The Rural Household Production of Health Approach: Applying Lessons from Zambia to Rural Cancer Disparities in the U.S.

The recent focus on rural–urban cancer disparities in the United States (U.S.) requires a comprehensive understanding of the processes and relations that influence cancer care seeking and decision making. This is of particular importance for Black, Latino, and Native populations living in rural areas in the U.S., who remain marginalized in health care spaces. In this article, we describe the household production of health approach (HHPH) as a contextually-sensitive approach to examining health care seeking and treatment decisions and actions. The HHPH approach is based on several decades of research and grounded in anthropological theory on the household, gender, and therapy management. This approach directs analytical attention to how time, money, and social resources are secured and allocated within the household, sometimes in highly unequal ways that reflect and refract broader social structures. To demonstrate the benefits of such an approach to the study of cancer in rural populations in the U.S., we take lessons from our extensive HHPH research in Zambia. Using a case study of a rural household, in which household members had to seek care in a distant urban hospital, we map out what we call a rural HHPH approach to bring into focus the relations, negotiations, and interactions that are central to individual and familial health care seeking behaviors and clinical treatment particular to rural regions. Our aim is to show how such an approach might offer alternative interpretations of existing rural cancer research in the U.S. and also present new avenues for questions and for developing interventions that are more sensitive to people’s realities.

An Intensive Care Unit Team Reflects on End-of-Life Experiences With Patients and Families in Chile

Background Deaths in the intensive care unit (ICU) represent an experience of suffering for patients, their families, and professionals. End-of-life (EOL) care has been added to the responsibilities of the ICU team, but the evidence supporting EOL care is scarce, and there are many barriers to implementing the clinical recommendations that do exist. Objectives To explore the experiences and perspectives of the various members of an ICU care team in Chile regarding the EOL care of their patients. Methods A qualitative study was performed in the ICU of a high-complexity academic urban hospital. The study used purposive sampling with focus groups as a data collection method. A narrative analysis based on grounded theory was done. Results Four discipline-specific focus groups were conducted; participants included 8 nurses, 6 nursing assistants, 8 junior physicians, and 6 senior physicians. The main themes that emerged in the analysis were emotional impact and barriers to carrying out EOL care. The main barriers identified were cultural difficulties related to decision-making, lack of interprofessional clinical practice, and lack of effective communication. Communication difficulties within the team were described along with lack of self-efficacy for family-centered communication. Conclusion These qualitative findings expose gaps in care that must be filled to achieve high-quality EOL care in the ICU. Significant emotional impact, barriers related to EOL decision-making, limited interprofessional clinical practice, and communication difficulties were the main findings cross-referenced.

“It’s a Tall Order But I’ll Try”: A Qualitative Study on Chinese Nurses’ Cognition and Experience Responding to Cancer Patients’ Requests to Hasten Death

Purpose: The purpose of this study is to understand the cognition and experience of oncology nurses in China when responding to a patient’s request to hasten death, to describe the obstacles that prevent their response, and to provide suggestions for dealing with the patient’s request. Methods: Researchers conducted a qualitative study that consisted of open-ended, semi-structured interviews with 18 registered nurses who had more than five years of working experience in the oncology department at a large-scale urban hospital. We analyzed these data for content and themes.Results: How to deal with patients’ requests to hasten death is a problem often encountered and handled by nurses in the Department of Oncology.Nurses have a certain understanding of the patients’ requests to hasten death. This study abstracts four themes: 1) the nurses’ cognition of the “Accelerate the process of death” ; 2) the methods they use to deal with the patients’ requests to hasten death; 3) the obstacles that prevent nurses from fulfilling the patients’ requests to hasten death; and 4) their suggestions for improvement.Conclusion: Nurses have a deep understanding of the real thoughts of patients who make a death request, and they hope to provide the corresponding psychological support and physical care. However, the lack of relevant knowledge, policy support, and cooperation of patients’ families are obstacles that prevent them from taking action. Therefore, increasing relevant training for nurses, encouraging multi-department cooperation, and developing standardized nursing processes may lay a foundation for oncology nurses to better undertake and guide such conversations.

Factors Associated with Congenital Heart Disease in Severely Malnourished Children under Five and Their Outcomes at an Urban Hospital, Bangladesh

Congenital heart disease (CHD) is one of the most common types of birth defect with a high morbidity and mortality, particularly in severely malnourished children under five. In this study, we aim to identify the predicting factors for CHD and their outcomes. 694 malnourished children under five years of age admitted between April 2015 and December 2017 constituted the study population. Of them, 64 were cases of CHD, and by comparison 630 were without CHD. CHD was diagnosed clinically and confirmed by echocardiogram. 64% of the cases had a single defect. Cases were more likely to be present with diarrhea, cough, respiratory distress, cyanosis, hypoxemia, hypoglycemia and hypernatremia on admission. The cases also had a high proportion of severe sepsis, bacteremia, heart failure, respiratory failure and death, compared to those without CHD. Cough (95% CI = 1.09–18.92), respiratory distress (95% CI = 1.46–5.39) and hypoxemia (95% CI = 1.59–6.86) were found to be the independent predictors for CHD after regression analysis, and their early identification might be helpful to lessen ramifications, including mortality, in such populations, especially in resource-limited settings.

Real-time prediction of patient disposition and the impact of reporter confidence on mid-level triage accuracies: an observational study in Israel

AimThe emergency department (ED) is the first port-of-call for most patients receiving hospital care and as such acts as a gatekeeper to the wards, directing patient flow through the hospital. ED overcrowding is a well-researched field and negatively affects patient outcome, staff well-being and hospital reputation. An accurate, real-time model capable of predicting ED overcrowding has obvious merit in a world becoming increasingly computational, although the complicated dynamics of the department have hindered international efforts to design such a model. Triage nurses’ assessments have been shown to be accurate predictors of patient disposition and could, therefore, be useful input for overcrowding and patient flow models.MethodsIn this study, we assess the prediction capabilities of triage nurses in a level 1 urban hospital in central Israeli. ED settings included both acute and ambulatory wings. Nurses were asked to predict admission or discharge for each patient over a 3-month period as well as exact admission destination. Prediction confidence was used as an optimisation variable.ResultTriage nurses accurately predicted whether the patient would be admitted or discharged in 77% of patients in the acute wing, rising to 88% when their prediction certainty was high. Accuracies were higher still for patients in the ambulatory wing. In particular, negative predictive values for admission were highly accurate at 90%, irrespective of area or certainty levels.ConclusionNurses prediction of disposition should be considered for input for real-time ED models.

Personality predictors of emergency department post-discharge outcomes

Personality traits are important predictors of health behaviors, healthcare utilization, and health outcomes. However, we know little about the role of personality traits for emergency department outcomes. The present study used data from 200 patients (effective Ns range from 84 to 191), who were being discharged from the emergency department at an urban hospital, to investigate whether the Big Five personality traits were associated with post-discharge outcomes (i.e., filling prescriptions, following up with primary care physician, making an unscheduled return to the emergency department). Using logistic regression, we found few associations among the broad Big Five domains and post-discharge outcomes. However, results showed statistically significant associations between specific Big Five items (e.g., “responsible”) and the three post-discharge outcomes. This study demonstrates the feasibility of assessing personality traits in an emergency medicine setting and highlights the utility of having information about patients’ personality tendencies for predicting post-discharge compliance.

Quantification and progress over time of specific antibodies against SARS-CoV-2 in breast milk of lactating women vaccinated with BNT162b2 Pfizer-BioNTech COVID-19 vaccine (LacCOVID)

Importance: To our knowledge, this is the first study to analyze long–term passage (6 months after immunization) of specific antibodies induced by BNT162b2 COVID–19 vaccine through breast milk. Objectives: Main objective: to determine SARS–CoV–2 vaccine induced antibody levels in the breast milk of lactating women 4 weeks after mRNA BNT162b2 Pfizer–BioNTech COVID–19 complete vaccination. Secondary objectives: to analyze SARS–CoV–2 antibody levels (breast milk and serum) at different time–points after vaccination, examine the correlation of SARS–CoV–2 antibody levels between serum and breast milk, describe adverse events related to vaccination (AErV) in both mothers and infants and determine the rate of COVID–19 infections. Design: Prospective cohort study between February and September 2021. Setting: Parc Sanitari Sant Joan de Deu, an urban hospital in Spain. Participants: During our health worker vaccination campaign at our hospital between January and March 2, we recruited 33 lactating women vaccinated with BNT162b2 Pfizer–BioNTech COVID–19. Results: A total of 33 volunteers were included in the study. The median (IQR) age of mothers was 38 (36–39) years and 15 (10–22) months for the infants. Primary end–point: at 4 w after second dose median (IQR) IgG–S1 levels for serum–milk pairs were 12,478 (6,870–20,801) to 50.4 (24.3–104) arbitrary units (AU) per mL. Secondary end–points: SARS–CoV–2 antibody levels at different time–points were (serum–milk): 519 (234–937) to 1 (0–2.9) AU/mL at 2w after first dose, 18,644 (9,923–29,264) to 78 (33.7–128) AU/mL at 2w, 4,094 (2,413–8,480) to 19.9 (10.8–51.9) AU/mL at 12w, and 1,350 (831–2,298) to 8.9 (7.8–31.5) at 24w after second dose. We found a positive correlation of SARS–CoV–2 antibody levels between serum and breast milk (Pearson correlation coefficient 0.68). No serious AErV were observed. We found two (6%) COVID–19 vaccine breakthrough infections. Conclusions: Pfizer–BioNTech COVID–19 vaccination is safe during breastfeeding and it transmits antibodies into breast milk with a positive correlation with serum levels, and both decrease over time in a 6–month follow–up. Infants of breastfeeding vaccinated women could be protected for at least six months after vaccination and serum determination of SARS–CoV–2 IgG–S1 could indicate the breastmilk levels of antibodies during this period.