Vasectomy provider decision-making balancing autonomy and non-maleficence: qualitative interviews with providers.

Background: Male sterilization, or vasectomy, is 99.9% effective at preventing pregnancy with less than a 2% risk of complications. Despite the high efficacy, low risk, low cost, and gender equity benefits of vasectomy, just 2% of women reported that they and their partners relied on vasectomy as their contraceptive method globally in 2019. Health care providers can be both a facilitator and a barrier in men's health generally, and may be in vasectomy provision as well. This study sought to describe the decision-making rationales of experienced vasectomy providers when evaluating patient candidacy in complex cases. Methods: Fifteen vasectomy providers belonging to the global Vasectomy Network google group from seven countries participated in online interviews using a semi-structured in-depth interview guide. Providers were asked about their vasectomy training, their reasons for vasectomy provision, challenging cases they have faced, and approaches used to manage challenging cases. Vignettes were used to further elicit decision-making rationale. Thematic analysis was conducted using MAXQDA20. Results: Provider decision-making was predicated on ensuring patients were well-informed, able to consent, and certain about their choice to have a vasectomy. Once those foundational conditions were met, providers filtered patient characteristics through their training, laws and policies, sociocultural norms, experience, and peer influence to produce a cost-benefit breakdown. Based on the cost-benefit analysis, providers determined whether to weigh autonomy or non-maleficence more heavily when determining vasectomy patient candidacy. Conclusions: Despite clinical best practices that promote prioritizing patient autonomy over non-maleficence, some providers continued to weigh non-maleficence over autonomy in vasectomy patient candidacy evaluations. Non-maleficence was particularly prioritized in cases providers deemed to be at higher risk of regret. The findings of this study suggest vasectomy provider training should emphasize evidence-based best practices in shared decision-making and patient-centered care to facilitate vasectomy provision that honors patient autonomy and rights.

Silence in Conversations About Advancing Pediatric Cancer.

Background and Objectives: Skillful use of silence by clinicians can support patient-centered communication. However, what makes a period of silence feel meaningful is not well understood. This study aimed to characterize profound, skillful silences during difficult conversations between pediatric oncologists, children with advancing cancer, and their families. Methods: We audio-recorded serial disease reevaluation discussions between pediatric oncologists, patients with high-risk cancer, and their families across 24 months or until death, whichever occurred first. Using an inductive process, we performed content analysis across all dialogue recorded at timepoints of disease progression to examine types of silence. Results: 17 patient-parent dyads with disease progression yielded 141 recorded conversations. Inductive coding yielded a layered typology of silence, including "intentional silence" (≥5 seconds), "profound silence" (≥5 seconds following receipt of difficult information, juxtaposed with statements of shared understanding, emotion, or enlightenment), and "stacked silence" (series of silences juxtaposed within dialogue). Intentional silence lasting ≥5 seconds occurred 238 times in 35/49 "bad news" recordings; nearly half (103/238) of these silences were identified as profound silence, in which silences appeared to create space for processing, allowed for questions to emerge, and synergized with empathic and affirmational statements. In most cases, profound silences involved the juxtaposition, or stacking, of multiple silences close together. Conclusions: Profound silences occur often during conversations about advancing pediatric cancer and share distinct characteristics. Opportunities exist to teach clinicians to use profound and stacked silences with intention during difficult conversations as a fundamental aspect of communication.

Clinician Emotions Surrounding Pediatric Oncology Patient Deterioration.

BACKGROUND: Pediatric oncology patients have a high rate of clinical deterioration frequently requiring critical care. Patient deterioration events are distressing for clinicians, but little is known about how Pediatric Early Warning Systems (PEWS) impact clinicians' emotional responses to deterioration events. METHODS: Semi-structured interviews were conducted with 83 nurses, pediatricians, oncologists, and intensive care clinicians who had recently participated in a patient deterioration event at two pediatric oncology hospitals of different resource-levels: St. Jude Children's Research Hospital (N = 42 participants) in Memphis, Tennessee or Unidad Nacional de Oncología Pediátrica (N = 41 participants) in Guatemala City, Guatemala. Interviews were conducted in the participants' native language (English or Spanish), transcribed, and translated into English. Each transcript was coded by two researchers and analyzed for thematic content. RESULTS: Emotions around patient deterioration including concern, fear, and frustration were reported across all disciplines at both hospitals. Concern was often triggered by an elevated PEWS score and usually resulted in increased attention, which reassured bedside clinicians that patients were receiving necessary interventions. However, persistently elevated PEWS scores, particularly at St. Jude Children's Research Hospital, occasionally resulted in a false sense of relief, diminishing clinician attention and negatively impacting patient care. Nurses at both institutions described how PEWS amplified their voices, engendering confidence and empowerment, two of the only positive emotions described in the study. CONCLUSION: Clinicians experienced a range of emotions while caring for high-risk patients in the setting of clinical deterioration. These emotions have the potential to contribute to compassion fatigue and burnout, or to resilience. Acknowledgment and further investigation of the complex interplay between PEWS and clinician emotions are necessary to maximize the impact of PEWS on patient safety while simultaneously supporting staff wellbeing.

Gender, power and intimate relationships over the life course among Ethiopian female peer educators living with HIV.

Historically, Ethiopian women have faced numerous challenges to gender equity at the individual, relational and community levels; such inequalities can lead to increased risk of HIV acquisition. Over the past two decades, some progress has been made towards changing policies and norms to reduce gender inequality. We sought to understand the ways in which marriage and other romantic/sexual relationships of a group of Ethiopian women living with HIV had been impacted by gender norms, relational power dynamics and HIV status over the life course. We conducted in-depth interviews with 19 women living with HIV who were working as peer educators at a large clinic in Addis Ababa, Ethiopia. Reflecting on their early lives, participants often described traumatic prior relationships characterised by rape, forced marriage and HIV nondisclosure. In the aftermath of being diagnosed with HIV, participants' more recent relationships embodied a more egalitarian dynamic characterised by mutual support for HIV care engagement and open communication. Participants' narratives illustrate encouraging examples of ways in which HIV-positive women can form and maintain equitable and satisfying personal relationships even in the context of obstacles at multiple levels.

"It Is Not Natural Anymore": Nutrition, Urbanization, and Indigenous Identity on Bolivia's Andean Plateau.

The objective of this article was to characterize how urbanization and indigenous identity shape nutrition attitudes and practices in El Alto, a rapidly urbanizing and predominantly indigenous (Aymara) community on Bolivia's Andean plateau. We took a qualitative ethnographic approach, interviewing health care providers ( n = 11) and conducting focus groups with mothers of young children ( n = 4 focus groups with 25 mothers total [age = 18-43 years, 60% Aymara]). Participants generally described their urban environment as being problematic for nutrition, a place where unhealthy "junk foods" and "chemicals" have supplanted healthy, "natural," "indigenous" foods from the countryside. Placing nutrition in El Alto within a broader context of cultural identity and a struggle to harmonize different lifestyles and worldviews, we propose how an intercultural framework for nutrition can harmonize Western scientific perspectives with rural and indigenous food culture.

Physical, Social, and Political Inequities Constraining Girls' Menstrual Management at Schools in Informal Settlements of Nairobi, Kenya.

Access to adequate water and sanitation is limited in informal settlements, contributing to girls' challenges managing menstruation at school, especially when they cannot access materials to absorb menstrual blood and appropriate facilities for hygiene. This study documents differences between girls' experience of menstruation at public schools (where the Kenyan government provides menstrual pads) and private schools (where pads are not provided) in two informal settlements of Nairobi, Kenya. Results showed that supply chains to public schools were not reliable, and equitable pad provision was not assured. Girls in private schools struggled to access pads because they were not provided. Sanitation facilities were physically available, but Muslim girls were unable to practice ablution due to the design of toilets in our study schools. Girls experienced fear and anxiety due to harassment from male peers and had incomplete information about menstruation from teachers. Findings suggest that practitioners and policy-makers should acknowledge the diversity of school populations and monitor programs to ensure efforts do not contribute to inequity.

Influences in fertility decisions among HIV-infected individuals in Lilongwe, Malawi: a qualitative study.

BACKGROUND: The motivation to have a child may be complex with numerous influencing factors, particularly among individuals living with HIV. This study sought to understand factors influencing fertility decision-making for HIV-infected men and women in Lilongwe, Malawi. METHODS: Thirteen focus groups were conducted among HIV-infected individuals enrolled in antiretroviral treatment services. RESULTS: Participants identified a hierarchy of influences in fertility decisions including the importance of childbearing, patriarchal influence, family influences and concern regarding HIV transmission. CONCLUSIONS: Addressing fertility conversations beyond the confines of a relationship may be important, as family plays a significant role in fertility choices. Childbearing remains a fundamental desire among many individuals with HIV; however, concerns regarding transmission risk need to be addressed with efforts made to overcome misconception and assist individuals in balancing what may be competing influences.

'He's still with these girls': exploring perceptions of HIV risk among men with behaviourally bisexual male partners.

Recent studies have called for more nuanced research into the relationships between behaviourally bisexual men and their sexual partners. To address this, we conducted a longitudinal qualitative study with self-identifying gay men; participants took part in timeline-based interviews and relationship diaries. We conducted a thematic analysis of verbatim transcripts to understand how relationship motivations, emotions and relationship dynamics influenced perceptions of HIV risk with behaviourally bisexual male partners. Participants described how partnership types (main and casual) and relationship dimensions (exclusivity, commitment, emotional attachment and relationship designation) strongly influenced perceptions of HIV risk and shaped their decisions to choose behaviourally bisexual male sex partners. Results reveal the crucial role relationship dynamics play in the shaping of HIV risk perceptions, sexual decision-making and HIV risk between partners, and provide potential insight on how to message HIV risk to gay men and their behaviourally bisexual male partners. It is imperative that HIV prevention is able to message key concepts of risk, decision-making and partner negotiation in a way that does not act to stereotype or create stigma against behaviourally bisexual men and their male partners.

Using participant-empowered visual relationship timelines in a qualitative study of sexual behaviour.

This study examines how the use of participant-empowered visual relationship timelines adds to the quality of an ongoing qualitative data collection in a case study examining the influence of emotions on sexual risk-taking and perceptions of HIV risk among men who have sex with men. Gay and bisexual men (n = 25) participated in a 10-week, three-phase study. During a baseline in-depth interview, participants created a visual timeline using labelled stickers to retrospectively examine their dating/sexual histories. Participants then completed three web-based quantitative personal relationship diaries, tracking sexual experiences during follow-up. These data were extracted and discussed in a timeline-based debrief interview. The visual cues assisted with data collection by prompting discussion through the immediate identification of patterns, opportunities for self-reflection, and rapport-building. The use of flexible data collection tools also allowed for a participant-empowered approach in which the participant controlled the interview process. Through this process, we learned strategies for improving a participant-empowered approach to qualitative research, including: allowing visual activities to drive the interview, using flexible guidelines to prompt activities, and using discrete imagery to increase participant comfort. It is important that qualitative data collection utilise more participatory approaches for gains in data quality and participant comfort.

Transiciones a la adultez: exploración sobre las relaciones románticas y normativas de masculinidad de los adolescentes en el Bañado Sur, Asunción / Transitions to adulthood: exploration of romantic relationships and norms of masculinity adolescents in Bañado Sur, Asunción

Introducción: muchas veces los hombres jóvenes se definen a sí mismos y a su identidad masculina a través de relaciones románticas y sexuales; sus decisiones sexuales pueden afectar su transición hacia la madurez, así como la adquisición de infecciones de transmisión sexual, VIH y tasas de embarazos. Objetivo: Este artículo analiza cómo influyen en el modo en que actúan en las relaciones sexuales y románticas y la formación de su identidad masculina, los grupos de amigos de hombres jóvenes paraguayos, sus familias. Metodología: En el 2010 llevamos a cabo cinco charlasen grupo en Asunción, Paraguay, en las que se examinaron las normas comunitarias con grupos de adolescentes entre 14 y 19 años de edad. Luego entrevistamos a la mitad de los miembros de cada grupo para examinar sus relaciones con amigos, la familia, mujeres jóvenes y sus creencias sobre las normas de género existentes. Resultados: Los jóvenes describieron dos tipos de normas masculinas (“pareja/proveedor” y “macho”) y dos tipos de relaciones románticas (“casual” y “formal”). Muchas veces se encontró una concordancia en el lenguaje utilizado para describir cada abanico de conductas, lo que pone de relieve la relación existente entre las normas masculinas y las relaciones románticas.

Introduction: Many times young men define themselves and their male identity through romantic and sexual relationships; their sexual decisions can affect their transition to adulthood as well as the acquisition of sexually transmitted infections, HIV and pregnancy rates. Objective:This article discusses how to influence the waythey act in sexual and romantic relationshipsand the formation of their male identity, groupsof young men Paraguay an friends, their families. Methodology: In 2010 we conducted five talks group in Asuncion, Paraguay, in which Community rules were examined with groups of teenagers between 14 and 19 years old. Then we interviewed half of the members of each group to examine their relationships with friends, family, young women and their beliefs about existing gender norms. Results: Young described two types of male norms(“partner / supplier” and “male”) and two types of romantic relationships (“casual” and “formal”).Many times a match was found in the languageused to describe each range of behaviors, which highlights the relationship between male normsand romantic relationships. The rules received bythe neighborhood as models that were more machobehavior by young people themselves informedcharacteristics. The rules can not be changed unlessyoung people talk about their behavior clearly notnormative. This demonstrates that further studieson the formation, meaning and transformation of male standards are needed.

Un perfil de las obstetras en Paraguay / A Profile of midwifery in Paraguay

Introducción: Este estudio trata de desarrollar un perfil descriptivo de las obstetras en Paraguay. El estudio incluyó tres componentes: investigación de los antecedentes de los documentos oficiales y entrevistas a informantes claves para completar cuestionarios, entrevistas cualitativas con parteras y obstetras del Paraguay, y la observación de los participantes. Métodos: Los datos de los documentos oficiales y los cuestionarios fueron tabulados utilizando estadística descriptiva, entrevistas individuales y entrevistas de grupos pequeños de obstetras, estudiantes de obstetricia y médicos gineco-obstetras y se llevaron a cabo en cinco regiones de salud del Paraguay. Resultados: Participaron veintidós obstetras, nueve estudiantes de obstetricia, nueve gineco-obstetras y cinco dirigentes de las organizaciones profesionales de la salud. Tres temas destacados surgieron de las entrevistas. El primero fue la evolución del rol de la obstetra en el sistema de salud, sobre todo en la capital, Asunción. El segundo fue qué tanto las obstetras como los médicos gineco-obstetras informaron acerca de que las mujeres no tenían preparación suficiente para el parto y el periodo prenatal.

Introduction: This study sought to develop adescriptive profile of midwifery in Paraguay. Itinvolved three components: background research from official documents and key informant interviewsto complete questionnaires, qualitative interviews with Paraguayan midwives and obstetricians, and participant observation. Methods: Data from official documents and questionnaires weretabulated using descriptive statistics. Individual interviews and small-group interviews of midwives, student midwives, and obstetricians were conductedin five health departments of Paraguay. Results: Twenty-two midwives, nine student midwives, nine obstetricians, and five leaders of professional health organizations participated. Three salientthemes were identified from the interviews. Firstwas the changing role of the midwife in the health system, particularly in the capital city of Asunción.Second, midwives and obstetricians both reported that women were not sufficiently prepared for laborand birth during the antenatalperiod. Limited antenatal education and childbirth classes existed and midwives felt that this was amajor barrier to vaginal birth. Finally, access tomidwife-provided antenatal care is perceived to belimited. Obstetricians are now providing antenatal care more often than they used to, and in some public hospitals they also attend vaginal deliveries. Limiting the utilization of midwives may well be amajor contributor to the rising rates of caesarean sections. Midwives are not fulfilling their potentialto prepare women for labor and birth, despitetheir high-level professional training. They havethe potential to improve antenatal preparation forlow-intervention birth, and this would be a moreeffective use of human resources for both obstetricians and midwives.

Understanding Female Condom Use and Negotiation Among Young Women in Cape Town, South Africa.

CONTEXT: In most countries, female condoms are not widely available and uptake has been slow. More information is needed on how women and men successfully negotiate female condom use. METHODS: In-depth interviews were conducted at two sites in Cape Town, South Africa, with 14 women and 13 men who had used female condoms. A structured interview guide was used to elicit information on how women negotiate female condom use, and how male partners negotiate or respond to negotiations of female condom use. Thematic analysis was used to identify key patterns in the data. RESULTS: Participants reported that female condoms are easier for women to negotiate than male condoms, largely because the method is understood to be under a woman's control. The main barrier to use was lack of familiarity with the method; strong negative reactions from partners were not a major barrier. Personal comfort and tensions with partners usually improved after first use. Some male respondents preferred the method because it shifts responsibility for condom use from men to women. CONCLUSIONS: Findings suggest that female condoms empower women to initiate barrier method use, and that programs designed to educate potential users about female condoms and familiarize them with the method may be useful. That some men preferred female condoms because they wanted women to take responsibility for condom use is cause for concern, and suggests that counseling efforts should be directed toward men as well as women, and should include a discussion of gender dynamics and responsibility that emphasizes condom use as a choice that couples make together.

An exploration of men's knowledge, attitudes, and perceptions of HIV, HIV risk, and willingness to test for HIV in Yendi District, Northern Ghana.

We explored men's HIV knowledge, perceptions of HIV risk, and willingness to test for HIV in preparation for the initiation of formalized voluntary counseling and testing (VCT) services at Yendi Hospital in Yendi District, Ghana. A multi-method approach was used, including surveys of 129 male hospital patrons, three men-only focus group discussions, and eight interviews with clinical staff at the hospital. History of condom use, perception of risk, paying for an HIV test, and age were all significantly associated (p < .05) with willingness to test. An aversion to the hospital was the most prominent theme among participants. Aversion was due to perceived lack of confidentiality, preference for traditional healers, perceived costs, and fear of testing. Our participants (a) expressed the need for VCT services, (b) recommended that VCT target men for HIV prevention and VCT patronage, and (c) thought locations outside of hospitals should provide testing services.

'Sometimes people let love conquer them': how love, intimacy, and trust in relationships between men who have sex with men influence perceptions of sexual risk and sexual decision-making.

Men who have sex with men account for a disproportionate burden of HIV incidence in the USA. Although much research has examined the drivers of sexual risk-taking, the emotional contexts in which men make sexual decisions has received little attention. In this three-phase, 10-week longitudinal qualitative study involving 25 gay and bisexual men, we used timeline-based interviews and quantitative web-based diaries about sexual and/or dating partners to examine how emotions influence HIV risk perceptions and sexual decision-making. Participants described love, intimacy, and trust as reducing HIV risk perceptions and facilitating engagement in condomless anal intercourse. Lust was not as linked with risk perceptions, but facilitated non condom-use through an increased willingness to engage in condomless anal intercourse, despite perceptions of risk. Results indicate that gay and bisexual men do not make sexual decisions in an emotional vacuum. Emotions influence perceptions of risk so that they do not necessarily align with biological risk factors. Emotional influences, especially the type and context of emotions, are important to consider to improve HIV prevention efforts among gay and bisexual men.

Breast cancer treatment experiences by race and location in Georgia's Women's Health Medicaid Program.

BACKGROUND: This study seeks to understand the breast cancer treatment patterns and experiences of women enrolled in Georgia's Breast and Cervical Cancer Prevention and Treatment Act program, the Women's Health Medicaid Program (WHMP), and whether these experiences vary by race or location. METHODS: We conducted a mixed-methods analysis of WHMP breast cancer enrollees by race and urban/rural location. Quantitative analysis used a hazard rate model approach to identify differences in the timing of diagnosis, enrollment into Medicaid, and various modalities of treatment for 810 enrollees. Qualitative analysis used a systematic retrieval and review of coded data from 34 in-depth disease life history interview transcripts to a complete, focused analysis of enrollees' cancer treatment experiences. FINDINGS: African-American women began treatment, on average, 6 days later after diagnosis than White women, driven by delays of one month among African-American women with late-stage cancers. This time delay for African-American women was not significant on multivariate analysis of time from enrollment to treatment. Once enrolled in WHMP, women reported gaining access to equitable breast cancer treatment regardless of race or location, with the exception of breast reconstruction, for which some women in our sample reported barriers to care. CONCLUSIONS: The equitable access to cancer treatment and other health services provided by WHMP to low-income, uninsured women in Georgia with breast cancer makes it a critical health care safety net program in Georgia, the need for which will continue through the implementation of the Affordable Care Act.

A profile of midwifery in Paraguay.

OBJECTIVE: The goal of this study was to provide a descriptive profile of midwifery in Paraguay. DESIGN: The study involved three components: background research from official documents and key informant interviews to complete questionnaires, qualitative interviews with Paraguayan midwives and obstetricians, and participant observation. Data from official documents and questionnaires were tabulated using descriptive statistics. Individual interviews and small-group interviews of midwives, student midwives, and obstetricians were conducted in five health departments of Paraguay. SETTING: The research took place in the capital of Paraguay, Asunción, and four additional health departments: Central, Cordillera, Guira, and Misiones. PARTICIPANTS: Twenty-two midwives, nine student midwives, nine obstetricians, and five leaders of professional health organisations in Paraguay participated in this study. FINDINGS: Three salient themes were identified throughout the interviews. First was the understanding of the changing role of the midwife in the health system, particularly in and around the capital city of Asunción. Second, midwives and obstetricians both reported that women were not sufficiently prepared for labour and birth during the antenatal period. Limited antenatal education and childbirth classes existed and midwives felt that this was a major barrier to vaginal birth. Finally, access to midwife-provided antenatal care is perceived to be limited. A major barrier to accessing midwifery care for women in the capital is related to the midwives' changing role in practice. Obstetricians are now providing antenatal care more often than they used to, and in some public hospitals they also attend vaginal deliveries. KEY CONCLUSIONS AND IMPLICATIONS: Limiting the utilisation of midwives may well be a major contributor to the rising rates of caesarean sections. Women are not prepared for labour and birth in the antenatal period, or are scheduled for elective caesarean sections antenatal ly. Midwives are not fulfilling their potential to prepare women for labour and birth, despite their high-level professional training. Midwives have the potential to improve antenatal preparation for low-intervention birth. This transition in care provision would be a more effective use of human resources for both obstetricians and midwives.

'But I'm not like that': young men's navigation of normative masculinities in a marginalised urban community in Paraguay.

Young men often define themselves and their masculine identity through romantic and sexual relationships, and their resulting sexual decisions can affect their successful transition into adulthood, as well as STI, HIV and pregnancy rates. This paper looks at how young Paraguayan men's peer groups, family and masculine identity formation influence their behaviours in sexual and romantic relationships. In Asunción, Paraguay, we conducted five focus-group discussions (FGDs) examining neighbourhood norms in 2010, with male peer groups ranging in age from 14 to 19 years. We then interviewed half the members from each peer group to examine their relationships with friends, family and young women and their beliefs about existing gender norms. Young men described two types of masculine norms, 'partner/provider' and macho, and two types of romantic relationships, 'casual' and 'formal'. The language used to describe each spectrum of behaviours was often concordant and highlights the connection between masculine norms and romantic relationships. The perceived norms for the neighbourhood were more macho than the young men's reported behaviours. Norms cannot change unless young men speak out about their non-normative behaviours. This provides evidence for more research on the formation, meaning and transformation of male gender norms.

Salud sexual y reproductiva en adolescentes en Asunción, Paraguay: una evaluación cualitativa de necesidades / Sexual and reproductive health among adolescents in Asuncion, Paraguay: a qualitative assessment of needs

El propósito primordial de la evaluación de necesidades fue enriquecer la habilidad del CEPEP para incrementar la salud sexual y reproductiva adolescente en Asunción al construir un entendimiento de la comunidad circundante y población adolescente a fin de desarrolloar y lograr las actividades planeadas.