Thematic Saturation Research Articles

Medical student perceptions and experiences of incivility: a qualitative study

BackgroundIncivility is rude, dismissive or aggressive behaviour in the workplace. Rates of incivility are increasing in healthcare settings, with minority groups at greatest risk. Medical students are particularly vulnerable to incivility whilst on clinical placements, with detrimental consequences on students’ learning and mental health. Therefore, this study explored the perceptions and experiences of incivility from healthcare workers amongst medical students.MethodsAn online qualitative questionnaire study employing a thematic analysis. Students in years 3–5 or intercalating at a large West Midlands medical school were recruited between May–June 2022. Qualitative free-text questions explored students’ experiences of incivility from healthcare workers over the past 12 months, and actions in response to incivility. Data were analysed using thematic analysis. All researchers agreed thematic saturation was reached at 50 responses, with all year-groups represented.ResultsFive core themes were identified: abuse of hierarchy; exclusion; discrimination; response to incivility; barriers to action. Participants reported a range of uncivil behaviour from staff, including mocking, exclusion and discrimination. Discriminatory incivility targeted students’ protected characteristics, including race, sex, sexual orientation and disability. In response to experiencing or witnessing incivility, participants varied in their preferred mode of action. Many viewed formal escalation to senior staff as favourable action. Meanwhile, other participants would not escalate concerns and instead respond with peer support or allyship. Marked barriers prevented students from challenging or reporting incivility, including a lack of confidence; failures and fears of reporting systems; and perceived severity of abuse.ConclusionOur findings identify the extensive incivility experienced by medical students on clinical placements, which is frequently perpetuated by abusive workplace hierarchy. Whilst students recognise the importance of reporting uncivil behaviours, barriers to reporting include unrecognised incivility, psychological consequences and failed reporting systems. In order to reform toxic educational environments, we recommend medical schools to integrate formal civility training into the curriculum and restructure accessible, supportive reporting systems.

Drivers of decision-making regarding infant sleep practices among mothers with opioid use disorder.

To understand the perspectives and perceived facilitators of and barriers to following safe infant sleeping practices among mothers with opioid use disorder (OUD). Using the Theory of Planned Behavior (TPB) framework, we conducted qualitative interviews with mothers with OUD regarding infant sleep practices. We created codes and generated themes, concluding data collection upon achieving thematic saturation. Twenty-three mothers with infants 1-7 months of age were interviewed from 08/2020 to 10/2021. Mothers chose sleeping practices they perceived made their infants safer, more comfortable, and minimized infant withdrawal symptoms. Mothers in residential treatment facilities were influenced by facility infant sleep rules. Hospital sleep modeling and varied advice by providers, friends and family influenced maternal decisions. Mothers reported factors unique to their experience with OUD that influenced their decisions about infant sleep that should be considered when developing tailored interventions to promote safe infant sleep in this population.

"I'd rather see action": Application and recruitment experiences of underrepresented in emergency medicine trainees.

The emergency medicine (EM) physician workforce is largely composed of white men. Despite recruitment efforts over the past decade, there has not been a significant increase of trainees with underrepresented racial and ethnic identities in EM (URM). Prior studies have focused on institutional strategies to improve diversity, equity, and inclusion (DEI) in EM residency recruitment but have been limited in describing URM trainees' perspectives. We sought to assess URM trainees' perspectives on DEI in the EM residency application and selection process. This study was conducted at an urban academic medical center in the United States from November 2021 to March 2022. Junior residents were invited to participate in individual semistructured interviews. We used a combined deductive-inductive approach to categorize responses in predetermined areas of interest then elicit dominant themes within each category through consensus discussions. Thematic saturation was reached after eight interviews, indicating adequate sample size. Ten residents participated in semistructured interviews. All identified as racial or ethnic minorities. Three dominant themes emerged relating to authenticity, representation, and being treated as a learner first. Participants assessed the authenticity of a program's DEI efforts by evaluating the time frame and scope of DEI efforts. Participants reported a desire for representation of other URM colleagues in a residency program and training environment. While participants wanted their lived experience as URM trainees acknowledged, they were wary of being viewed solely through the lens of future DEI leaders rather than as learners first. URM residents value multifaceted commitment to DEI efforts, representation, and being seen as learners first when assessing residency programs. Programs seeking to recruit URM residents should develop a department-wide, multipronged, comprehensive DEI plan and showcase how their program will contribute to an applicant's professional development.

Active Duty to Veteran: Challenges Faced by Service Men and Women Reintegrating to Civilian Life in the South Carolina Lowcountry

Objective: One in 4 active-duty US military personnel report needing support for mental health issues. This proportion increases to 41% of all US military veterans, suggesting mental health status may worsen by the transition from active duty to civilian life. In this study, we explore the lived experiences of veterans in the South Carolina Lowcountry as they transition from active service to civilian life, with an emphasis on identifying services and support for this population. Methods: We used a qualitative design employing a grounded theory approach. We conducted semi-structured interviews with 20 veterans in the first year of reintegration to civilian life that examined the following areas: (1) social isolation; (2) physical isolation; and (3) self-reported levels of mental distress. Results: Thematic saturation was reached with the following emerging themes: (1) perceived mental distress due to social and physical isolation, (2) difficulty transitioning from the military “family” to one’s actual family, (3) confusion regarding identity and place in society, and an expressed (4) need for services to support this critical period in a veteran’s life. Conclusions: Our interview data provide insight about the experiences of military veterans as they return to civilian life and offer evidence for the need for better integration into the social and physical fabric of the population using both existing and enhanced community-based support programs

Using key stakeholder interviews to inform implementation of a cancer center collaborative intervention to improve clinical trial accruals.

e18650 Background: Cancer clinical trial (CT) participation rates in the US are low, especially among BIPOC populations. Patient enrollment to CTs is influenced by structural characteristics of the care delivery system, and the nature of individual needs and available resources. We are developing a multi-level intervention across 3 cancer centers in New York City by creating a collaborative pool of, and a referral system for breast, prostate, and liver cancer CTs to increase overall participation, particularly among BIPOC populations. To inform implementation of this intervention, we explored key stakeholder perceptions and attitudes around CT enrollment process across 3 hospitals within one such cancer center. Methods: We conducted semi-structured interviews with 23 key stakeholders to determine the attitudinal and structural factors affecting CT accrual at 1 cancer center and its 2 community hospital affiliates. Stakeholders included oncologists, nurses, informaticists, oncology leadership and research staff, identified using a targeted and snowball sampling approach. Guided by the Behavioral Model of Health Service Use, we identified themes related to enabling, predisposing, and need factors, and coded transcripts until theme saturation in Dedoose. Results: Key approaches to improve CT participation focused on these structural enabling themes: increased availability of CTs, personnel to screen and enroll patients, well-timed and technology-assisted clinician notification of a potential CT match (within or outside home institution), along with an institutional culture encouraging stakeholder engagement, provider outreach, and care coordination. Important predisposing and enabling themes related to stakeholders’ beliefs about patients included: financial access, knowledge and perceptions about CTs, language barriers, motivation, and medical mistrust. Knowledge about open trials, and skepticism or enthusiasm about CTs were important predisposing themes related to clinicians. Need theme affecting implementation was clinician judgment about their patients’ eligibility for CT evaluated based on functional status, comorbidities, age, advanced cancer stage, progression of disease, change in therapy, and drug targets. Conclusions: We identified actionable enabling, predisposing, and need factors that serve as barriers to CT accrual and to successful implementation of our intervention. Major findings were structural and attitudinal, including lack of staffing resources for clinicians, and financial assistance and access for patients. Updated information about open CTs, implementation of e-screening tools for patient enrollment, addressing clinician skepticism for enrollment by increased recognition for their research efforts, as well as delivery of culturally sensitive patient education around CTs may improve CT enrollment.

Identifying sources and mechanisms for missed opportunities in discussing cognition and capacity among older adults with advanced cancer, their caregivers, and physicians.

e24019 Background: Impaired cognition increases the risk of treatment-related toxicity and adverse cancer outcomes. Thus, communication about cognition is essential for informed decision making, particularly for patients with abnormal cognitive screening results (e.g. Mini-Cog). We aimed to qualitatively explore missed opportunities in discussing cognition and capacity in oncology clinical encounters for patients with an impaired Mini-Cog score. Methods: This secondary analysis examined audio recordings of clinical encounters from a nationwide, multi-center, cluster-randomized trial (NCT02054741; PI: Mohile; funding NCI UG1CA189961). Eligible patients were age 70 years or older with at least one geriatric assessment (GA) domain impairment, either receiving or considering cancer treatment for incurable cancer. Patients were randomly assigned to usual care or GA-guided communication intervention (GA summary with recommendations was provided to patient, caregiver, oncologist). Clinical encounters in both arms were audio-recorded and transcribed. A sample size of 75 patients with impaired Mini-Cog was utilized to meet thematic saturation. Transcribed interviews were open-coded by 2-4 independent coders using a constant comparative method to simultaneously code and analyze for thematic elements. Missed opportunity for cognitive or capacity conversations was identified when a cognitive or capacity concern was mentioned but not acknowledged and/or addressed by other participants in the conversation, or when concerns were alluded to but not described in sufficient detail. Results: A total of 74 patients were evaluated with mean age 78.7 years (SD 6.0). The majority were male (53.3%), white (86.7%), non-Hispanic (100%), with gastrointestinal (26.7%) or lung (25.3%) cancer. Overall, 48 missed opportunities were identified across the 75 clinical encounters (cognition 39 [81.3%]; capacity 9 [18.8%]); oncologists, patients, and caregivers all contributed as sources of missed opportunities to discuss cognition/capacity (63%, 24%, 13% respectively). Mechanistically, when oncologists were the source of the missed opportunity, it was due to: 1) a lack of response to either caregiver or patient’s concern, or 2) not allowing space for the patient or caregiver to elaborate or clarify. When patients were the source of a missed opportunity, it was due to: A) cognitive impairment preventing meaningful conversation, B) minimization or deflection of concern by the patient, or C) lack of engagement in conversation. Conclusions: We identified several underlying mechanisms of missed opportunities in discussing cognition/capacity in oncology clinical encounters. Discussing cognition/capacity in the context of oncology is critical and future work should develop interventions to enhance communication about cognition. Clinical trial information: NCT02054741 .

Artistic Originality of the Novel “Farewell to Arms!” by E. Hemingway

Indifference of authorities was a main symbol of the time preceded creation of the novel Farewell to Arms!. To save democracy it was reflected in the propaganda of war. The calls were especially persistent in May 1918. At this moment, the elderly felt the apathy of the strong and did not want to participate in this wrong war, young men (such as eighteen-year-old Hemingway) did not understand anything and went to the front. Most of them were destined to die. The fate loved Ernest: it saved him from joining the army several times. Later, when the young man could no longer wait, it saved him from direct participation in hostilities. In vain, because the war engages even Red Cross employees in physical and moral battles: it raises many unsolvable questions, makes them doubt the honesty of what is happening and tries to devalue the highest feelings. Many decisive measures were to be taken to preserve the soul. Many artistic devices would come in need to describe the experience. The study of these mediums is the subject of this research, the proof of their artistic power is the goal. The research was carried out on the materials of the English and Russian versions of the novel, critical articles by researchers of the writer's work. The comprehensive method of literary analysis was used. We revealed high thematic saturation in the novel because of our research effords. The author raised many problems: an intellectual in war, people's attitude to war, religion and war, morality and war, the fall of man in war, the influence of official propaganda on people; showed originality of the use of synthesis and montage (combination of pictures of different quality and meaning), sophisticated contrast; confirmed validity of the breach of the chronological principle.

Perceptions of the Shared Learning Environment by Vascular and General Surgery Residents

Perceptions of the Shared Learning Environment by Vascular and General Surgery Residents

Recommendation-making in the emergency department: A qualitative study of how Canadian emergency physicians guide treatment decisions about resuscitation in critically ill patients.

Emergency physicians are frequently responsible for making time-sensitive decisions around the provision of life-sustaining treatment. These decisions can involve goals of care or code status discussion, which will often substantially alter a patient's care pathway. A central part of these conversations that has received relatively little attention are recommendations for care. By proposing a best course of action or treatment via a recommendation, a clinician can ensure that their patients receive care that is concordant with their values. The objective of this study is to explore emergency physicians' attitudes toward recommendations about resuscitation in critically ill patients in the emergency department (ED). We recruited Canadian emergency physicians via multiple recruitment strategies to ensure maximum variation sampling. Semi-structured qualitative interviews were conducted until thematic saturation occurred. Participants were asked about their perspectives and experiences with respect to recommendation-making in critically ill patients and to identify areas for improvement in this process in the ED. We used a qualitative descriptive approach and thematic analysis to identify themes around recommendation-making in the ED for critically ill patients. Sixteen emergency physicians agreed to participate. We identified four themes and multiple subthemes. Major themes included identification of the roles and responsibilities of the emergency physician (EP) with respect to making a recommendation, the logistics or process of making a recommendation, barriers to making a recommendation, and how to improve recommendation-making and goals of care conversations in the ED. Emergency physicians provided a range of perspectives on the role of recommendation-making in critically ill patients in the ED. Several barriers to the inclusion of a recommendation were identified and many physicians provided ideas on how to improve goals of care conversations, the recommendation-making process, and ensure that critically ill patients receive care that is concordant with their values.

(008) Suggestions for Modifications to the Female Sexual Function Index to be Inclusive of All Populations – Cognitive Interviews with Sexual and Gender Minority and Heterosexual Persons

Abstract Introduction Patient-reported outcome measures that were initially designed for research studies including heterosexual, partnered, educated cisgender women may have limited applicability for clinical use among Sexual and Gender Minority (SGM) patients and patients without a partner. Objective We aimed to conduct cognitive interviews with both SGM persons and heterosexual women to determine readability, comprehension, and applicability of questionnaire items to assess sexual function in populations with diverse sexual practices, focusing on items from the Female Sexual Function Index (FSFI), and to establish content validity of a modified measure. Methods We conducted four rounds of cognitive interviews with 52 participants (28 SGM, 24 heterosexual) who provided feedback on their comprehension and wording of FSFI questionnaire items and response scales. Participants made recommendations for changes to the questionnaire, which was iteratively revised between interview rounds. Two independent coders analyzed the transcripts using structural coding based on five predefined codes (i.e., satisfaction with item, specificity/language change needed, missing/suggested item, patient definitions of concepts, and confusion with item). Results After four rounds of cognitive interviews and revisions to the questionnaire, participants found the final version of the questionnaire acceptable and understandable, thereby reaching thematic saturation and establishing content validity of the modified FSFI. Modifications included: replacing all instances of “sexual stimulation” and “intercourse” with “sexual activity (alone or with a partner)”; broadening the definition of “vaginal penetration” beyond penile-vaginal penetration; adding skip logic to include the option “no sexual activity”. Participants identified missing concepts important to their sexual health, such as including the use of external lubricant. Heterosexual participants found the questionnaire initially refined by SGM participants to be acceptable, and offered targeted feedback including clarifying the clinical relevance of certain domains (e.g., questions about “emotional closeness”), clarifying terminology (e.g., sexually aroused (turned on) and naturally lubricated (wet)) and re-ordering domains (e.g., “pain should be asked about earlier”). Conclusions Feedback from direct interviews supports modifying FSFI items and further psychometric testing. This and other similar questionnaires need to be adapted to the broader clinical practice population such that all persons’ experiences are accurately reflected and assessed, ultimately assuring that sexual health needs can be met more inclusively. Further research in racially and educationally diverse populations is needed. Disclosure No

Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: a qualitative analysis

BackgroundAlthough depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders’ perceptions regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care.MethodsThis single-center, qualitative study was conducted within a tertiary care orthopedic department. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders’ interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention.ResultsPatients included 30 adults out of 85 approached (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person support from a mental health specialist into orthopedic care.ConclusionsAlthough digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients.Trial registrationNot applicable.

Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework

BackgroundThere is a large and growing unmet need for rehabilitation – a diverse category of services that aim to improve functioning across the life course – particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries.MethodsWe conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework.ResultsThe novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries’ national government’s health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies – particularly from civil conflict – and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility.ConclusionsThis framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services.

Parental Experiences With Access to Care for Obstructive Sleep-Disordered Breathing: A Qualitative Study.

Despite evidence-based guidelines for obstructive sleep-disordered breathing (SDB), recent studies continue to highlight treatment inequities. We used qualitative research methods to examine parental facilitators and barriers to SDB treatment. Qualitative interviews. Tertiary care center. Semistructured interviews were conducted (January-April 2022) with parents of children with SDB who underwent tonsillectomies to understand the processes of SDB detection and accessing specialty care. Interviews were conducted until thematic saturation was reached and coded using NVivo software. Of the 17 parents who completed the key informant interviews, 6 (35%) were of non-Hispanic black race, and 3 (17.6%) interviews were conducted in Spanish. Parents noted that the more knowledge their primary care provider (PCP) had about SDB, the easier it was to obtain a diagnostic workup (41%). The most common barrier included difficulty obtaining a specialist (otolaryngology or sleep medicine) referral from their PCP and encountering providers who were dismissive of parent-reported symptoms related to SDB, leading them to seek a second opinion or self-refer (53%). Medicaid coverage was a strong facilitator to receipt of care (59%). Three (17.6%) parents noted alienation in the process due to racial bias or language barriers. Parental interviews revealed that facilitators of SDB treatment included high clinician knowledge and perceived importance of SDB as well as Medicaid insurance which decreased financial strain. Parents also cited the attainment of referrals as a significant barrier to obtaining specialty evaluation. These findings identify potential modifiable areas to tailor future interventions for timely and equitable SDB care.

Southeastern US anesthesia providers’ perspectives on abortion provision: Inductive findings from a qualitative study

ObjectivesHealth care providers, including anesthesia providers, hold varied personal views on abortion, which influences their involvement in multidisciplinary abortion care. We aimed to explore Southeastern US anesthesia providers’ perspectives on abortion provision and factors impacting their decision to provide anesthesia for hospital-based induced abortion. Study designWe conducted in-depth, individual interviews with currently practicing anesthesia providers in the Southeastern United States. We recruited participants from regional anesthesiology conferences and via snowball sampling. A semistructured interview guide explored domains of obstetric experiences, standardized abortion cases, and personal abortion attitudes. We coded data iteratively and analyzed data thematically using inductive approaches with qualitative software. ResultsFifteen participants completed interviews, at which point thematic saturation occurred. Participants represented a range of provider type and prior abortion experience. Participants weighed “personal and professional viewpoints” in considering their willingness to provide anesthesia care for hospital-based abortion. Many participants who personally disagreed with some abortion indications were still willing to provide anesthesia in those cases, some implicitly naming principles of medical ethics to justify differing professional and personal opinions. Participants also considered their “role in abortion decision-making”: all participants reported that the abortion decision belongs to the patient or their obstetrician and not the anesthesia provider. ConclusionsSoutheastern US anesthesia providers are influenced by multiple factors when considering their participation in hospital-based abortion care. Acknowledging differences in professional and personal viewpoints and identifying roles in abortion decision-making might be important to engaging anesthesia providers in abortion care, especially for high-risk medical or fetal indications. ImplicationsThis original, qualitative study identified several inductive themes that characterize how Southeastern US anesthesia providers formulate their level of participation in hospital-based abortion care. Acknowledging differences in professional and personal viewpoints and identifying roles in abortion decision-making might facilitate interdisciplinary abortion care, especially for high-risk medical or fetal indications.

Understanding cigarette smoking among mothers with opioid use disorder

BackgroundCigarette smoking is highly prevalent among mothers with opioid use disorder (OUD). Organizations such as the American College of Obstetrics and Gynecology recommend cessation of cigarettes during the pre- and postnatal periods. Factors that inform decisions to continue or stop smoking cigarettes among pregnant and postpartum mothers with OUD are unclear. AimsThis study aimed to understand (1) the lived experience of mothers with OUD regarding cigarette smoking and (2) barriers and facilitators to reduction of cigarette smoking during the pre- and postnatal periods. MethodsGuided by the Theory of Planned Behavior (TPB) framework, we completed semi-structured, in-depth interviews with mothers with OUD with infants 2–7 months of age. We used an iterative approach to analysis by conducting interviews and developing and revising codes and themes until we reached thematic saturation. ResultsFifteen of 23 mothers reported smoking cigarettes prenatally and postnatally, 6 of 23 smoked cigarettes during the prenatal period only, and 2 mothers were non-smokers. We found that mothers: 1) believed that smoke exposure had negative health consequences and may exacerbate withdrawal symptoms for their infants; 2) implemented risk mitigation practices, which were dictated both by themselves and by outside rules, to reduce the harmful effects of smoke around infants; 3) were motivated to quit or cut-down on smoking because of the desire to optimize the health and well-being of their infants; 4) continued to smoke because they felt that the stress related to caregiving and their own recovery were a higher priority than quitting smoking; and 5) were influenced by exposure to smokers with whom they lived, as well as by the varied advice of medical providers, family, and friends. ConclusionWhile mothers with OUD acknowledged the negative health impact of cigarette smoke exposure to their infants, many experienced stressors related to recovery and caregiving unique to those with OUD that impacted their cigarette smoking behaviors.

Health-seeking behavior and its associated technology utilization among community-dwelling older adults in Singapore: Qualitative study.

Understanding older people's health-seeking behavior (HSB) is crucial to uncovering their health needs and priorities, as well as developing appropriate policies to address these needs and avert their disease progression. Technologies play an active role in our daily lives, and they have been incorporated into health activities to support the aging population and facilitate their HSB. However, prior research in HSB has mainly focused on behaviors during illness, and there is limited research on how technologies have been utilized in older people's health-seeking activities. This study aimed to investigate the HSB and associated technology utilization among the older population, ultimately proposing implications for practice to address their unmet health needs. This paper presented partial data from a larger qualitative study, which has been approved by the Institutional Review Board and employed a phenomenological approach. Semi-structured interviews were conducted between April 2022 and July 2022, either on Zoom or face-to-face. Inclusion criteria included being aged 50 and above, long-term residing in Singapore, and being able to speak English or Mandarin. The interviews were manually transcribed verbatim, and a thematic analysis was performed with the individual as the unit of analysis to understand group phenomena. Fifteen interviews were conducted to reach thematic saturation. We identified five main consequences of HSB, which were aligned with Poortaghi et al.'s model. Regarding technology utilization in health-seeking, four themes were extracted: 1) the most widely used digital technologies are the mobile health apps and wearable devices with associated wellness programs launched by the government and local companies, and they have the potential to enhance health communication, promote health maintenance, and increase access to health services; 2) information communication technologies and social media, though not primarily designed for health purposes, play a significant role in easing the process of seeking health information and managing symptoms; 3) while the outbreak of the COVID-19 pandemic has resulted in some alterations to older adults' well-being, it has catalyzed the adoption of telehealth as a complement to access healthcare services; and 4) older adults have different considerations when selecting technologies to facilitate their health-seeking and fulfill their health needs. Four archetypes were also proposed based on our findings and the insights gained from our participants' observations in their social networks. These findings led to several implications for practice regarding health communication and promotion, health education, technology design and improvement, telemonitoring service implementation, and solutions to address the needs of each proposed archetype. Unlike the commonly held belief that older adults resist technologies and lack technological proficiency, our findings showed that technologies could play a promising role in facilitating older adults' health-seeking. Our findings have implications for the design and implementation of health services and policies.

Challenges to diagnosing and managing preeclampsia in a low-resource setting: A qualitative study of obstetric provider perspectives from Ghana.

Preeclampsia is a leading cause of global maternal morbidity and mortality. The greatest burden of disease is in low- and middle-income countries where healthcare providers face significant, understudied, challenges to diagnosing and managing preeclampsia. This qualitative study used semi-structured interviews to explore the challenges of diagnosing and managing preeclampsia from the perspectives of obstetric doctors. Participants were doctors who provide obstetric care at the Korle Bu Teaching Hospital, an urban tertiary hospital in Ghana. Purposive sampling identified doctors with meaningful experience in managing patients with preeclampsia. Thematic saturation of data was used to determine sample size. Interviews were audio recorded, transcribed verbatim, coded using an iteratively-developed codebook, and thematically analyzed. Interviews were conducted with 22 participants, consisting of 4 house officers, 6 junior obstetrics/gynecology residents, 8 senior obstetrics/gynecology residents, and 4 obstetrics/gynecology consultants. Doctors identified critical challenges faced at the patient, provider, and systems levels in detecting and managing preeclampsia, each of which mediates the health outcomes of a pregnancy complicated by preeclampsia. Challenges centered around three overarching global themes: (1) low education levels and health literacy among women, (2) insufficient number of healthcare providers highly trained in obstetric care, and (3) inadequate health infrastructure to support critically ill patients with preeclampsia. Recognizing and addressing root challenges to preeclampsia care has great potential to improve outcomes in pregnancies complicated by preeclampsia in low-resource settings.

Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds

BackgroundChest pain is a frequent consultation issue in primary care, with coronary artery disease (CAD) being a serious potential cause. Primary care physicians (PCPs) assess the probability for CAD and refer patients to secondary care if necessary. Our aim was to explore PCPs’ referral decisions, and to investigate determinants which influenced those decisions.MethodsPCPs working in Hesse, Germany, were interviewed in a qualitative study. We used ‘stimulated recall’ with participants to discuss patients with suspected CAD. With a sample size of 26 cases from nine practices we reached inductive thematic saturation. Interviews were audio-recorded, transcribed verbatim and analyzed by inductive-deductive thematic content analysis. For the final interpretation of the material, we used the concept of decision thresholds proposed by Pauker and Kassirer.ResultsPCPs reflected on their decisions for or against a referral. Aside from patient characteristics determining disease probability, we identified general factors which can be understood as influencing the referral threshold. These factors relate to the practice environment, to PCPs themselves and to non-diagnostic patient characteristics. Proximity of specialist practice, relationship with specialist colleagues, and trust played a role. PCPs sometimes felt that invasive procedures were performed too easily. They tried to steer their patients through the system with the intent to avoid over-treatment. Most PCPs were unaware of guidelines but relied on informal local consensus, largely influenced by specialists. As a result, PCPs gatekeeping role was limited.ConclusionsWe could identify a large number of factors that impact referral for suspected CAD. Several of these factors offer possibilities to improve care at the clinical and system level. The threshold model proposed by Pauker and Kassirer was a useful framework for this kind of data analysis.

Adolescent Experiences With Social Media and Suicidality.

Examine social media experiences of the suicidal adolescent presenting to the emergency department with an acute mental health crisis. We used qualitative interviews to obtain in-depth understanding of both negative and positive impacts of social media use on acute adolescent suicidal behavior. A bilingual transcriptionist transcribed audio recordings. Three investigators independently reviewed transcripts to identify themes and develop initial coding scheme through "open coding." Using grounded theory, data collection proceeded along with cultivation of themes until thematic saturation was achieved. Thematic saturation was determined when no new themes were generated from the data. Data were coded in Dedoose software to facilitate reporting of themes and quotes. Techniques to ensure trustworthiness included iterative data collection, use of a coding framework, and multiple coders. Seventeen interviews were conducted from May to October 2020. Median participant age was 15 years. Twenty-four percent were of Hispanic ethnicity and 82% identified as cisgender. Major themes include distraction from negative emotions; facilitated communication resulting in improved social connectedness; metric of connectedness; comparison of self to others; and desensitization and normalization to suicidal acts. Minor theme of increased time on social media is also discussed. These themes echoed components of current suicide theory. Acutely suicidal adolescents report social media experiences that reflect themes of social alienation and learned capacity for suicidal acts. Themes echo components of current suicide theory.Our participants also reported positive uses of social media. These protective experiences should be leveraged to inform strategies to interrupt behaviors leading to acute suicidality.

Factors Influencing Patient Experience After Cubital Tunnel Syndrome Surgery

The purpose of this study was to use qualitative methodology to better understand patient experiences after cubital tunnel surgery, with the goal of identifying areas of improvement in delivery of care. Patients who underwent surgery (in situ decompression or anterior transposition) for cubital tunnel syndrome within the last 12 months, which was performed by one of three fellowship-trained hand surgeons, were identified. Participants were invited to an interview regarding "their experiences with ulnar nerve surgery." An interview guide with semistructured, open-ended questions regarding the decision for surgery, treatment goals, and the recovery process was used. Interim data analyses were conducted to assess emerging themes, and interviews were continued until thematic saturation was achieved. Seventeen participants completed interviews; the mean age of study participants was 57 years, and 71% were women. The mean time between surgery and the interview was 6 months. Participants identified the following two key areas that could improve their surgical experience: (1) the need for detailed preoperative education about the surgery and recovery process, (2) and the importance of discussing treatment goals and expectations. Participants suggested providing both written and online resources to patients, including specific details about incision size and recovery process in education materials, and setting expectations for symptom resolution. Although the overall patient experience after cubital tunnel surgery was positive, participants noted that there is a need for providing improved educational resources and counseling before surgery. Addressing education and counseling needs before cubital tunnel surgery will help surgeons to improve delivery of care.