Specialist and primary care physicians' views on barriers to adequate preparation of patients for renal replacement therapy: a qualitative study.

BACKGROUND: Early preparation for renal replacement therapy (RRT) is recommended for patients with advanced chronic kidney disease (CKD), yet many patients initiate RRT urgently and/or are inadequately prepared. METHODS: We conducted audio-recorded, qualitative, directed telephone interviews of nephrology health care providers (n = 10, nephrologists, physician assistants, and nurses) and primary care physicians (PCPs, n = 4) to identify modifiable challenges to optimal RRT preparation to inform future interventions. We recruited providers from public safety-net hospital-based and community-based nephrology and primary care practices. We asked providers open-ended questions to assess their perceived challenges and their views on the role of PCPs and nephrologist-PCP collaboration in patients' RRT preparation. Two independent and trained abstractors coded transcribed audio-recorded interviews and identified major themes. RESULTS: Nephrology providers identified several factors contributing to patients' suboptimal RRT preparation, including health system resources (e.g., limited time for preparation, referral process delays, and poorly integrated nephrology and primary care), provider skills (e.g., their difficulty explaining CKD to patients), and patient attitudes and cultural differences (e.g., their poor understanding and acceptance of their CKD and its treatment options, their low perceived urgency for RRT preparation; their negative perceptions about RRT, lack of trust, or language differences). PCPs desired more involvement in preparation to ensure RRT transitions could be as "smooth as possible", including providing patients with emotional support, helping patients weigh RRT options, and affirming nephrologist recommendations. Both nephrology providers and PCPs desired improved collaboration, including better information exchange and delineation of roles during the RRT preparation process. CONCLUSIONS: Nephrology and primary care providers identified health system resources, provider skills, and patient attitudes and cultural differences as challenges to patients' optimal RRT preparation. Interventions to improve these factors may improve patients' preparation and initiation of optimal RRTs.

Perceived acceptability of home-based couples voluntary HIV counseling and testing in Northern Tanzania.

It is estimated that 5.6% of the Tanzanian population ages 15-49 are infected with HIV, but only 30% of adults have ever had an HIV test. Couples' testing has proven to increase testing coverage and introduce HIV prevention, but barriers include access to testing services and unequal gender dynamics in relationships. Innovative approaches are needed to address barriers to couple's testing and increase uptake of HIV testing. Using qualitative data collection methods, a formative study was conducted to assess the acceptability of a home-based couples counseling and testing (HBCCT) approach. Eligible study participants included married men and women, HIV-infected individuals, health care and home-based care providers, voluntary counseling and testing counselors, and community leaders. A total of 91 individuals participated in focus group discussions (FGDs) and in-depth interviews conducted between September 2009 and January 2010 in rural settings in Northern Tanzania. An HBCCT intervention appears to be broadly acceptable among participants. Benefits of HBCCT were identified in terms of access, confidentiality, and strengthening the relationship. Fears of negative consequences from knowing one's HIV status, including stigma, blame, physical abuse, or divorce, remain a concern and a potential barrier to the successful provision of the intervention. Lessons for implementation highlighted the importance of appointments for home visits, building relationships of confidence and trust between counselors and clients, and assessing and responding to a couple's readiness to undergo HIV testing. HBCCT should addresses HIV stigma, emphasize confidentiality, and improve communication skills for disclosure and decision-making among couples.

Perceived cannabis use norms and cannabis use among adolescents in the United States.

Due to changes in cannabis policies, concerns about cannabis use (CU) in adolescents have increased. The population of nonwhite groups is growing quickly in the United States. We examined perceived CU norms and their association with CU and CU disorder (CUD) for White, Black, Hispanic, Native-American, Asian-American, Native Hawaiian/Pacific Islander (NH/PI), and mixed-race adolescents. Data were from adolescents (12-17 years) in the 2004-2012 National Surveys on Drug Use and Health (N = 163,837). Substance use and CUD were assessed by computer-assisted, self-interviewing methods. Blacks, Hispanics, Native-Americans, and mixed-race adolescents had greater odds of past-year CU and CUD than Whites. Among past-year cannabis users (CUs), Hispanics and Native-Americans had greater odds of having a CUD than Whites. Asian-Americans had the highest prevalence of perceived parental or close friends' CU disapproval. Native-Americans and mixed-race adolescents had lower odds than Whites of perceiving CU disapproval from parents or close friends. In adjusted analyses, adolescent's disapproval of CU, as well as perceived disapproval by parents or close friends, were associated with a decreased odds of CU in each racial/ethnic group, except for NHs/PIs. Adolescent's disapproval of CU was associated with a decreased odds of CUD among CUs for Whites (personal, parental, and close friends' disapproval), Hispanics (personal, parental, and close friends' disapproval), and mixed-race adolescents (personal, close friends' disapproval). Racial/ethnic differences in adolescent CU prevalence were somewhat consistent with adolescents' reports of CU norm patterns. Longitudinal research on CU health effects should oversample nonwhite adolescents to assure an adequate sample for analysis and reporting.

An identity-based motivational model of the effects of perceived discrimination on health-related behaviors

Perceived discrimination is associated with increased engagement in unhealthy behaviors. We propose an identity-based pathway to explain this link. Drawing on an identity-based motivation model of health behaviors (Oyserman, Fryberg, & Yoder, 2007), we propose that erceptions of discrimination lead individuals to engage in ingroup-prototypical behaviors in the service of validating their identity and creating a sense of ingroup belonging. To the extent that people perceive unhealthy behaviors as ingroup-prototypical, perceived discrimination may thus increase motivation to engage in unhealthy behaviors. We describe our theoretical model and two studies that demonstrate initial support for some paths in this model. In Study 1, African American participants who reflected on racial discrimination were more likely to endorse unhealthy ingroup-prototypical behavior as self-characteristic than those who reflected on a neutral event. In Study 2, among African American participants who perceived unhealthy behaviors to be ingroup-prototypical, discrimination predicted greater endorsement of unhealthy behaviors as self-characteristic as compared to a control condition. These effects held both with and without controlling for body mass index (BMI) and income. Broader implications of this model for how discrimination adversely affects health-related decisions are discussed.

Determinants and Implications of Self-perceived Authenticity: Beliefs About Authenticity and Reactions to Behavioral Incongruence

Although many perspectives suggest that authenticity is important for well-being, people do not always have direct access to the psychological processes that produce their behaviors and, thus, are not able to judge whether they are behaving consistently with their personality, attitudes, values, motives, and goals. Even so, people experience subjective feelings of authenticity and inauthenticity, raising the question of factors that influence people’s judgments of whether they are being authentic. The present studies used descriptive, correlational, experimental, and experience sampling designs to examine possible influences on self-judgments of authenticity, including the congruence between people’s behavior and inner dispositions, the positivity of the behavior, their personal beliefs about authenticity, features of the interaction, and trait authenticity. Studies 1A and 1B examined the role of people’s beliefs about authenticity in self-judgments of authenticity. Studies 2A and 2B investigated the criteria that people use to judge their behavior as authentic versus inauthentic and challenged those criteria to see whether self-perceived authenticity was affected. And, Study 3 used an experience sampling design to study people’s experiences of state authenticity in daily life. Together the studies offer insights into the determinants of self-perceived authenticity and show that many factors that influence people’s feelings of authenticity are peripheral, if not irrelevant, to actual authenticity.