Understanding low uptake of contraceptives in resource-limited settings: a mixed-methods study in rural Burundi.

BACKGROUND: Family planning can reduce deaths, improve health, and facilitate economic development in resource-limited settings. Yet, modern contraceptive methods are often underused. This mixed-methods study, conducted in rural Burundi, sought to explain low uptake of contraceptives by identifying utilization barriers. Results may inform development of family planning interventions in Burundi and elsewhere. METHODS: We investigated uptake of contraceptives among women of reproductive age in two rural districts of Burundi, using an explanatory sequential, mixed-methods research design. We first assessed availability and utilization rates of modern contraceptives through a facility-based survey in 39 health clinics. Barriers to uptake of contraceptives were then explored through qualitative interviews (N = 10) and focus groups (N = 7). RESULTS: Contraceptives were generally available in the 39 clinics studied, yet uptake of family planning averaged only 2.96%. Greater uptake was positively associated with the number of health professionals engaged and trained in family planning service provision, and with the number of different types of contraceptives available. Four uptake barriers were identified: (1) lack of providers to administer contraception, (2) lack of fit between available and preferred contraceptive methods, (3) a climate of fear surrounding contraceptive use, and (4) provider refusal to offer family planning services. CONCLUSIONS: Where resources are scarce, availability of modern contraceptives alone will likely not ensure uptake. Interventions addressing multiple uptake barriers simultaneously have the greatest chance of success. In rural Burundi, examples are community distribution of contraceptive methods, public information campaigns, improved training for health professionals and community health workers, and strengthening of the health infrastructure.

Reproductive counseling by clinic healthcare workers in Durban, South Africa: perspectives from HIV-infected men and women reporting serodiscordant partners.

BACKGROUND: Understanding HIV-infected patient experiences and perceptions of reproductive counseling in the health care context is critical to inform design of effective pharmaco-behavioral interventions that minimize periconception HIV risk and support HIV-affected couples to realize their fertility goals. METHODS: We conducted semistructured, in-depth interviews with 30 HIV-infected women (with pregnancy in prior year) and 20 HIV-infected men, all reporting serodiscordant partners and accessing care in Durban, South Africa. We investigated patient-reported experiences with safer conception counseling from health care workers (HCWs). Interview transcripts were reviewed and coded using content analysis for conceptual categories and emergent themes. RESULTS: The study findings indicate that HIV-infected patients recognize HCWs as a resource for periconception-related information and are receptive to speaking to a HCW prior to becoming pregnant, but seldom seek or receive conception advice in the clinic setting. HIV nondisclosure and unplanned pregnancy are important intervening factors. When advice is shared, patients reported receiving a range of information. Male participants showed particular interest in accessing safer conception information. CONCLUSIONS: HIV-infected men and women with serodiscordant partners are receptive to the idea of safer conception counseling. HCWs need to be supported to routinely initiate accurate safer conception counseling with HIV-infected patients of reproductive age.

Psychometric evaluation of the Spanish version of CONNECT: a measure of continuity of care in mental health services.

This article provides the results of the psychometric testing of the Spanish version of CONNECT(-S), a measure of continuity of care in mental health services. CONNECT-S is a multidimensional measure designed for use with seriously mentally ill respondents. Consisting of 12 scales and one single-item indicator, it addresses qualities of interaction in current relationships between mental health service providers and consumers in five conceptual domains: (1) practitioner knowledge of their clients, (2) creating flexibility, (3) practitioner availability, (4) practitioner co-ordination, and (5) smoothing transitions. One-hundred-and-fifty participants took part in the study. Participants were recruited from mental health outpatient clinics in both the Puerto Rican (n = 109) and the San Antonio (n = 41) samples. Internal consistency for scales in a combined site estimate ranged from 0.68 to 0.96. Test-retest reliability ranged from fair to substantial in all but one scale. Concurrent validity hypotheses based on a priori predictions were mostly supported. The Spanish translation and adaptation of CONNECT-S provided sound psychometric results across both sites. CONNECT-S addresses the gap in measurement of continuity of care for the two largest US Latino subgroups, Mexican Americans and Puerto Ricans; and provides an encouraging starting point for a measure that is both relevant and culturally sensitive.

Social relationships, stigma and adherence to antiretroviral therapy for HIV/AIDS.

Research on adherence to combination antiretroviral therapy has up to now focused largely upon problems of definition and measurement, and on the identification of barriers and supports. This paper examines the intersection between taking HAART and building a life with HIV/AIDS. Data consist of 214 qualitative interviews with 52 HIV-positive, active illegal drug users. A interpretive analysis drawing upon stigma and fear of disclosure as analytical constructs was applied to explain working tensions between efforts to develop social relationships on the one hand, and attempts to safeguard health through adherence on the other. The analysis specifies a mechanism through which stigma as a social process results in marginalization and exclusion. The hierarchical organization of multiple stigma is also noted. Loneliness and the desire for relatedness is intensified by drug use. Results suggest that persons with HIV/AIDS will not consistently subordinate other interests to prioritize adherence. Interventions aimed at supporting long-term adherence must address experienced conflicts between 'health' and 'life'.

Clinician experiences of managed mental health care: a rereading of the threat.

The threat mental health professionals perceive in managed care, as indicated by their writings on the subject, is re-examined in light of evidence from an ethnographic study. Fieldwork focusing on clinician experiences of managed care was carried out at an urban community mental health center. Existing explanations of "the threat"--the possibility of deprofessionalization and the potential for deterioration in the quality of care--proved inadequate to account for the power it wielded at this site, perhaps because its full impact had yet to be felt at the time of data collection. A "rereading" suggests the meaning of managed care for this group of clinicians lies in the prospect of being gradually, unknowingly, and unwillingly reprofessionalized from critics into proponents simply by virtue of continuing to practice in a managed care context, and in losing a moral vision of good mental health treatment in the process.

Toward a model of social course in chronic illness: the example of chronic fatigue syndrome.

Retrospective, narrative accounts of illness experience in chronic fatigue syndrome provide the empirical basis for a preliminary conceptual model of social course in chronic illness. Qualities of distress interact with culturally specific expectations for social life and personal conduct to trigger microsocial processes of marginalization: role constriction, delegitimation, impoverishment, and social isolation. Marginalizing processes are opposed by acts of resistance initiated by ill individuals and directed toward integration in social worlds. Social distance from the perceived centers of CFS sufferers' interpersonal worlds expands and contracts with the changing predominance of marginalizing and resisting influences over time. Social course thus consists of successive, bi-directional movements along a 'continuum of marginality' by persons living lives with chronic illness.

An ethnographic study of the meaning of continuity of care in mental health services.

OBJECTIVE: As a step toward developing a standardized measure of continuity of care for mental health services research, the study sought to identify the interpersonal processes of giving and receiving day-to-day services through which individual providers create experiences of continuity for consumers. METHODS: Ethnographic methods of field observation and open-ended interviewing were used to investigate the meaning of continuity of care. Observations were carried out at two community mental health centers and a psychiatric emergency evaluation unit in Boston. Sixteen recipients and 16 providers of services at these sites were interviewed. RESULTS: Six mechanisms of continuity were identified, labeled, defined, and described through analysis of field notes and interview transcripts: pinch hitting, trouble shooting, smoothing transitions, creating flexibility, speeding the system up, and contextualizing. The mechanisms elaborate dimensions and principles of continuity cited by other observers and also suggest new formulations. CONCLUSIONS: The mechanisms identified in this study facilitate operationalization of the concept of continuity of care by specifying its meaning through empirically derived indicators. Ethnography promises to be a valuable methodological tool in constructing valid and reliable measures for use in mental health services research.

Sociosomatics and illness in chronic fatigue syndrome.

OBJECTIVE: This study examines social processes that construct the course of chronic illness. Specifically, it identifies and describes mechanisms that constitute the process of role constriction in employment for individuals with chronic illness. METHOD: Sixty-six persons meeting the Centers for Disease Control case definition of chronic fatigue syndrome (CFS) participated in a longitudinal study involving three waves of data collection over 3 years. Qualitative and quantitative methods were combined in the research, which included face-to-face semistructured interviews, telephone interviews, and self-report questionnaires. Materials presented in this study are drawn principally from the Year 1 face-to-face and telephone interviews. RESULTS: When patterns of symptoms and of the illness course in CFS intersect with work requirements, they impede performance and place ill individuals at risk for job loss. Persons with CFS devise and implement specific strategies to resist role constriction and remain in the work force. CONCLUSIONS: Role constriction is a social process of marginalization in chronic illness. Opposing forces of marginalization and resistance define the social course in chronic illness and suggest that chronicity can be thought of as a marginalized position in social space.

Health status in patients with chronic fatigue syndrome and in general population and disease comparison groups.

PURPOSE: To measure the functional status and well-being of patients with chronic fatigue syndrome (CFS), and compare them with those of a general population group and six disease comparison groups. PATIENTS AND METHODS: The subjects of the study were patients with CFS (n = 223) from a CFS clinic, a population-based control sample (n = 2,474), and disease comparison groups with hypertension (n = 2,089), congestive heart failure (n = 216), type II diabetes mellitus (n = 163), acute myocardial infarction (n = 107), multiple sclerosis (n = 25), and depression (n = 502). We measured functional status and well-being using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), which is a self-administered questionnaire in which lower scores are indicative of greater impairment. RESULTS: Patients with CFS had far lower mean scores than the general population control subjects on all eight SF-36 scales. They also scored significantly lower than patients in all the disease comparison groups other than depression on virtually all the scales. When compared with patients with depression, they scored significantly lower on all the scales except for scales measuring mental health and role disability due to emotional problems, on which they scored significantly higher. The two SF-36 scales reflecting mental health were not correlated with any of the symptoms of CFS except for irritability and depression. CONCLUSION: Patients with CFS had marked impairment, in comparison with the general population and disease comparison groups. Moreover, the degree and pattern of impairment was different from that seen in patients with depression.

Prevalence of fatigue and chronic fatigue syndrome in a primary care practice.

BACKGROUND: Our goals were to determine the prevalence of unusual, debilitating fatigue and the frequency with which it was associated with the chronic fatigue syndrome (CFS) or other physical or psychological illness in an outpatient clinic population. METHODS: We prospectively evaluated a cohort of 1000 consecutive patients in a primary care clinic in an urban, hospital-based general medicine practice. The study protocol included a detailed history, physical examination, and laboratory and psychiatric testing. RESULTS: Five patients who came because of CFS studies were excluded. Of the remaining 995, 323 reported fatigue, and 271 (27%) complained of at least 6 months of unusual fatigue that interfered with their daily lives. Of the 271, self-report or record review revealed a medical or psychiatric condition that could have explained the fatigue in 186 (69%). Thus, 85 (8.5%) of 995 patients had a debilitating fatigue of at least 6 months' duration, without apparent cause. Of these patients, 48 refused further evaluation, and 11 were unavailable for follow-up; 26 completed the protocol. Three of the 26 were hypothyroid, and one had a major psychiatric disorder. Of the remaining 22 patients, three met Centers for Disease Control and Prevention criteria for CFS, four met British criteria, and 10 met the Australian case definition. The point prevalences of CFS were thus 0.3% (95% confidence interval [CI], 0% to 0.6%), 0.4% (95% CI, 0% to 0.8%), and 1.0% (95% CI, 0.4% to 1.6%) using the Centers for Disease Control and Prevention, British, and Australian case definitions, respectively. These estimates were conservative, because they assumed that none of the patients who refused evaluation or were unavailable for follow-up would meet criteria for CFS. CONCLUSIONS: While chronic, debilitating fatigue is common in medical outpatients, CFS is relatively uncommon. Prevalence depends substantially on the case definition used.

Society, mind and body in chronic fatigue syndrome: an anthropological view.

An anthropological view of chronic fatigue syndrome places the study of illness in social context. Data from an interview study of 50 chronically fatigued patients demonstrate the relation of local social worlds--families, workplaces, communities--to the meaning and experience of illness. Negative life events and difficulties, multiple commitments, and a hectic pace are among prominent themes in the subjects' local worlds. These themes are reflected in: (1) attributions of illness onset to social sources, (2) the symbolism of the core complaint of fatigue, and (3) an illness-induced, positively valued lifestyle transformation suggesting the rejection of culturally prescribed 'busyness'. Dichotomous definitions of the relation of mind and body are shown to be part of culture, not Nature, in the paper's second section. The 'mind-body dichotomy' and the differing values attached to physical and psychological disorders by a naturalistic scientific paradigm explain the delegitimizing experiences of sufferers, who find their illness dismissed as psychosomatic and therefore 'not real'. A conceptualization of chronic fatigue syndrome which links local social worlds to psychological distress, felt bodily sensation and biological changes is proposed. Collaborative teams of social scientists and medical researchers might fruitfully pursue aspects of social context in relation to psychiatric, immunological and viral dimensions of the illness.

Culture and somatic experience: the social course of illness in neurasthenia and chronic fatigue syndrome.

An anthropological view of culture and somatic experience is presented through elaboration of the notion that illness has a social course. Contemporary anthropology locates culture in local worlds of interpersonal experience. The flow of events and processes in these local worlds influences the waxing and waning of symptoms in a dialetic involving body and society over time. Conversely, symptoms serve as a medium for the negotiation of interpersonal experience, forming a series of illness-related changes in sufferers' local worlds. Thus, somatic experience is both created by and creates culture throughout the social course of illness. Findings from empirical research on neurasthenia in China, and chronic fatigue syndrome (CFS) in the United States, corroborate this formulation. Attributions of illness onset to social sources, the symbolic linking of symptoms to life context, and the alleviation of distress with improvement in circumstances point to the sociosomatic mediation of sickness. Transformations occasioned by illness in the lives of neurasthenic and CFS patients confirm the significance of bodily distress as a vehicle for the negotiation of change in interpersonal worlds. An indication of some of the challenges anthropological thinking poses for psychosomatic medicine concludes the discussion.

The prevalence of bulimia among college students.

A survey was conducted to determine the prevalence of bulimia and bulimic symptoms in a nonclinical sample of 907 college freshmen and seniors. Using criteria based on the Diagnostic and Statistical Manual of Mental Disorders, 4 per cent of the women and 0.4 per cent of the men were classified as bulimic. Symptoms of bulimia, such as binge eating, purging behaviors, and extreme fear of gaining weight, were much more prevalent.