, perceived attitude of the caregiver towards epidural analgesia (EA), pain catastrophising and coping with labour pain. Multiple logistic regression analysis was performed with PEA as dependent variable.

RESULTS

PEA was 9.9% in Dutch midwifery care, 25.5% in Dutch obstetrical care and 38.3% in Belgian care (p value < 0.001). In the Netherlands, maternal age of 35 years or older (OR 4.95; 95% confidence interval (CI) 2.03-12.08), positive attitude of the caregiver towards EA (OR 5.83; 95% CI 2.57-13.23) and a lower degree of coping (OR 3.61; 95% CI 2.24-5.82) were independently associated with PEA. In Belgium, only a lower degree of coping was associated with PEA (OR 4.06; 95% CI 2.45-6.73).

CONCLUSIONS

In both countries, women with a lower degree of coping had a higher PEA. Care setting in the Netherlands was not an independent variable.

A systematic approach towards the development of a set of quality indicators for public reporting in community-based maternity care

OBJECTIVE

to demonstrate the process and outcome of a systematic approach towards the development of a set of quality indicators for public reporting on quality of community-based maternity care.

DESIGN AND SETTING

a four-stepped approach was adopted. Firstly, we defined key elements of community-based maternity care, by performing a systematic search on care guidelines/ standards. Secondly, the literature was searched for existing indicators for maternity care, which were subsequently categorised according to the key elements and systematically selected on suitability of public presentation. The emerging set of indicators suitable for public reporting was presented to five health-care professionals using a Delphi technique (step 3). Based on the comments of the professionals, the set was adjusted and subsequently presented to the health-care consumers (a sample of pregnant women) in step four to test its validity, after which the final set was composed.

PARTICIPANTS

health-care professionals in the field of maternity care and pregnant women.

FINDINGS

key elements of community-based maternity care were extracted from eight guidelines and care standards. We then extracted 10 documents with 223 indicators in total, from which 19 indicators covering the key elements were included in the first set and presented to experts. Based on their comments three indicators were deleted and four indicators were added to the set or slightly rephrased. These were subsequently judged by 13 pregnant women. Seventy-five per cent of the indicators were judged positively by them; no indicator was judged negatively. The set of indicators was thus left unchanged after this final step. KEY CONCLUSIONS AND IMPLICATIONS FOR CLINICAL PRACTICE: the systematic approach adopted in this study resulted in an indicator set that was considered valid by both maternity care professionals and pregnant women, and is likely to satisfy the essential requirements on clinimetric properties. The next step will be to pilot test the indicator set on feasibility in daily clinical practice and to refine the set when necessary. In the future, maternity care professionals may use the set to present the quality of care they provide and to define issues of improvement. Pregnant women may use the information to make a founded choice between maternity care professionals, which ultimately should result in improved safety and quality of maternity care as well as patient satisfaction. Although we focused on the Dutch, community-based maternity care system, the approach used may be extrapolated to other care processes and health-care systems. Extrapolation of the results itself (i.e. the indicator set) may need to be limited to systems with an emphasis on community-based maternity care.

Factors influencing prenatal screening for Down's syndrome: evidence from Zhejiang (China)

This article attempts to identify the factors that influence prenatal screening uptake. About 1400 postdelivery, still-hospitalized women in 15 hospitals in Zhejiang Province were surveyed from November to December 2007. Univariate analysis was used to describe screening uptake and compare respondents with different characteristics. Stepwise logistic regression (forward) was then used to assess the relative strength of those influencing factors. It was found that 49.7% of the respondents received maternal serum prenatal screening. The factors that influenced prenatal screening service utilization included place of residence (urban vs countryside), migrant versus nonmigrant status, attitudes toward screening, frequency of routine prenatal checkups, and doctor's advice. Migrants had a lower probability of getting screened than permanent residents (odds ratio = 0.456; 95% confidence interval [CI] = 0.31, 0.68). The screening uptake probability of women with doctor's advice was 12 times as great as that of women without doctor's advice (95% CI = 7.91, 18.69).

Class, race, ethnicity and information needs in post-treatment cancer patients

OBJECTIVE

Health information-seeking behaviors (HISBs) are associated with active participation in cancer care decisions which, in turn, may positively impact health outcomes. The goal of this study was to develop a taxonomy of topics for which post-treatment cancer patients sought information, and to explore HISB patterns by sociodemographic factors and cancer type.

METHODS

We examined how health information seeking is associated with social determinants in a survey of 521 post-treatment cancer patients.

RESULTS

Four major topics of interest were found: disease/treatment, self-care management, health services, and work/finance. Assessment of the relationship between social determinants and these four topics showed associations for (1) HISBs on disease/treatment topics decreased with age and increased with education; (2) HISBs on self-care management increased with education and varied by cancer type; (3) HISBs on health services increased with education; and (4) HISBs on work/finance decreased with age and wealth, but increased with debt.

CONCLUSION

These results demonstrate one pathway through which social determinants may drive communication inequalities, which may result in increased disparities in health outcomes.

PRACTICE IMPLICATIONS

Further exploration of the relationship between social determinants and information-seeking among post-treatment cancer patients may contribute to the development of strategies to reduce health disparities.

Public attitudes toward ancillary information revealed by pharmacogenetic testing under limited information conditions

PURPOSE

Pharmacogenetic testing can inform drug dosing and selection by aiding in estimating a patient's genetic risk of adverse response and/or failure to respond. Some pharmacogenetic tests may generate ancillary clinical information unrelated to the drug treatment question for which testing is done-an informational "side effect." We aimed to assess public interest and concerns about pharmacogenetic tests and ancillary information.

METHODS

We conducted a random-digit-dial phone survey of a sample of the US public.

RESULTS

We achieved an overall response rate of 42% (n = 1139). When the potential for ancillary information was presented, 85% (±2.82%) of respondents expressed interest in pharmacogenetic testing, compared with 82% (±3.02%) before discussion of ancillary information. Most respondents (89% ± 2.27%) indicated that physicians should inform patients that a pharmacogenetic test may reveal ancillary risk information before testing is ordered. Respondents' interest in actually learning of the ancillary risk finding significantly differed based on disease severity, availability of an intervention, and test validity, even after adjusting for age, gender, education, and race.

CONCLUSION

Under the limited information conditions presented in the survey, the potential of ancillary information does not negatively impact public interest in pharmacogenetic testing. Interest in learning ancillary information is well aligned with the public's desire to be informed about potential benefits and risks before testing, promoting patient autonomy.

Experiences of family physicians who practise primary care obstetrics in groups

OBJECTIVE

The purpose of this study was to explore the experiences of family physicians in primary care obstetrical groups.

METHODS

Using a qualitative approach, in-depth interviews were conducted with 12 Edmonton family physicians who participated in primary care obstetrical groups. Experiences with respect to several aspects of group obstetrical practice were examined including advantages and challenges of primary care obstetrical groups, provision of patient care by a group, fit with other work commitments, and sustainability of the groups. Study data were audiotaped and transcribed verbatim. Independent and team analysis was iterative and interpretive.

RESULTS

Primary care obstetrical groups were found to preserve a family physician's enjoyment of obstetrics and allowed for continuity of care. They afforded work-life balance, allowed for collaboration, and provided support and a social network for group members. Such groups were found to facilitate short-term family physician absences, although long-term absences (such as maternity leaves) were considered challenging. Participants described conflict within primary care obstetrical groups and considered sustainability to be a challenge.

CONCLUSION

Family physicians' continued involvement in obstetrics could be facilitated by their participation in primary care obstetrical groups.

Psychosocial factors influencing breast cancer risk appraisal among older women

Although the incidence of breast cancer increases with age, many older women are uninformed about the increased risk and have lower mammography screening rates than younger women. Understanding older women's perceptions of risk might assist health care providers in offering appropriate resources that result in screening. In this study, we explored psychosocial components influencing older women's breast cancer risk appraisal. To identify key psychosocial components of breast cancer risk appraisal, we conducted focus group interviews. Data saturation occurred with four groups (N = 36) of older Black (58%) and White (42%) women with no prior history of breast cancer. On analysis of the data, we found three themes representing psychosocial factors influencing breast cancer risk appraisal with this cohort. Our findings revealed that worry/fear/anxiety, self-regulating empowerment, and realistic optimism were psychosocial mechanisms older Black and White women in this sample used in appraising breast cancer risk.

Pain acceptance and personal control in pain relief in two maternity care models: a cross-national comparison of Belgium and the Netherlands

BACKGROUND

A cross-national comparison of Belgian and Dutch childbearing women allows us to gain insight into the relative importance of pain acceptance and personal control in pain relief in 2 maternity care models. Although Belgium and the Netherlands are neighbouring countries sharing the same language, political system and geography, they are characterised by a different organisation of health care, particularly in maternity care. In Belgium the medical risks of childbirth are emphasised but neutralised by a strong belief in the merits of the medical model. Labour pain is perceived as a needless inconvenience easily resolved by means of pain medication. In the Netherlands the midwifery model of care defines childbirth as a normal physiological process and family event. Labour pain is perceived as an ally in the birth process.

METHODS

Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Two questionnaires were filled out by 611 women, one at 30 weeks of pregnancy and one within the first 2 weeks after childbirth either at home or in a hospital. However, only women having a hospital birth without obstetric intervention (N = 327) were included in this analysis. A logistic regression analysis has been performed.

RESULTS

Labour pain acceptance and personal control in pain relief render pain medication use during labour less likely, especially if they occur together. Apart from this general result, we also find large country differences. Dutch women with a normal hospital birth are six times less likely to use pain medication during labour, compared to their Belgian counterparts. This country difference cannot be explained by labour pain acceptance, since - in contrast to our working hypothesis - Dutch and Belgian women giving birth in a hospital setting are characterised by a similar labour pain acceptance. Our findings suggest that personal control in pain relief can partially explain the country differences in coping with labour pain. For Dutch women we find that the use of pain medication is lowest if women experience control over the reception of pain medication and have a positive attitude towards labour pain. In Belgium however, not personal control over the use of pain relief predicts the use of pain medication, but negative attitudes towards labour.

CONCLUSIONS

Apart from individual level determinants, such as length of labour or pain acceptance, our findings suggest that the maternity care context is of major importance in the study of the management of labour pain. The pain medication use in Belgian hospital maternity care is high and is very sensitive to negative attitudes towards labour pain. In the Netherlands, on the contrary, pain medication use is already low. This can partially be explained by a low degree of personal control in pain relief, especially when co-occurring with positive pain attitudes.

Women's needs for CAM information to manage menopausal symptoms

OBJECTIVE

To identify the information needs of women regarding complementary and alternative medicine (CAM) treatment options to alleviate menopausal symptoms.

METHODS

Self-administered questionnaires were mailed to women responding to notices posted in family physicians' offices and a women's health center. Survey questions addressed preferred topics, formats and sources of information; experiences with information searching; and what signified good, trustworthy information.

RESULTS

The women in this study (n = 413) indicated several challenges including a lack of time to gather information, gaps in, and lack of, relevant information, and poor information quality. They expressed interest in information about the menopausal process, conventional and CAM treatment options, and the safety of treatments. Personal consultation with health-care professionals was the preferred way for obtaining information. The majority of women preferred evidence-based information but there was also a substantial number of women who chose to rely on 'softer' evidence such as personal accounts. These results suggested two different subgroups; however, the data indicate that these are not mutually exclusive since many respondents showed a preference for both types of information.

CONCLUSIONS

Women feel they are not sufficiently informed to make safe decisions regarding CAM treatment options to alleviate menopausal symptoms. Family physicians are a trusted information source and have an important role in providing women with that information. Brochures containing evidence-based information and a list of newsletters or books that include personal accounts, available in physician's offices and during personal consultations at women's health centers, are offered as a possible solution. A website is another possibility for distributing this information.

Health information seeking behavior

Seeking information about one's health is increasingly documented as a key coping strategy in health-promotive activities and psychosocial adjustment to illness. In this article, the authors critically examine the scientific literature from 1982 to 2006 on the concept of health information-seeking behavior (HISB) to determine its level of maturity and clarify the concept's essential characteristics. A principle-based method of concept analysis provides the framework for exploring the nature of HISB. The authors reviewed approximately 100 published articles and five books reporting on HISB. Although HISB is a popular concept used in various contexts, most HISB definitions provide little insight into the concept's specific meanings. The authors describe the concept's characteristics, contributing to a clearer understanding of HISB, and discuss operationalizations, antecedents, and outcomes of HISB. Such an analysis of HISB might guide further theorizing on this highly relevant concept and assist health care providers in designing optimal informational interventions.

Awareness and attitudes regarding prenatal testing among Texas women of childbearing age

Despite increased visibility and availability of prenatal testing procedures, very little is known about the attitudes among the populace toward these procedures. Using a computer assisted telephone interview of pregnant and non-pregnant women of childbearing age we analyze awareness and attitudes regarding prenatal tests among a diverse group of women of childbearing age in Texas. We also examine maternal characteristics associated with awareness and the willingness to undergo these procedures. While 89% were aware that such tests are available, younger, black and less educated women were less likely to know about prenatal tests for birth defects. Seventy-two percent of respondents said they would want their baby tested while Hispanic and black women were significantly more likely to express an interest than non-Hispanic whites. This study demonstrates the variability of knowledge and beliefs and confirms the importance of taking time to understand an individual's personal beliefs, knowledge and attitudes about prenatal diagnosis.

Knowledge and decision-making for labour analgesia of Australian primiparous women

OBJECTIVE

to assess and investigate knowledge of labour pain management options and decision-making among primiparous women.

DESIGN

a semi-structured guide was used in focus groups to gather pregnant women's knowledge concerning labour analgesia. Attitudes to labour and pain relief, knowledge of pain relief, trustworthiness of knowledge sources, and plans and expectations for labour pain relief were investigated.

SETTING

a major tertiary obstetric hospital in metropolitan Sydney, Australia.

PARTICIPANTS

twenty five primiparous women, who were 25 weeks or more gestation, and planning a vaginal birth.

FINDINGS

although women considered themselves knowledgeable, they were unable to describe labour analgesic risks or benefits. There was a large discrepancy between perception and actual knowledge. The main source of knowledge was anecdotal information. Late in pregnancy was considered the ideal time to be given information about labour analgesia. Women described their labour pain relief plans as flexible in relation to their labour circumstances; however, most women wanted to take an active role in decision-making.

KEY CONCLUSIONS

the large discrepancy between perceived knowledge and actual knowledge of the likely consequences of labour analgesia suggests that women rely too heavily on anecdotal information.

IMPLICATIONS FOR PRACTICE

clinicians should be aware that some women overestimate their knowledge and understanding of analgesic options, which is often based on anecdotal information. Standardised labour analgesia information at an appropriate time in their pregnancy may benefit some women and assist health-care providers and women to practice shared decision-making.

Communicating with women about mammography

BACKGROUND/METHODS

We report survey results of the types of tools used to communicate with women about breast cancer screening and the content areas included in each tool for member countries of the International Breast Cancer Screening Network (IBSN).

RESULTS

In addition to using pamphlets and invitation letters, new technologies are being used such as the Internet which allows for easy updating of information and can provide interactive modules. Several countries have addressed the needs of specific populations such as indigenous populations or blind women. All countries provide basic information, although they do not provide all the same information.

CONCLUSION

More research is needed to understand what women need to make an informed decision about mammography and to learn what the best modalities are to provide this information.

Advanced breast cancer: aetiology, treatment and psychosocial features

Breast cancer is a common form of cancer in women of varying age. Due to the relationship between breasts, sexuality and reproduction, this form of cancer has an interconnected psychological and psychosocial influence on the well-being of women. Current understanding of the aetiology and pathogenesis of the disease has evolved as evidence supporting a role for genes such as the HER2 gene has emerged. HER2-positive breast cancer is a particularly progressive form of the disease as a result of its ability to differentiate and spread. Trastuzumab (Herceptin) forms part of the current treatment for this form of breast cancer; albeit costly, it has been shown to improve survival rates in women. For this reason it is now a recommended treatment for early-stage breast cancer. During and after treatment cycles, the breast cancer nurse and medical practitioners should be available to provide emotional support and advice on the manifestations of the disease, coping strategies and how breast cancer patients manage close family relatives.

Exploring the Subconcepts of the Wittmann-Price Theory of Emancipated Decision-Making in Women's Health Care

PURPOSE

To explore the subconcepts of the Wittmann-Price Theory of Emancipated Decision-Making (EDM); which is proposed as a new theoretical model for the nursing care of women to increase women's satisfaction with decision-making about healthcare issues. Infant feeding method was used as the clinical exemplar.

DESIGN AND METHOD

A descriptive correlational design was used to test the five identified subconcepts of EDM (empowerment, flexible environment, personal knowledge, reflection, and social norms) in women's healthcare. The relationship of emancipated decision-making and satisfaction were explored with the Subject Demographic Questionnaire (SDQ), the Wittmann-Price Theory of Emancipated Decision-making Scale (EDMS), and the Satisfaction with Decision (SWD) scale. The research design was retrospective, without random sampling of subjects. Four research questions were posed for this investigation. Women who had uncomplicated deliveries and met the selected criteria were enrolled (N=97).

FINDINGS

All five subconcepts of EDM were scored on subscales on the EDMS; flexible environment and personal knowledge had the highest mean scores. Pearson correlations showed that all five subscales were significantly related to each other except reflection with personal knowledge and reflection with social norms. A significant relationship was found between the EDM and satisfaction with the decision. Personal knowledge and flexible environment were the best predictors of satisfaction with the decision.

CONCLUSIONS

The Wittmann-Price Theory of EDM is a theoretical model with implications for nursing care of women who are involved in a healthcare decision, such as choice of infant feeding. Further studies are needed to determine the importance of each of the subconcepts in relation to emancipated decision-making.

How do the accounts of the patients on pregnancy and birth process enlighten medical team in terms of narrative ethics?

OBJECTIVE

The aim of this study is to evaluate the relationship between the patient and the physician, midwife and nurse during the process of pregnancy and birth, and to ascertain the importance of communication within this relationship; find out the experiences of patients about the communication process.

METHODS

Three hundred eighty-eight people were interviewed about the pregnancy and birth process. Chi square (chi(2)) and t-tests were used for the statistical evaluation of the data. Forty-nine pregnant women, who were participating in any pregnancy training program, were asked to write down their experiences related to the pregnancy and birth process in a notebook. Thirty-two (65.3%) of these notebooks were taken back 3 months after the delivery, and these notebooks were evaluated within the framework of "narrative ethics" and common themes were found out in order to be discussed in this paper.

RESULTS

It is found out that communication skills of doctors and midwives/nurses were of primary importance for all the participants.

CONCLUSION

Pregnancy and birth are special processes and being informed is of great importance in this process. Every woman has a story to tell about her pregnancy and birth processes.

PRACTICE IMPLICATION

These findings may contribute to the development of new hypotheses. Hence, similar research projects should be conducted, and the findings should be compared.

An analysis of paper-based sources of information on complementary therapies

This study involved an investigation into the availability of paper-based publications containing information on complementary therapies (CTs) within a single cancer centre in the North West. The publications were collected during a 1-week period in July 2003 from the four most likely locations in the site that a patient would visit, to ensure that the research related to data that was readily available. An evaluation grid was developed, and the quantity and quality of the data presented about CTs were analysed. A total of 80 publications were collected. Forty-five (56.3%) related to breast cancer specifically, of which only six (20.7%) made reference to CTs. Thirty-five (43.8%) related to cancer in general, of which only 16 (45.7%) made reference to CTs. The type of information relating to CTs was of very limited value to assist in reaching any decisions as to their use. As a result, it was recommended that the healthcare service prepare and publish a leaflet, specifically relating to the use of CTs in the treatment of cancer, to be freely available within the site for the use of its breast cancer patients.

Exploring the continuum: medical information to effective clinical practice. Paper I: the translation of knowledge into clinical practice

This paper investigates the translation of medical information into clinical practice and the role of thoughtful dissent by exploring the influence of sociological factors on change, the impact of evidence-based medicine (EBM), and the role of industry. Changing practice related to hormone therapy for menopausal and post-menopausal women provides context for this discussion. Medical change involves diffusion of ideas to potential users and ongoing reconciliation of new information with old ideas; this process is influenced by sociological factors including values and experiences, interpersonal relationships and local context. While EBM has alerted doctors to the importance of high quality research and theoretically provides a tool for translating research into practice, there are important problems with its application: (1) it has resulted in a reductionist approach to research and illness; (2) there is a considerable gap between research findings and the complex environment of clinical practice; and (3) EBM has been appropriated by experts, thus corporately developed 'standard-of-care' documents have become instruments of external regulation, and EBM has ceased to be a tool in the hand of individual clinicians. In addition, industry impacts the translation of knowledge by significantly influencing academia, researchers, medical publications, consensus conferences, and practising doctors. While questioning doctrinaire practices or directives is a daunting prospect for individual clinicians, the translation of knowledge into practice and evolution of medical thought is dependent on the progressive role of thoughtful dissent.

The experience of making treatment decisions for women with early stage breast cancer: a diagrammatic representation

Women who are making decisions about treatment for early stage breast cancer interact with a number of people when they are considering their treatment options and the impact breast cancer will have on their lives. Previous research has considered patient preferences for involvement in treatment decision-making and proposed factors that may influence breast cancer treatment decisions. However, to date, there has been a paucity of research focusing on the experience of making treatment decisions from the women's perspective. The aim of this paper is to describe the relationships between the women, the medical practitioners and other people, and to consider features that may be influential in the experience of making treatment decisions. Two models are proposed to represent concepts that are linked to the experience of making treatment decisions. The first model proposed has been formulated to represent factors that may influence the treatment decision. The second model highlights aspects of the women's lives that may be affected. This paper discusses concepts that are presented in the conceptual models and makes suggestions for future studies relating to the experience of making treatment decisions for women with breast cancer.

Women's perceptions of future risk after low-energy fractures at midlife

PURPOSE

Low-energy fractures experienced by women at midlife and beyond place them at increased risk of future fractures and may be early indicators of low bone density. We report here on women's postfracture narratives to provide insight into how family physicians might tailor their messages to patients in communicating risk.

METHODS

An interview guide was used in face-to-face interviews with women aged 40 years and older. Patients were asked to describe their fracture experience and recovery during the subsequent year. Interviews were audiorecorded and transcribed verbatim. Analysis was done initially using an immersion-crystallization approach.

RESULTS

Twenty-two women participated in this research. The analysis showed women's reactions to information about their risk fell into 3 groups. The first took a laissez faire approach, preferring to wait and see what the future held. The second group recognized some of the things they should be doing but were inconsistent in maintaining changes or seeking relevant information. The third group saw information about future risk as salient and important to their daily lives. They actively sought out information, including discussions with their family physicians.

CONCLUSIONS

Discovering whether patients have had an injury and, if so, how they perceive future risk is important because the invisibility of this health hazard calls for vigilance early on in women's lives. Family physicians can help patients move from perceiving the fractures as isolated accidents to understanding them as indicators of future risk by discussing the importance of bone health in the short and long term.

After the Fall: Women's Views of Fractures in Relation to Bone Health at Midlife

Past research has established the link between low energy fractures and the risk for future fractures. These fractures are potential markers for investigation of bone health, and may be precursors for osteoporosis. In spite of its significant public health burden, including burden of illness and economic costs, many individuals are not aware of the risk factors for and consequences of osteoporosis. This is a study of women aged 40 and older who experienced low energy fractures (e.g., from non-trauma sources and falls from no higher than standing height). We gathered data, using focus group interviews, about their experiences and understanding of the fractures in relation to bone health. Women often attributed the fractures to particular situations and external events (e.g., slipping on ice, tripping on uneven ground), and viewed the fractures as accidents. Women often felt that others are at risk for poor bone health, but believed that they themselves are different from those really at risk. Although the fractures are potential triggers for preventive efforts, few women connected their fracture to future risk. What is perceived by women (and others) as random and an accident is often a predictable event if underlying risk factors are identified. Only when there is more awareness of poor bone health as a disease process and fractures as markers for bone fragility will women, men and health care providers take action to prevent future fractures and established bone disease.

Factors associated with the difference in score between women's and doctors' decisional conflict about hormone therapy: a multilevel regression analysis

OBJECTIVE

To explore factors associated with the difference in score between women's and doctors' decisional conflict about hormone therapy (HT).

DESIGN

Secondary analysis.

SETTING AND PARTICIPANTS

family doctors were randomized to prepare women for counselling about HT using either a decision aid or a pamphlet.

MAIN VARIABLES STUDIED

After each counselling session, decisional conflict was assessed in women and doctors using the Decisional Conflict Scale (DCS) and the Provider Decision Process Assessment Instrument (PDPAI), respectively. The difference in score between the DCS and PDPAI was computed and entered as the dependent variable in a multilevel regression analysis.

MAIN OUTCOME RESULTS

A total of 40 doctors and 167 women were included in the analysis. The intra-doctor correlation coefficient was 0.25. Factors associated with women experiencing higher decisional conflict than their doctor were: age of doctor >45 years, women who were undecided about the best choice after the counselling session, women with a university degree and women who said that their doctor usually does not give them control over treatment decision. Factors associated with doctors experiencing more decisional conflict than women were: doctors who were undecided about the quality of the decision, length of visit <30 min and women who thought that the decision was shared with their doctor.

CONCLUSION

In order to reduce the disparities between women's and doctors' decisional conflict about HT, interventions aimed at raising awareness of doctors about shared decision-making should be encouraged.