Kenyan palliative care providers' and leaders' perceptions of palliative care research needs and support to facilitate rigorous research.

BACKGROUND: Palliative care (PC) can reduce symptom distress and improve quality of life for patients and their families experiencing life-threatening illness. While the need for PC in Kenya is high, PC service delivery and research is limited. Qualitative research is needed to explore potential areas for PC research and support needed to enable that research. This insight is critical for informing a national PC research agenda and mobilizing limited resources for conducting rigorous PC research in Kenya. OBJECTIVES: To explore perceptions of priority areas for PC research and support needed to facilitate rigorous research from the perspective of Kenyan PC providers and leaders. METHODS: Focus groups (FGs) were conducted in November and December of 2018 using a semi-structured interview guide. FGs were audio-recorded, transcribed, and analyzed using a thematic content analysis approach. RESULTS: Three FGs were conducted (n = 22 participants). Ten themes related to PC research emerged, including research on: 1) beliefs about death, disease, and treatment to inform PC; 2) awareness about PC, 3) integration of PC within the health system; 4) understanding caregiver experiences and needs; 5) community health volunteers (CHVs) and volunteer programs; 6) evaluation of costs and benefits of PC; 7) treatment approaches, including complementary and alternative medicine (CAM) and advanced diagnostics at end of life; 8) other suggestions for research, 9) populations in need of PC research; and 10) resources for enabling research. CONCLUSIONS: Kenyan PC providers and leaders identified key areas requiring increased scientific inquiry and critical resources needed to enable this research. These findings can help to focus future PC research in Kenya and encourage funding agencies to prioritize the issues identified.

Out of the shadows: non-communicable diseases and palliative care in Africa.

Non-communicable diseases (NCDs) in Africa have been comparatively neglected, partly due to donor-driven funding priorities. This is despite NCDs being the principal cause of mortality globally, with the majority incidence occurring in low-income and middle-income nations. Most of the patients with NCDs will suffer from pain, breathlessness and other physical symptoms, or need support with psychosocial or spiritual problems. Reflecting regional disease prevalence, late-stage clinical presentation, limited funding and restricted access to curative therapies, palliative care need in Africa is significantly high. Although palliative care provision has advanced significantly on the continent in the past decade, much of this development was driven by services for adult HIV patients. However, recent international and regional political declarations and commitments constitute a new global NCD agenda that calls for the integration of palliative care into the NCD response. This could be achieved under a chronic care model of service provision in partnership with other clinical providers in an integrated care continuum spanning prevention, early detection, diagnosis, treatment, survivorship and the end of life. Four important challenges have to be addressed if palliative care is to contribute meaningfully to this NCD agenda: (1) existing variation in the ability of countries to deal with NCDs per se; (2) ensuring clinical partners are integrated effectively with palliative care; (3) agreeing implementation is linked to relevant national-level and patient-level metrics; and (iv) underpinning palliative care and NCD care with a rigorous and locally relevant evidence base demonstrating appropriate, feasible and effective care.

Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Africa: a report from the Global Opioid Policy Initiative (GOPI).

With nearly 1.1 billion inhabitants living in more than 50 countries, Africa is the world's poorest and most socioeconomically underdeveloped continent. Despite some advances for individual states, many African countries have very low opioid consumption and, overall, the continent has the lowest consumption per capita of any in the world. This article presents the findings of the first systematic study of the availability and accessibility of opioids for the management of cancer pain across the continent. Data are reported on the availability and accessibility of opioids for the management of cancer pain in 25 of 52 countries, with 744 million of the region's 1127 million people (66%) covered by the survey. Many countries had severely restricted formularies of opioids and only 15 of 25 had morphine available in oral IR, CR and injectable formulations. Even when opioids are on formulary they are often unavailable, and access is significantly impaired by widespread over-regulation that is pervasive across the region.

A national survey of violence experienced by community mental health researchers.

BACKGROUND: In recent years there has been a vigorous debate concerning the relationship between violence and mental illness. Psychiatric hospital staff are especially likely to experience violence. 'Detached staff' working in the community appear to be at greatest risk. The present study examines reported aggression towards field-based community mental health researchers (CMHRs). It aimed to investigate the nature and extent of violence experienced by CMHRs, to establish which CMHR characteristics act as precipitators of violent incidents and to identify training needs. METHODS: This national survey, conducted between December 1997 and March 1998 at the Department of Mental Health, University of Exeter, used a postal questionnaire circulated among CMHRs working in England, Scotland and Wales. RESULTS: Whilst this study did not achieve comprehensive coverage of all eligible CMHRs, it indicates that, even allowing for response bias, occupational violence is not uncommon among CMHRs: 51% (n = 33) ever experienced at least one verbally violent incident, 9% (n = 6) a mildly violent incident and 2% (n = 1) a severely violent incident. In the 12 months preceding the study, 45% of CMHRs (n = 29) had experienced at least one verbally violent incident and 8% (n = 5) a mildly violent incident. Male CMHRs are more likely (P < 0.05) to experience violence than their female counterparts. CONCLUSIONS: The findings indicate a need to improve existing safety training, procedures and awareness among this occupational group. Additional comparative research among other community-based groups is, however, required.

Sex preference and contraceptive behaviour among men in Mbeya region, Tanzania.

While recent studies confirm parental child sex preference in less developed countries, its pattern varies. Son preference is especially prevalent in Bangladesh, China, India, and Pakistan. Sex preference in sub-Saharan Africa is a neglected area of enquiry. Completed research focuses on women's views to the neglect of men, despite the latter's importance as primary decision-makers. This study identifies factors influencing contraceptive behaviour among men in Mbeya region, Tanzania, demonstrating how it is affected by their preferred family sex composition. Data used were collected from a cross-sectional survey of 600 men aged 16-50 and six focus groups conducted in the region's rural and urban areas. Using single statements and Coombs' Scales, sex preference was found to be prevalent in the study area, with sons strongly preferred to daughters. Sex preference is significantly associated with the number of existing daughters a man has, his marital status, residence and occupation. Findings suggest programmes should be initiated to challenge men's attitudes towards one-sex family composition. Men should be educated about the advantages of small family sizes and persuaded that both children's sexes are equally important. Such measures can assist men in reconsidering their desired family sizes, reduce biases towards one sex, minimise marital problems and improve women's status. Efforts to increase contraceptive use in Tanzania will be hampered, however, if men maintain their preference for sons over daughters.

The effects of hypnosis on dissociative identity disorder: a reexamination of the evidence.

OBJECTIVE: To examine the possibility that hypnosis has significant iatrogenic effects on dissociative identity disorder (DID). METHOD: This paper reexamines previously published data that have been interpreted as indicating that hypnosis does not exert significant iatrogenic effects on DID. RESULTS: The use of hypnosis is associated with differences in DID phenomenology and number of DID patients in treatment. CONCLUSION: Hypnosis may have significant iatrogenic effects on DID.

Dissociative identity disorder and the sociocognitive model: recalling the lessons of the past.

In a recent article in this journal, D. H. Gleaves (1996) criticized the sociocognitive model (SCM; N. P. Spanos, 1994) of dissociative identity disorder (DID) and argued in favor of a posttraumatic model (PTM) in which DID is conceptualized as a consequence of childhood abuse and other traumatic events. The present authors demonstrate that (a) many of Gleaves's arguments were predicated on misunderstandings of the SCM, (b) scrutiny of the evidence regarding the psychopathology and assessment of DID raises questions concerning the PTM's conceptual and empirical underpinnings, (c) the treatment literature suggests that iatrogenic factors play an important role in the etiology of DID, and (d) the evidence linking child abuse to DID is more problematic than implied by Gleaves. The present authors conclude that Gleaves's analysis underemphasized the cultural manifestations of multiple role enactments and that the history of DID imparts a valuable lesson to contemporary psychotherapists.

Effectiveness of treatment for dissociative identity disorder.

In a recent study by Ellason and Ross, patients with Dissociative Identity Disorder reported a decrease in symptoms on the Millon Clinical Multiaxial Inventory-II over a 2-yr. follow-up period. Patients judged to have achieved integration of their personalities rated themselves as more substantially improved on the Millon-II than did patients judged not to have achieved integration. Ellason and Ross suggested that this improvement reflected the influence of treatment; however, for several reasons, their findings are open to alternative interpretations. First, in the absence of proper control conditions, one cannot rule out the contribution of other factors to the over-all improvement of patients such as regression of symptoms toward the mean following the initial assessment. Second, patients self-reported improvement was less substantial when data were reanalyzed using more appropriate statistical criteria. Third, the greater improvement observed among integrated patients relative to nonintegrated patients may reflect influences other than differential responsiveness to treatment, such as less severe pathology prior to treatment. More systematic research is needed to clarify the effect of treatment on Dissociative Identity Disorder.

Was Anna O.'s black snake hallucination a sleep paralysis nightmare? Dreams, memories, and trauma.

The final traumatic event recalled by Anna O. during her treatment with Josef Breuer was a terrifying hallucination she once had of a black snake attacking her ailing father. This event has been variously interpreted as indicating an underlying psychodynamic conflict, as a temporal lobe seizure, and as an hypnotic confabulation. We argue, however, that the hallucination--during which Anna O.'s arm was reportedly "asleep" due to nerve blockage--was probably a sleep paralysis nightmare. Sleep paralysis nightmares continue to be overlooked or misdiagnosed in clinical practice, and, in recent years, have been implicated in the controversy surrounding memories of trauma and sexual abuse.

Attitudes of men towards family planning in Mbeya region, Tanzania: a rural-urban comparison of qualitative data.

Family planning programmes in Tanzania date back to the 1950s. By the early 1990s, however, only 5-10% of women of childbearing age used contraceptives in the country. Low contraceptive prevalence in Tanzania is reportedly attributable to men's opposition to family planning. This paper employs focus groups to explore the role of Tanzanian men in family planning. More specifically, it presents a rural-urban comparison of the attitudes of men in Mbeya region, Tanzania, to family size preference, sex composition, partners' communication on family planning matters and contraceptive behavior. Findings indicate that men express positive attitudes towards fertility-regulating methods. There is, moreover, little rural-urban variation in male attitudes towards family planning in the study area. Possible reasons for this normative convergence (including structural similarities and rural-urban migration between the two communities) are discussed.

PIP: This study explored the attitudes of rural and urban men toward family planning (FP) in Tanzania. Data were obtained from focus groups conducted among a sample of men aged 16-50 years living in both urban (Mabatini, Ruanda, and Sisimba) and rural (Iwindi, Mapogoro, and Tembela) districts of Mbeya region in the southern highlands in 1994. The total fertility rate was 7.4 children/woman in the region. Focus group discussions addressed four themes: attitudes toward family size, sex composition, communication about FP, and contraceptive use. Findings indicate that male attitudes toward FP did not vary between urban and rural areas. The similarities are attributed to pervasive cultural norms and little structural variation between areas. Men preferred more sons and believed that larger families cost more. Men in urban areas were more aware of the cost of large families. Men considered it their responsibility to allow women to use FP. Men were suspicious of modern methods, doubted their safety, and feared that women would be unfaithful if allowed to use contraception. Men believed that condoms were useful for prevention of HIV/AIDS with prostitutes and did not associate use with FP. Men believed that FP was directed to women and not sufficiently directed to men, and that women knew more about FP. The family size desired ranged from 4-6 children in rural areas, to 2-4 children in urban areas, which suggests unmet need. Negative attitudes of men towards FP should be addressed in IEC campaigns.

A voice-enabled, structured medical reporting system.

Kurzweil Applied Intelligence received a research grant from the National Institute of Standards and Technology (NIST) Advanced Technology Program to develop a prototype voice-enabled, structured medical reporting system. In typical usage, the physician dictates to the system, which then uses automatic speech recognition and medical knowledge bases to produce a structured report. This report can then be formatted and viewed on a computer screen, stored in databases of patient information, transmitted to other systems, used to support outcome studies, or viewed on a Web browser. The output reports are structured according to two standard, platform-independent formats: SGML and CORBA. These formats represent the data in a way that can be read by both computers and humans, and efficiently communicated to a wide range of databases and communications protocols.

Focus groups.

This paper introduces focus group methodology and discusses its relevance to those researching health care provision. As a qualitative data collection technique, the focus group has advantages over other qualitative methods, such as the in-depth interview and nominal group technique. This paper highlights these advantages after providing guidelines on group composition, the management of group discussion and the process of analysing results.

Speculations in "Temporal delays in incorporation of events into dreams": a reply to Roll.

Previously we pointed out similarities between patterns of delayed incorporations of daytime stimuli into dreams and delayed memory processes in rats. In commenting upon this article, Roll argued that this reductionistic leap is unwarranted. We contend that it would be remiss not to make note of this potential connection, especially in view of recent major contributions of animal research to the understanding of REM sleep and dreams. We also suggest that the disruption-avoidance-adaptation model constitutes a preferable psychological explanation for the dream-lag effect than Roll's psychoanalytic model of repression and repetition compulsion.