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The roles that rapid, point-of-care tests will play in healthcare in low-income settings are likely to expand over the coming years. Yet, very little is known about how they are incorporated into practice, and what it means to use and rely upon them. This paper focuses on the rapid diagnostic test for malaria (mRDT), examining its introduction into low-level public health facilities in Tanzania within an intervention to improve the targeting of costly malaria medication. We interviewed 26 health workers to explore how a participatory training programme, mobile phone messages, posters and leaflets shaped the use and interpretation of the test. Drawing on notions of biopolitics, this paper examines how technologies of the self and mechanisms of surveillance bolstered the role mRDT in clinical decision-making. It shows how the significance of the test interacted with local knowledge, the availability of other medication, and local understandings of good clinical practice. Our findings suggest that in a context in which care is reduced to the provision of medicines, strict adherence to mRDT results may be underpinned by increasing the use of other pharmaceuticals or may leave health workers with patients for whom they are unable to provide care. [ABSTRACT FROM PUBLISHER]

Gypsies, Roma and Travellers (GRT) experience a significantly high number of measles cases and have low levels of measles, mumps and rubella (MMR) immunisation. There is little evidence on: why immunisation levels are low; beliefs and practices surrounding the MMR vaccine; or the factors that promote or hinder uptake. This paper presents data from five focus groups with 16 GRT mothers in Kent, South East England. Between them, they had 35 children of whom just under half had not received the course of vaccinations. Focus groups explored the issues GRT parents consider when making vaccination decisions in the context of wider social, ideological, material and practical considerations. Four interrelated themes were identified: way of life and access; engaging with health care staff; perceptions and evaluations of risk; and strategies to minimise MMR-related risks. Our findings provide little support for explanations that emphasise cultural values or practices in shaping immunisation behaviour. Poor service provision, situational constraints related to living circumstances, and multifaceted and severe health issues, which precede and inform decisions over childhood immunisation, were more significant in explaining low uptake. [ABSTRACT FROM PUBLISHER]

Abortion stigma is experienced not only by women but also by providers and health professionals in a wide range of legal contexts. This paper analyses interviews with providers who work in the public health system in the Metropolitan Area of Buenos Aires, Argentina. A court ruling in 2012, FAL/12, changed the interpretation of abortion's legal status, clarifying the decriminalisation of abortion in cases of rape, and also requiring public policies and procedures to speed up access to legal abortion. Between 2014 and 2017, we conducted 27 in-depth, semi-structured interviews with abortion providers in public facilities across healthcare services in the Metropolitan Area of Buenos Aires. We found the way that health providers dealt with abortion stigma evolved over the course of time, as the abortion debate moved from the margins to the heart of political debate and public policies in Argentina between 2007 and 2017. Providers' experiences changed as the social and legal context changed. FAL/12 – as a clear, legal ruling – was a landmark and turning point in the way health professionals in public health facilities conduct their activities, making it possible for them to move from providing silent and hidden abortion care, to acknowledging it with pride. [ABSTRACT FROM AUTHOR]

Currently, the life expectancy of black Americans is about five years shorter than that of white Americans when factoring for gender. Poor patient compliance is often used as an explanation for why black people have worse health outcomes. The proof, however, is anecdotal and relies primarily on discourses about black people's general dysfunction. Black patients often respond in kind to problems they experience with health care access. They often conclude that the medical professionals they work with are racist. In most cases, neither of these explanations is correct. This paper argues that behavioral explanations for health care disparities shift attention away from structural issues, namely health care rationing and the limits of therapeutic medicine. The lack of an open discussion about the structural issues is part of the reason the goal initiated by the Clinton administration to end racial disparities by 2010, Healthy People 2010, largely failed. [ABSTRACT FROM AUTHOR]

Clinicians make judgments about patients' rehabilitation potential because it is considered by many as a prerequisite for referral to rehabilitation. However, the concept is rarely defined. This research aimed to clarify the concept of rehabilitation potential in the context of acquired brain injury patient referral to post-acute rehabilitation. Literature search (conducted in Medline, CINAHL and Embase) and article selection followed a scoping review methodology while a concept analysis methodology guided data extraction and analysis. Eighteen documents met inclusion criteria. Findings suggest four defining attributes of the concept. Rehabilitation potential (1) emerges from clinicians' interpretation of patient characteristics and is influenced by the health care environment, (2) involves the prediction of how a patient might improve with rehabilitation interventions, (3) is a multi-level concept and (4) can change over time. The most critical consequence to assessing a patient's rehabilitation potential is the impact on the patient's opportunity to access post-acute rehabilitation services. Rehabilitation potential is a concept rooted in clinical reasoning. We propose an operational definition and a conceptual model to provide a solid foundation for future research to advance policy and clinical decision-making regarding equitable access to post-acute rehabilitation. Rehabilitation potential is a concept rooted in clinical reasoning and emerges from clinicians' prediction of how a patient might improve with rehabilitation interventions. Rehabilitation potential is not a dichotomous concept but a multi-level concept with each level falling along a continuum. It may be inaccurate/inappropriate to definitively state that a patient has or does not have rehabilitation potential, as patients may demonstrate varying levels of rehabilitation potential. Rehabilitation potential can change with time requiring re-assessment to readjust recommendations accordingly with regards to appropriate rehabilitation interventions at any given time. [ABSTRACT FROM AUTHOR]

Medical methods of abortion, MMA, has been legal in India since 2002. Guidelines stipulate that it should be administered by a provider or acquired via prescription. 1.2 million women having abortions in India use MMA acquired from health facilities [Singh, S., Shekhar, C., Acharya, R., Moore, A. M., Stillman, M., Pradhan, M. R., ... Browne, A. (2018). The incidence of abortion and unintended pregnancy in India, 2015. The Lancet Global Health, 6(1), e111–e120. doi:]. We undertook a study of abortion in Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh in 2015 to better understand under what conditions and how MMA is being administered in facilities. The majority of facilities that provide MMA are in the private sector and located in urban areas. Most facilities offer MMA both at the facility and as a prescription, although some facilities only offer MMA as a prescription. A high proportion of facilities report that women typically take the medication at home. (Re)training providers in MMA protocols and counselling, increasing the number of facilities offering MMA, and stocking of the drugs would help improve women's access to MMA and the information they need to be able to use this method safely. Key Messages: In the six states in our sample, Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh, 8% of abortions in 2015 were done using medical methods of abortion (MMA) acquired from health facilities. The majority of facilities that provide MMA in the six states are in the private sector and are located in urban areas. Health facilities in Madhya Pradesh and Tamil Nadu are comparatively better in their provision of MMA with Assam, Bihar, Gujarat and Uttar Pradesh demonstrating poorer provision of MMA. There are many opportunities for improvement in the practices of MMA provision through improved training of providers, accessibility to the medications and better support of women using MMA. [ABSTRACT FROM AUTHOR]

Existing research suggests the provision of communication aids for children with complex communication needs can have significant positive impacts on health and quality-of-life. The process of clinical decision-making related to the recommendation of high-tech communication aids is not well documented or evaluated, and research evidence related to the provision of these aids remains limited. This study aimed to understand the factors that specialized AAC professionals in the UK consider when recommending high-tech communication aids. Purposive sampling was used to recruit teams to six focus groups, each of which centred on a team's recent recommendation process (i.e. a discussion following a real-time assessment session, where the team attempted to arrive at an agreed recommendation for a specific child). Thematic network analysis was used to interpret data from the focus group discussions. Participants identified a wide range of child characteristics, access features, and communication aid attributes in weighing up decisions for individual children. Findings suggest that specialized AAC professionals in the UK prioritize access features over language considerations in their communication aid recommendations. An explanatory model was developed to illustrate the interaction effect that several competing considerations may have on decision-making. Implications for clinical practice and future research are discussed. [ABSTRACT FROM AUTHOR]

In Canada, limited resources and increasing demand place pressure on the public healthcare system, something that is likely to increase. In this context, wait lists in outpatient physiotherapy departments (OPD) will get longer, system inefficiencies will arise, and frustrations and ethical concerns will be experienced by patients and staff. To better understand the perceptions of OPD staff regarding priority setting, treatment frequency, treatment duration, and wait list management strategies, we conducted an Interpretive Description study involving semi-structured interviews in three OPDs in Montreal. Participants discussed factors that influenced their decision making about who was prioritized to receive care, strategies that were used to respond to an imbalance between needs and resources in the OPDs and procedures to manage wait lists to help improve access to care. While clinical needs are central in approaches to prioritization, other non-clinical factors relating to the patient, the physiotherapist, and the institution also influence decisions. We examine these findings through the lens of complexity theory, providing insight into opportunities and obstacles for the implementation of management strategies in OPDs. These strategies will need to be carefully evaluated in order to create evidence-based guidelines for wait list management in other settings. [ABSTRACT FROM AUTHOR]

Shared decision-making (SDM) has been slow to disseminate in mental health. We conducted focus groups with ten individuals with serious mental illness (SMI) treated in a 90 day, outpatient transitional care clinic. Parallel groups were held with family caregivers (n = 8). Individuals with SMI wanted longer visits, to have their stories heard, more information about options presented simply, to hear from peers about similar experiences, and a bigger say in treatment choices. Caregivers wanted to be invited to participate to a larger extent.  Results suggest that after a decade, SDM may not have the expected penetration in community mental health. [ABSTRACT FROM PUBLISHER]

Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers’ knowledge of a patient's virological status increased confidence in adherence counseling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring. [ABSTRACT FROM PUBLISHER]