Motivation, justification, normalization: talk strategies used by Canadian medical tourists regarding their choices to go abroad for hip and knee surgeries.

Contributing to health geography scholarship on the topic, the objective of this paper is to reveal Canadian medical tourists' perspectives regarding their choices to seek knee replacement or hip replacement or resurfacing (KRHRR) at medical tourism facilities abroad rather than domestically. We address this objective by examining the 'talk strategies' used by these patients in discussing their choices and the ways in which such talk is co-constructed by others. Fourteen interviews were conducted with Canadians aged 42-77 who had gone abroad for KRHRR. Three types of talk strategies emerged through thematic analysis of their narratives: motivation, justification, and normalization talk. Motivation talk referenced participants' desires to maintain or resume physical activity, employment, and participation in daily life. Justification talk emerged when participants described how limitations in the domestic system drove them abroad. Finally, being a medical tourist was talked about as being normal on several bases. Among other findings, the use of these three talk strategies in patients' narratives surrounding medical tourism for KRHRR offers new insight into the language-health-place interconnection. Specifically, they reveal the complex ways in which medical tourists use talk strategies to assert the soundness of their choice to shift the site of their own medical care on a global scale while also anticipating, if not even guarding against, criticism of what ultimately is their own patient mobility. These talk strategies provide valuable insight into why international patients are opting to engage in the spatially explicit practice of medical tourism and who and what are informing their choices.

Knowledge brokers, companions, and navigators: a qualitative examination of informal caregivers' roles in medical tourism.

INTRODUCTION: Many studies examining the phenomena of medical tourism have identified health equity issues associated with this global health services practice. However, there is a notable lack of attention in this existing research to the informal care provided by the friends and family members who typically accompany medical tourists abroad. To date, researchers have not examined the care roles filled by informal caregivers travelling with medical tourists. In this article, we fill this gap by examining these informal caregivers and the roles they take on towards supporting medical tourists' health and wellbeing. METHODS: We conducted 21 interviews with International Patient Coordinators (IPCs) working at medical tourism hospitals across ten countries. IPCs work closely with informal caregivers as providers of non-medical personal assistance, and can therefore offer broad insight on caregiver roles. The interviews were coded and analyzed thematically. RESULTS: Three roles emerged: knowledge broker, companion, and navigator. As knowledge brokers, caregivers facilitate the transfer of information between the medical tourist and formal health care providers as well as other staff members at medical tourism facilities. The companion role involves providing medical tourists with physical and emotional care. Meanwhile, responsibilities associated with handling documents and coordinating often complex journeys are part of the navigation role. CONCLUSIONS: This is the first study to examine informal caregiving roles in medical tourism. Many of the roles identified are similar to those of conventional informal caregivers while others are specific to the transnational context. We conclude that these roles make informal caregivers an integral part of the larger phenomenon of medical tourism. We further contend that examining the roles taken on by a heretofore-unconsidered medical tourism stakeholder group sheds valuable insight into how this industry operates and that such knowledge is necessary in order to respond to the health equity debates that surround this particular global health services practice.

"You're dealing with an emotionally charged individual...": an industry perspective on the challenges posed by medical tourists' informal caregiver-companions.

BACKGROUND: Patients engage in medical tourism when they privately obtain a medical care abroad. Previous research shows that many medical tourists travel abroad with friends and family members who provide support and assistance. Meanwhile, very little is known about this important stakeholder group, referred to here as caregiver-companions. In this article we examine the challenges that can be posed by caregiver-companions and the overall practice of informal caregiving in medical tourism from an industry perspective. Specifically, we report on the findings of interviews conducted with international patient coordinators (IPCs) who work at destination facilities. IPCs come into regular contact with caregiver-companions in their professional positions and thus are ideally suited to comment on trends they have observed among this stakeholder group as well as the challenges they can pose to medical tourists, health workers, and facilities. METHODS: We conducted 20 semi-structured interviews with 21 IPCs from 16 different facilities across nine countries. Topics probed in the interviews included caregiver-companion roles, IPCs' and others' interaction with caregiver-companions, and potential health and safety risks posed to medical tourists and caregiver-companions. Thematic analysis of the verbatim transcripts was employed. RESULTS: Although most participants encouraged medical tourists to travel with a caregiver-companion, many challenges associated with caregiver-companions were identified. Three themes best characterize the challenges that emerged: (1) caregiver-companions require time, attention and resources; (2) caregiver-companions can disrupt the provision of quality care; and (3) caregiver-companions can be exposed to risks. IPCs pointed out that caregiver-companions may, for example, have a negative impact on the patient through cost of accompaniment or inadequate care provision. Caregiver-companions may also create unanticipated or extra work for IPCs, as additional clients and by ignoring established organizational rules, routines, and expectations. Furthermore, caregiver-companions may be susceptible to stresses and health and safety risks, which would further deteriorate their own abilities to offer the patient quality care. CONCLUSIONS: Although caregiver-companions can pose challenges to medical tourists, health workers, and medical tourism facilities, they can also assist in enhancing best care and offering meaningful support to medical tourists. If caregiver-companions are open to collaboration with IPCs, and particularly in the form of information sharing, then their experience abroad can be safer and less stressful for themselves and, by extension, for the accompanied patients and facility staff.

Ethical and legal implications of the risks of medical tourism for patients: a qualitative study of Canadian health and safety representatives' perspectives.

OBJECTIVES: Medical tourism involves patients' intentional travel to privately obtain medical care in another country. Empirical evidence regarding health and safety risks facing medical tourists is limited. Consideration of this issue is dominated by speculation and lacks meaningful input from people with specific expertise in patient health and safety. We consulted with patient health and safety experts in the Canadian province of British Columbia to explore their views concerning risks that medical tourists may be exposed to. Herein, we report on the findings, linking them to existing ethical and legal issues associated with medical tourism. DESIGN: We held a focus group in September 2011 in Vancouver, British Columbia with professionals representing different domains of patient health and safety expertise. The focus group was transcribed verbatim and analysed thematically. PARTICIPANTS: Seven professionals representing the domains of tissue banking, blood safety, health records, organ transplantation, dental care, clinical ethics and infection control participated. RESULTS: Five dominant health and safety risks for outbound medical tourists were identified by participants: (1) complications; (2) specific concerns regarding organ transplantation; (3) transmission of antibiotic-resistant organisms; (4) (dis)continuity of medical documentation and (5) (un)informed decision-making. CONCLUSIONS: Concern was expressed that medical tourism might have unintended and undesired effects upon patients' home healthcare systems. The individual choices of medical tourists could have significant public consequences if healthcare facilities in their home countries must expend resources treating postoperative complications. Participants also expressed concern that medical tourists returning home with infections, particularly antibiotic-resistant infections, could place others at risk of exposure to infections that are refractory to standard treatment regimens and thereby pose significant public health risks.

Use of medical tourism for hip and knee surgery in osteoarthritis: a qualitative examination of distinctive attitudinal characteristics among Canadian patients.

BACKGROUND: Medical tourism is the term that describes patients' international travel with the intention of seeking medical treatment. Some medical tourists go abroad for orthopaedic surgeries, including hip and knee resurfacing and replacement. In this article we examine the findings of interviews with Canadian medical tourists who went abroad for such surgeries to determine what is distinctive about their attitudes when compared to existing qualitative research findings about patients' decision-making in and experiences of these same procedures in their home countries. METHODS: Fourteen Canadian medical tourists participated in semi-structured phone interviews, all of whom had gone abroad for hip or knee surgery to treat osteoarthritis. Transcripts were coded and thematically analysed, which involved comparing emerging findings to those in the existing qualitative literature on hip and knee surgery. RESULTS: Three distinctive attitudinal characteristics among participants were identified when interview themes were compared to findings in the existing qualitative research on hip and knee surgery in osteoarthritis. These attitudinal characteristics were that the medical tourists we spoke with were: (1) comfortable health-related decision-makers; (2) unwavering in their views about procedure necessity and urgency; and (3) firm in their desires to maintain active lives. CONCLUSIONS: Compared to other patients reported on in the existing qualitative hip and knee surgery literature, medical tourists are less likely to question their need for surgery and are particularly active in their pursuit of surgical intervention. They are also comfortable with taking control of health-related decisions. Future research is needed to identify motivators behind patients' pursuit of care abroad, determine if the attitudinal characteristics identified here hold true for other patient groups, and ascertain the impact of these attitudinal characteristics on surgical outcomes. Arthritis care providers can use the attitudinal characteristics identified here to better advise osteoarthritis patients who are considering seeking care abroad.

Activin C antagonizes activin A in vitro and overexpression leads to pathologies in vivo.

Activin A is a potent growth and differentiation factor whose synthesis and bioactivity are tightly regulated. Both follistatin binding and inhibin subunit heterodimerization block access to the activin receptor and/or receptor activation. We postulated that the activin-beta(C) subunit provides another mechanism regulating activin bioactivity. To test our hypothesis, we examined the biological effects of activin C and produced mice that overexpress activin-beta(C). Activin C reduced activin A bioactivity in vitro; in LNCaP cells, activin C abrogated both activin A-induced Smad signaling and growth inhibition, and in LbetaT2 cells, activin C antagonized activin A-mediated activity of an follicle-stimulating hormone-beta promoter. Transgenic mice that overexpress activin-betaC exhibited disease in testis, liver, and prostate. Male infertility was caused by both reduced sperm production and impaired sperm motility. The livers of the transgenic mice were enlarged because of an imbalance between hepatocyte proliferation and apoptosis. Transgenic prostates showed evidence of hypertrophy and epithelial cell hyperplasia. Additionally, there was decreased evidence of nuclear Smad-2 localization in the testis, liver, and prostate, indicating that overexpression of activin-beta(C) antagonized Smad signaling in vivo. Underlying the significance of these findings, human testis, liver, and prostate cancers expressed increased activin-betaC immunoreactivity. This study provides evidence that activin-beta(C) is an antagonist of activin A and supplies an impetus to examine its role in development and disease.