Dancing around infertility: the use of metaphors in a complex medical situation

How Individuals Use Metaphors to Negotiate Fertility Treatment Decision-Making with Their Romantic Partners

Fertility problems, or the inability to conceive or carry a pregnancy to term for a period of over 12 months while engaging in unprotected sex, affects 12% of women and 9% of men of childbearing age. To answer calls for more research about individuals' fertility decision-making (DM) with their partners, we conducted in-depth, semi-structured interviews with 53 individuals who have experienced fertility decision-making with a romantic partner at some point in their lives. Our findings indicate at least three primary ways individuals and their partners navigated their decision-making communication in their infertility "journeys:" (1) the Driver-Navigator, (2) Driver-Passenger, and (3) Driver-Backseat Driver approaches. All decision-making communication approaches were viewed by individuals as collaborative (i.e. shared), but varied in degrees of "togetherness" (high, moderate, low) in how they communicated with each other about treatment decisions. Implications include helping couples and their clinicians to be aware of their DM approach(es) and offering alternative DM approaches based on understanding how and why certain approaches may (not) be effective in addressing goals, needs, and identities.

How Does Physician (Non)accommodation Affect Patient Behavioral Intention? Using a Web-Based Experiment to Examine Indirect Effects of Language Type on Behavioral Intention Through Goal Inferences and Source Appraisals

Drawing on communication accommodation theory (CAT), we investigated how physician (non)accommodation indirectly affects participants' intention to engage in advocated health behaviors through participant goal inferences and source appraisals. We conducted a 3 (language type: medical jargon, analogies, literal language) × 2 (health topic: coronary artery disease, influenza vaccine) web-based experiment. Participants recruited from an online research panel (N = 545) were randomly assigned to a condition and watched a video featuring a physician explaining medical information and providing health recommendations. In a serial mediation analysis, results suggested two parallel indirect effects (relational vs. informational). Relative to underaccommodation (i.e. medical jargon), physician accommodation (i.e. literal language, analogies) had positive, indirect effects on participant health behavioral intention through goal inferences and assessment of physicians (i.e. warmth, expertise). Compared to the use of literal language, physician use of analogies had a positive, indirect effect on participant behavioral intention solely through the relational path, not the informational path. These findings extend CAT by explicating a mechanism underlying physician (non)accommodation and patient outcomes, offering practical implications for physicians to foster relationships with patients and facilitate patient comprehension.

"I Surrendered": Metaphors in Residents' Stories about Communication Challenges

It is well-known that communication with patients can be challenging for residents. Although some studies have focused on residents' experiences of communication challenges, few, if any, have investigated the language residents use when describing such challenges. In this study, we explore the metaphors residents use when asked to share stories about challenging communication situations. Metaphor has been the focus of research in a variety of health-related disciplines; here, we use it to gain an understanding of why these situations are seen as challenging. Methodologically, we draw on metaphor-led discourse analysis, which facilitates a systematic approach to the identification and analysis of metaphors. The empirical material consists of 138 Danish residents' 259 narratives about communication challenges. We identified more than 700 metaphors used in connection with accounting for communication challenges with patients. The metaphors are primarily driven by vehicles belonging to four groups, namely: "Location," "Movement," "Games and play," and "Battle and warfare." We discuss the implications of these metaphors in relation to residents' conceptualizations of communication and challenges.

Online peer support communities in the infertility journey: A systematic mixed-studies review

BACKGROUND

Infertile individuals desire support, as they are highly vulnerable to multi-dimensional distress. However, support from family, friends and professionals has been found to be inadequate for their needs. Online peer support communities are avenues where infertile individuals come together virtually to share experiences and provide peer support. Though they are known to fulfil the major need of understanding and sharing experiences, little is known about their actual role in supporting individuals struggling with infertility.

OBJECTIVE

To systematically consolidate and explore the role of online peer support communities for infertile individuals.

DESIGN

This is a systematic mixed-studies review.

METHODS

Eight published and unpublished databases were screened for English studies from inception to October 2022: PubMed, EMBASE, Cochrane, PsycINFO, CINAHL, Scopus and ProQuest. Forty-nine studies were included, and quality was appraised using the Mixed Methods Appraisal Tool. Data-based convergent qualitative (narrative and thematic) synthesis was conducted.

RESULTS

An overarching theme titled: Online peer support, a 'double-edged sword' and four themes were identified: 1) Receiving varied types of support with mutual benefits; 2) convenient and "safe haven" with diverse options for struggling couples; 3) herd mentality and negative collective emotions; and 4) credibility, confidentiality, and misinformation. The online communities were mainly utilised by couples in their late 20s to early 30s and the users were predominantly females. Online communities were mostly on forums and popular social media sites, public and unmoderated. Findings revealed that there were two-way benefits for both providers and receivers of peer support. Online communities were also found to be convenient and "safe haven" with diverse options for struggling couples. Conversely for some couples, online communities led to negative collective emotions and feelings of "unrelatedness" despite being among "similar others". Lastly, some couples raised concerns around the credibility, confidentiality, and misinformation from the online communities.

CONCLUSIONS

Whilst online communities are crucial in the individuals' journey through infertility, they can act as a 'double-edged' sword if not managed by professionals. Healthcare professionals can monitor online communities to improve fertility care for individuals; advice individuals to use online communities with caution, rain peer volunteers and develop expert-moderated peer support online communities.

REGISTRATION NUMBER

PROSPERO [CRD42022291461].

TWEETABLE ABSTRACT

Online peer-to-peer support communities may be a double-edged sword for infertile individuals.

"Your Ovaries Are Expired, Like an Old Lady" Metaphor Analysis of Saudi Arabian Women's Descriptions of Breast Cancer: A Qualitative Study

Background

Assessing and understanding the language that women use to express physical, emotional, and social concerns of breast cancer experiences can often be overlooked, even though there is evidence that effective communication between cancer patients and health care providers improves quality of life. This study aims to assess the use of metaphors in conceptualizing breast cancer experience lived by Saudi Arabian women.

Materials and Methods

This is an interpretative phenomenological qualitative study, a purposeful sample of 18 breast cancer patients at an oncology outpatient's clinic in Saudi Arabia were invited to engage in face-to-face interviews. Data was analyzed using Metaphor Identification Procedure (MIP).

Results

Four themes were constructed: dark hidden force, battling imminent death, dreaming and awakening calls, and inner and outer transformation.

Conclusion

Identifying metaphors may be beneficial toward improving communication between health care providers and breast cancer patients, who often experience difficulties expressing their needs.

Metaphors of War in Effective and Ineffective Coping of Medical Directors of COVID-19 Wards in Public Hospitals

The COVID-19 pandemic has challenged medical professionals worldwide with an unprecedented need to provide care under conditions of complexity, uncertainty, and danger. These conditions, coupled with the unrelenting stress of overwhelming workloads, exhaustion, and decision-making fatigue, have forced clinicians to generate coping mechanisms. This qualitative study explored the use of metaphors as a coping mechanism by clinical directors of COVID-19 wards in Israeli public general hospitals while they were exposed to death and trauma throughout the pandemic's first wave in Israel (March to June 2020). The study employs discourse methodology and metaphor mapping analysis to capture the personal, organizational, and social dimensions of effective and ineffective processes of coping with an extreme health crisis. Analysis revealed that the metaphors that clinical directors used reflect a dual process of mediating and generating the social construction of meaning and facilitating effective and ineffective coping. Effective coping was facilitated by war metaphors that created a sense of mission and meaningfulness at both the organizational and the individual levels. War metaphors that generated a sense of isolation and sacrifice intensified helplessness and fear, which undermined coping. We propose actionable recommendations to enhance effective coping for individuals and organizations in this ongoing pandemic.

From generalist to specialist: A qualitative study of the perceptions of infertility patients

Few studies explore in-depth accounts of women's and men's experiences with, and transitions between, obstetrician/gynaecologists (OB/GYNs) and reproductive endocrinologists during infertility diagnostic and treatment processes. This study examined this subject matter with data from qualitative, in-depth, semi-structured interviews. Between April 2007 and March 2008, the first author interviewed 20 women and eight men from a large midwestern metropolitan area in the USA who had used, or were in the process of using, any fertility treatment in the 5 years preceding the interview. Six couples and 16 individuals were interviewed, resulting in narratives of 22 distinct infertility journeys. The main complaints made by respondents about OB/GYNs were that they were insufficiently concerned with providing timely treatment and that they paid insufficient attention to male partners. Women felt that their concerns were taken more seriously by reproductive endocrinologists, but complained of insensitivity, depersonalization and misinformation, and were suspicious of a profit orientation.

'Just have some IVF!': A longitudinal ethnographic study of couples' experiences of seeking fertility treatment

We present findings from a longitudinal ethnographic study of infertile couples seeking treatment following initial GP referral to specialist fertility services. Repeated observations and interviews were undertaken with the same 14 heterosexual participants over an 18-month period. Heterosexual, non-donor couples comprise the majority of fertility clinic patients; however, research interest in this group has dwindled over time as IVF cycles have increased. In the United Kingdom, IVF is presented as a logical response to involuntary childlessness, and as an entirely predictable, and linear, course of action. The market is well-developed and often patients' first experience of privatised health care in the NHS. Our couples were challenged by this, and while they felt expected to move on to IVF, some wished to explore other options. While IVF is ubiquitous, the discomfort and challenge around fertility treatments remain; experiences are prolonged and characterised by recursive narratives and expressions of disequilibrium, which are rarely acknowledged and reflected in ongoing clinic-patient interactions. Our findings develop understanding of the process of 'mazing' (Image - The Journal of Nursing Scholarship, 1989, 21, 220), the pursuit of parenthood, by showing that the routine and normative status of IVF, at least in the current health care context, is at odds with the lived experiences of individuals.

Running-In(to) Transition: Embodied Practice under the Load of Infertility, Baby Loss, and Motherhood

Running is an embodied feminist practice that both shapes and reflects who women are. The field of tribology includes the science and technology of how surfaces interact in relative motion to one another, as well as how the "running-in" of these planes under load contributes to a "steady state" or balance. In this essay I employ embodiment and the tribology frameworks of running-in and steady state in order to explore meanings that emerge over a year-and-a half-long period as I engage two surfaces - my body and running - under the load of infertility, miscarriage, neonatal loss, motherhood, and transitioning into being 40-years-old. I use embodied and autoethnographic methodologies, including running, writing, and poetic inquiry in order to explore meanings born from this running-in process. In doing so, I bring to bear sociocultural challenges women experiences with infertility and perinatal loss, healthcare, and mothering that lead to an (un)steady state. I theorize this state as a space of freedom, the embodiment of health as I learn to craft a new normal and live well despite inescapable trauma.

In-vitro metaphors: ART beneficiaries' meaning-making about human embryos in the context of IVF in Portugal

This article proposes a metaphorical approach to the meaning-making of Portuguese assisted reproductive technology (ART) beneficiaries about human embryos created in vitro, based on the analysis of 30 in-depth interviews. This article draws from an ongoing research project on expert and lay definitions of human embryos developed in vitro, both in ART and scientific research. Four metaphors were identified in patients' utterances about the embryo's status and attributes: embryos are possibilities of success of treatment; utilities that can be the object of ownership and dispositional control; potential offspring with whom there are family and emotional ties; and a counter-gift to science or to other beneficiaries, in response to the generosity of professionals or gamete donors. These rhetorical devices seem to ease the tensions inherent in the technical procedures of medically assisted reproduction. Examining the meaning of attributive metaphors used by patients undergoing in-vitro fertilization about their embryos in vitro is thus essential to understanding their personal experiences, so that healthcare professionals can direct their actions/interventions towards their specific needs and concerns, which are not always spoken.

Perception of family sense of coherence among Chinese couples with infertility

AIMS AND OBJECTIVES

To explore perceptions of family sense of coherence among infertile couples and to provide a theoretical interpretation of the comprehensibility, manageability and meaningfulness of couples' experiences coping with infertility.

BACKGROUND

Infertility is a devastating experience for many couples and can have long-lasting psychosocial consequences. Family sense of coherence has the potential to facilitate a couple's adjustment to the life crisis of infertility and may provide a useful conceptual lens to understand experiences of infertility.

METHODS

Sixty-four couples with infertility participated in semi-structured interviews at subfertility clinics. Data were analysed using the constant comparative approach of grounded theory. COREQ guidelines were followed in reporting the study.

RESULTS

Three major themes related to infertility emerged from the interviews: comprehensibility, manageability and meaningfulness. The couples experienced psychological strain while making cognitive sense of infertility. The significance of children, which is embedded in traditional Chinese culture, created a sense of meaning and purpose in couples' lives and motivated them to mobilise both internal and external resources to cope with the demands of infertility and its treatment.

CONCLUSIONS

The findings indicate that the salutogenic model of family sense of coherence can contribute to our understanding of the experiences of infertility among Chinese couples.

RELEVANCE TO CLINICAL PRACTICE

The results offer a theoretical framework that healthcare professionals can use to help couples cope with the life crisis of infertility by strengthening their sense of family coherence.

Does Self-Identifying as Having a Health Problem Precede Medical Contact? The Case of Infertility

Studies of medical help-seeking presume that self-identifying as having a health problem precedes medical contact, but this ordering of the identity-behavior relationship has not been systematically examined. We used longitudinal data from the National Survey of Fertility Barriers (2004 to 2010) on 412 women with infertility to document the temporal relationship between self-identifying as having a fertility problem and making medical contact. The symbolic interactionist perspective suggests that infertility will be perceived as identity disruption and that in response women will align self-identity and medical behavior over time. Cross-tabulation analysis indicated that more women do self-identify as having a fertility problem first (24 percent) as opposed to making medical contact first (5.5 percent). There was also a tendency toward aligning self-identification and behavior over time. Latent class analyses revealed six patterns: 1) consistently involved, 2) early consulters, 3) consistently uninvolved, 4) consistent perceivers, 5) medical dropouts, and 6) early perceivers. Strong fertility intent and primary infertility, two identity-relevant characteristics, had the strongest associations with latent class membership. The relationship between self-identification and medical help-seeking is thus dynamic and complex.

Men's Use of Metaphors to Make Sense of Their Spouse's Miscarriage: Expanding the Communicated Sense-Making Model

With approximately 20 % of pregnancies ending in loss, miscarriage is a relatively common and stressful occurrence. Because romantic partners' coping efforts are intimately connected, the way one partner copes with the other's miscarriage has important implications for individual and relational well-being. Grounded in the communicated sense-making (CSM) model, the current study investigated how cis-gender men in heterosexual marriages (n = 45) communicatively constructed the meaning of their wife's miscarriage through metaphors. Analysis of interview data revealed two supra-themes-metaphors of miscarriage and metaphors of men's role as a husband. Metaphors of lost gift, cataclysm, death of a loved one, emptiness, and chaotic movement animated husbands' CSM about their wife's miscarriage. Men drew upon discourses of masculinity to make sense of their role as a husband in the miscarriage process as a rock, guard, repair man, and secondary character. We explore these findings in light of the master narrative of birth and propose an expansion of the CSM model to include metaphors as a key CSM device.

Multidimensional eHealth Literacy for Infertility

Infertility is a major public health issue and increasingly, the internet is used as a source of information and advice. The aim of this study is to understand the eHealth literacy of individuals and couples in relation to infertility. A non-probability sample of 27 participants was recruited from existing support groups, online advertising and snowballing representing the diverse population groups for whom involuntary childlessness is an issue. Information online was used both for decision making and developing interactive health literacy for health consultations. Participants may be both consumers and purveyors of information to others in distributed health literacy. Cognitive skills are required to appraise an inconsistent evidence base and potentially biased information from private providers of treatments. Accounts of geographical variations in treatment options, the cost of private treatment and for some, a sense that information and services were directed towards female and heterosexual couples, led some participants to political action online creating an important sense of empowerment. The study offers a new conceptual framework for eHealth literacy in the context of infertility, that combines use of the web and virtual communities in which functional, interactive, critical and distributed health literacy play a part in an online environment.

Calories in Context: Conceptual Metaphors and Consumers' Perception and Use of Calorie Information

The U.S. Food and Drug Administration (FDA) recently made changes to the nutrition facts label so that calories will be emphasized over all other nutrient information (U.S. Food and Drug Administration (FDA), 2016a, August 3). In light of calories' increased visibility, strategic health communicators need to understand both how individuals perceive calorie information and how calories influence consumption decisions. Therefore, a qualitative study was conducted to analyze the metaphors that structure consumers' thoughts about calorie information and food choices. In-depth interviews were conducted with 34 women from diverse racial/ethnic and socioeconomic backgrounds. Through the interviews and subsequent thematic analysis, metaphors were gathered that explained perceptions of different kinds of calories and how calories function in the diet. Five conceptual metaphors were uncovered. The metaphors individuals used varied based on their eating paradigms, and the metaphors were related to different approaches to consumption decisions. The implications of using these different calorie metaphors for translational communication interventions are further discussed.

DrawingOut - An innovative drawing workshop method to support the generation and dissemination of research findings

A growing body of literature has explored the potential for arts-based methods to generate and disseminate research, particularly on sensitive or complex topics. This article presents DrawingOut, a metaphor-centred drawing workshop designed to collect visual and textual data about individuals’ experiences of sensitive or taboo health experiences. The visual data, consisting of the artwork produced by participants, and the textual data, all conversations and discussions occurring during the workshop, can also be used to create engaging outputs for dissemination. We piloted DrawingOut in a study of nine women with a minority ethnic or religious background in Cardiff, UK. The women were invited to participate in a series of structured drawing activities. The conversations occurring during the workshop were recorded and then subjected to thematic analysis. Results showed that women’s views and experiences could be grouped in eight major themes covering their wellbeing, relationship with others, and healthcare views and experiences. We produced an A5 16-page booklet that presents the pilot study results, illustrated with participants’ own drawings and quotes, which was disseminated among participants, their community and other relevant stakeholders. This pilot study supports the view that healthcare actors can use the DrawingOut method to engage people to talk about sensitive health topics, while simultaneously providing them with an enjoyable and empowering research experience. In our pilot study the DrawingOut was successful in eliciting rich visual and textual data that captures a diversity of views and experiences, with the added benefit that these can be used to produce engaging outputs for dissemination.

Linguistic Strategies for Improving Informed Consent in Clinical Trials Among Low Health Literacy Patients

Background

Improving informed consent to participate in randomized clinical trials (RCTs) is a key challenge in cancer communication. The current study examines strategies for enhancing randomization comprehension among patients with diverse levels of health literacy and identifies cognitive and affective predictors of intentions to participate in cancer RCTs.

Methods

Using a post-test-only experimental design, cancer patients (n = 500) were randomly assigned to receive one of three message conditions for explaining randomization (ie, plain language condition, gambling metaphor, benign metaphor) or a control message. All statistical tests were two-sided.

Results

Health literacy was a statistically significant moderator of randomization comprehension (P = .03). Among participants with the lowest levels of health literacy, the benign metaphor resulted in greater comprehension of randomization as compared with plain language (P = .04) and control (P = .004) messages. Among participants with the highest levels of health literacy, the gambling metaphor resulted in greater randomization comprehension as compared with the benign metaphor (P = .04). A serial mediation model showed a statistically significant negative indirect effect of comprehension on behavioral intention through personal relevance of RCTs and anxiety associated with participation in RCTs (P < .001).

Conclusions

The effectiveness of metaphors for explaining randomization depends on health literacy, with a benign metaphor being particularly effective for patients at the lower end of the health literacy spectrum. The theoretical model demonstrates the cognitive and affective predictors of behavioral intention to participate in cancer RCTs and offers guidance on how future research should employ communication strategies to improve the informed consent processes.

Icons for health effects of cigarette smoke: a test of semiotic type

We sought to identify icons to effectively communicate health harms of chemicals in cigarette smoke. Participants were a convenience sample of 701 U.S. adults. A within-subjects online experiment explored the effects of icon semiotic type: symbolic (arbitrary, most abstract), indexical, and iconic (representative, most concrete). Outcomes were perceived representation, affect toward smoking, elaboration, perceived severity, and perceived effectiveness. For not-easy-to-visualize harms of cancer and addiction, symbolic icons received the highest ratings (all p < .001). For easy-to-visualize symptoms of heart attack/stroke, indexical icons received the highest ratings (all p < .001). For easy-to-visualize harm of reproductive organ damage, the iconic image did best (all p < .001). Icon type often had a larger impact among participants with higher health literacy. Symbolic icons may be most effective for health effects not easily visualized. Iconic or indexical icons may be more effective for health effects attributable to specific body parts or symptoms.

Using Visual Metaphors in Health Messages: A Strategy to Increase Effectiveness for Mental Illness Communication

Depression is highly prevalent among college students. Although treatment is often available on university campuses, many stigma-based barriers prevent students from seeking help. Communication strategies, such as the use of metaphors, are needed to reduce barriers. Specially, the use of visual metaphors, as a strategic message design tactic, may be an effective communication strategy to increase message appeal and engagement. Using a 2-phase approach, this study first identified common metaphors students use to conceptualize mental illness. Messages incorporating conceptual and visual metaphors were then designed and tested to determine their potential in reducing stigma. Participants (n = 256) were randomly assigned to 1 of 4 conditions in a between-subjects experiment: messages with visual and textual metaphors, messages with straightforward visuals and textual metaphors, text-based metaphor messages, or a control group. Overall, metaphorical messages are appealing, the use of visual metaphors leads to greater message engagement, and messages based on conceptual metaphors have the potential to reduce stigma. The use of conceptual and visual metaphors in campaign design is an effective strategy to communicate about a complex health topic, such as mental illness, and should be considered for use in campaigns to reduce barriers for help-seeking behavior.