Gender looms large in school-based bullying and harassment. Deeply-entrenched taboos and obligations position gender as a prime vehicle for elevating the status of some boys and offering a potent weapon against rivals and outcasts. Moreover, gender taboos are particularly important in the passage to manhood. This transition has long been recognized as a key site for the social engineering of boys into men – when ‘real men’ are made. While traditional societies have stage-managed this transition through the ritualised mentoring of young males by older men, modern societies have handed much of this responsibility to schooling and there has been a progressive decline in the involvement of adult males. However, the passage to manhood remains as important as ever and in the absence of older mentors, boys have found alternative ways to navigate this high-pressure period. Much of the boys’ gendered learning takes place in the school ground and on the streets, at arms length from adults and with peer groups policing their own ‘in-house’ masculinities. These peer-based codes of conduct are relayed to younger generations in the school ground, again at arms length from adults. While there are considerable class and cultural variations, there are also overarching, widely-shared codes. These arrangements can be both positive and negative. On the one hand, greater latitude is possible as boys re-work traditional masculinities. However, boys can also act-out masculinity in extreme ways and punish transgressions severely. At its worst , peer group aggression can spill onto the streets and form gangs.

This research aims to better understand performance under pressure as experienced by health and emergency staff in the workplace. Three basic questions underpin the work: (1) how do health and emergency workers experience and make sense of the ‘pressures’ entailed in their jobs? (2) What impacts do these pressures have on their working lives and work performance, both positively and negatively? (3) Can we develop a useful explanatory model for ‘working under pressure’ in complex, volatile and emergency situations? The present article addresses the first question regarding the nature of pressure; a subsequent article will address the question of its impact on performance. Using detailed interviews with workers in a range of roles and from diverse settings across Ecuador, our analysis aims to better understand the genesis of pressure, how people respond to it and to gain insights into managing it more effectively, especially with a view to reducing workplace errors and staff burnout. Rather than imposing preformulated definitions of either ‘pressure’ or ‘performance’, we took an emic approach to gain a fresh understanding of how workers themselves experience, describe and make sense of workplace pressure. This article catalogues a wide range of pressures as experienced by our participants and maps relationships between them. We argue that while individuals are often held responsible for workplace errors, both ‘pressure’ and ‘performance’ are multifactorial, involving individuals, teams, case complexity, expertise and organizational systems and these must be considered in order to gain better understandings of performing under pressure.

BACKGROUND:Non-adherence to prescribed medicines is linked to adverse health outcomes in people living with chronic health conditions (CHCs). Multiple factors are known to contribute to non-adherence to medicines including polypharmacy, demographic features and disease and health systems. Both non-prescription and prescription medicines contribute to polypharmacy; however, there is limited data on the influence of non-prescription medicines to non-adherence.AIM:Therefore, the aim of the study was to investigate the influence of non-prescription medicines to non-adherence in an Australian population.METHODS:Data from the 2016 National Survey of a random sample of Australian adult residents were utilised in this study to investigate factors associated with non-adherence. Descriptive statistics, χ2 , regression and generalised linear models were used to assess the relationships between variables of interest. Narrative response and comments were used to provide further insight.RESULTS:This study recruited 1217 participants to explore factors associated with non-adherence to medicines. Weak but statistically significant correlations were identified showing the number of CHCs, patient's age, number of prescription medicines, number of non-prescription medicines and total number of medicines associated with non-adherence.DISCUSSION:The findings suggest that people living with CHCs and taking multiple medicines, including non-prescription medicines, are likely to be non-adherent to prescription medicines. This study shows the possible involvement of non-prescription medicines in contributing to non-adherence in an Australian population and suggests that future studies with a broader demographic are warranted.

To the Editor Robertson et al1 conducted a crossover randomized clinical trial of gabapentin (GBP) vs pregabalin (PBG) in chronic sciatica (CS). We congratulate the authors for their effort toward improving CS management. However, some methodological issues hinder the conclusions in this trial.

Introduction:Pressure in the workplace has been studied in a number of settings. Many studies have examined pressure from physiological and psychological perspectives, mainly through studies on stress. Performing under pressure is a fundamentally important workplace issue, not least for complex, volatile, and emergency situations.Aim:This research aims to better understand performance under pressure as experienced by health and emergency staff in the workplace.Methods:Three basic questions underpin the work: (1) how do health and emergency workers experience and make sense of the ‘pressures’ entailed in their jobs? (2) What impacts do these pressures have on their working lives and work performance, both positively and negatively? (3) Can we develop a useful explanatory model for ‘working under pressure’ in complex, volatile, and emergency situations?The present paper addresses the first question regarding the nature of pressure; a subsequent paper will address the question of its impact on performance. Using detailed interviews with workers in a range of roles and from diverse settings across Ecuador, this study set out to better understand the genesis of pressure, how people respond to it, and to gain insights into managing it more effectively, especially with a view to reducing workplace errors and staff burnout. Rather than imposing preformulated definitions of either ‘pressure’ or ‘performance,’ we took an emic approach to gain a fresh understanding of how workers themselves experience, describe and make sense of workplace pressure.Results:This paper catalogs a wide range of pressures as experienced by our participants and maps relationships between them.Discussion:We argue that while individuals are often held responsible for workplace errors, both ‘pressure’ and ‘performance’ are multifactorial, involving individuals, teams, case complexity, expertise, and organizational systems, and these must be taken into account in order to gain better understandings of performing under pressure.

In this Australian, constructivist grounded theory study, we undertook in-depth interviews with 11 dying people and 8 caregivers to examine their perspectives on role relations at end-of-life. We found that situations of role alignment between dying people and their family and friends support positive relational and practical outcomes, whereas role mismatch can cause considerable distress. Factors contributing to role mismatch at end-of-life were: dying people and their caregivers' efforts to shield each other from emotional harm; fear of social exclusion; and unwanted focus on the dying identity. Our findings highlight a need for flexibility and adaptability in end-of-life role relations.

Despite the life-preserving benefits of antiretroviral therapy (ART), some people living with HIV (PLHIV) delay, decline or diverge from recommended treatment while paradoxically being willing to use potentially dangerous substances, such as recreational drugs (RD) and complementary medicines (CM). During 2016 and 2017, interviews were conducted with 40 PLHIV, in Australia to understand drivers underpinning treatment decisions. While many believed ART to be effective, they expressed concerns about long-term effects, frustration over perceived lack of autonomy in treatment decisions and financial, emotional and physical burdens of HIV care. In contrast, they ascribed a sense of self-control over the use of RD and CM, along with multiple professed benefits. The perceived burden of ART emerged as a motivator for deviating from recommended treatment, while positive views towards RD and CM appear to justify use. This study may serve as guidance for the development of future strategies to address barriers to treatment uptake and adherence and subsequently health outcomes for PLHIV in Australia and elsewhere.

Papua New Guinea (PNG) has a high burden of tuberculosis (TB), including drug-resistant TB (DR-TB). DR-TB has been identified in patients in Western Province, although there has been limited study outside the provincial capital of Daru. This study focuses on the Balimo region of Western Province, aiming to identify the proportion of DR-TB, and characterise Mycobacterium tuberculosis (MTB) drug resistance-associated gene mutations. Sputum samples were investigated for MTB infection using published molecular methods. DNA from MTB-positive samples was amplified and sequenced, targeting the rpoB and katG genes to identify mutations associated with rifampicin and isoniazid resistance respectively. A total of 240 sputum samples were collected at Balimo District Hospital (BDH). Of these, 86 were classified as positive based on the results of the molecular assays. For samples where rpoB sequencing was successful, 10.0% (5/50, 95% CI 4.4–21.4%) were considered rifampicin-resistant through detection of drug resistance-associated mutations. We have identified high rates of presumptive DR-TB in the Balimo region of Western Province, PNG. These results emphasise the importance of further surveillance, and strengthening of diagnostic and treatment services at BDH and throughout Western Province, to facilitate detection and treatment of DR-TB, and limit transmission in this setting.

Introduction: There is a high burden of tuberculosis (TB) in the Western Province, Papua New Guinea. This study aims to describe the spatial distribution of TB in the Balimo District Hospital (BDH) catchment area to identify TB patient clusters and factors associated with high rates of TB. Methods: Information about TB patients was obtained from the BDH TB patient register for the period 26 April 2013 to 25 February 2017. The locations of TB patients were mapped, and the spatial scan statistic was used to identify high- and low-rate TB clusters in the BDH catchment area. Results: A total of 1568 patients were mapped with most being from the Balimo Urban (n = 252), Gogodala Rural (n = 1010) and Bamu Rural (n = 295) local level government (LLG) areas. In the Gogodala region (Balimo Urban and Gogodala Rural LLGs), high-rate clusters occurred closer to the town of Balimo, while low-rate clusters were located in more remote regions. In addition, closer proximity to Balimo was a predictor of high-rate clustering. Discussion: There is heterogeneity in the distribution of TB in the Balimo region. Active case-finding activities indicated potential underdiagnosis of TB and the possibility of associated missed diagnoses of TB. The large BDH catchment area emphasizes the importance of the hospital in managing TB in this rural region.

Gender is constructed from social and cultural meanings that dynamically shift and vary. Previous work has assumed that the constructions of masculinity in Australia are like those in other Western societies, and typically focus on qualities such as physical strength, courage and sometimes military engagement. This study explores whether these assumptions hold, by conducting telephone interviews among 617 Queensland men, aged 18 years and above, across all geographical parts of Queensland. This survey was administered in 2013, as part of the Queensland Social Survey series. The study explores the diverse meanings associated with being a 'real man' given by the survey participants. Three main dimensions emerged from the thematic analysis: physicality; personality and character; social roles and relationships. The study confirmed that masculinities are dynamic and complex. Responses revealed a surprising emphasis on character and morality 44.5% (n = 684) as defining manhood, as against physical qualities 13.7% (n = 153).

ObjectivePapua New Guinea (PNG) has an emerging tuberculosis (TB) epidemic which has become a national public health priority. In Western Province, there are few data about TB outside Daru and the South Fly District. This study describes the epidemiology of TB diagnosed at Balimo District Hospital (BDH) in the Middle Fly District of Western Province, PNG. MethodsAll patients (n = 1614) diagnosed with TB at BDH from April 2013 to February 2017 were recorded. Incidence of reported new cases was calculated for the combined Balimo Urban and Gogodala Rural local level government areas. Analyses investigated patient demographic and clinical information, differences between pulmonary and extrapulmonary TB patients, and predictors of treatment failure. ResultsThe average case notification rate (2014-2016) was 727 TB cases per 100 000 people per year. One-quarter of TB cases were in children, and 77.1% of all cases had an extrapulmonary TB diagnosis. There was a 1:1.1 ratio of female to male TB cases. When comparing pulmonary and extrapulmonary TB patients, extrapulmonary TB was more likely in those aged up to 14 years and over 54 years. Extrapulmonary TB was more likely in new patients, and pulmonary TB more likely in previously treated patients. Residence in rural regions was associated with treatment failure. ConclusionThere is a high burden of TB in the Balimo region, including a very high proportion of extrapulmonary TB. These factors emphasise the importance of BDH as the primary hospital for TB cases in the Balimo region and the Middle Fly District, and the need for resources and staff to manage both drug-susceptible and drug-resistant TB cases. ObjectifLa Papouasie-Nouvelle-Guinee (PNG) a une epidemie de tuberculose (TB) emergente qui est devenue une priorite nationale de sante publique. Dans la province de l'Ouest, il y a peu de donnees sur la TB en dehors de Daru et du district de South Fly. Cette etude decrit l'epidemiologie de la TB diagnostiquee a l'Hopital de District a Balimo (BDH) dans le district de Middle Fly de la province de l'Ouest, en PNG. MethodesTous les patients (n=1614) ayant recu un diagnostic de TB a BDH entre avril 2013 et fevrier 2017 ont ete enregistres. L'incidence des nouveaux cas rapportes a ete calculee pour les zones gouvernementales combinees de Balimo Urban et de Gogodala Rural. Les analyses ont porte sur les donnees demographiques et cliniques des patients, les differences entre les patients a TB pulmonaire et extrapulmonaire et les facteurs predictifs d'echec du traitement. ResultatsLe taux moyen de notification des cas (2014-2016) etait de 727 cas de TB par 100.000 personnes par an. Un quart des cas de TB concernait des enfants et 77.1% de tous les cas avaient un diagnostic de TB extrapulmonaire. Il y avait un rapport de 1:1.1 femmes/hommes dans les cas de TB. En comparant les cas pulmonaires et extrapulmonaires, la TB extrapulmonaire etait plus probable chez les patients ages de moins de 14 ans et ceux de plus de 54 ans. La TB extrapulmonaire etait plus probable chez les nouveaux patients et la TB pulmonaire plus probable chez les patients precedemment traites. La residence dans les regions rurales etait associee a un echec du traitement. ConclusionLa charge de TB dans la region de Balimo est elevee, y compris une tres forte proportion de TB extrapulmonaire. Ces facteurs soulignent l'importance de BDH en tant qu'hopital primaire pour les cas de TB dans la region de Balimo et le district de Middle Fly, et le besoin de ressources et de personnel pour gerer a la fois les cas de TB sensible et resistante.

Introduction: Despite the risks involved, the use of drugs for recreational purposes is prevalent and generally well accepted. However, there is sparse research to explore the drivers of this phenomenon. Method: Semi-structured interviews were conducted with lay field observers of the recreational drug scene. The data were analyzed using ground theory to provide a framework for understanding motivators underpinning recreational drug use. Two ascribed benefits underpinned recreational drug use: 1) improved social connectedness and 2) enhanced performance. This paper reports on the relationship between drug use and performance enhancement. Results: Recreational drugs were used with the aim of enhancing performance in a number of ways, including to improve endurance, appearance, confidence, and personality. The majority of participants reported that drug taking offers personal and social benefits that outweighed the risks. Discussion and conclusions: In contrast to much of the literature, this study found that people perceived recreational drug use to have a range of positive effects that they wanted to take advantage of. This important finding adds to our understanding of the pulling power of drugs. Ultimately, the study highlights a need to rethink the preoccupation in drug strategies with negative physical, mental, and social outcomes as this would seem to be disconnected from actual experience and may result in a credibility gap for prevention education.

Importance Optimal pharmacologic treatment for chronic sciatica (CS) is currently unclear. While gabapentin (GBP) and pregabalin (PGB) are both used to treat CS, equipoise exists. Nevertheless, pharmaceutical regulation authorities typically subsidize one drug over the other. This hinders interchange wherever the favored drug is either ineffective or ill-tolerated. Objective To assess GBP vs PGB head to head for the treatment of CS. Design, Setting, and Participants A preplanned interim analysis of a randomized, double-blind, double-dummy crossover trial of PGB vs GBP for management of CS at half the estimated final sample size was performed in a single-center, tertiary referral public hospital. A total of 20 patients underwent randomization from March 2016 to March 2018, and 2 were excluded with 1 lost to follow-up and the other requiring urgent surgery unrelated to the study. Patients attending a specialist neurosurgery clinic with unilateral CS were considered for trial recruitment. Chronic sciatica was defined as pain lasting for at least 3 months radiating into 1 leg only to, at, or below the knee level. Imaging (magnetic resonance imaging with or without computed tomography) corroborating a root-level lesion concordant with symptoms and/or signs was determined by the trial clinician. Inclusion criteria included patients who had not used GBP and PGB and were 18 years or older. Analyses were intention to treat and began February 2018. Interventions Randomly assigned participants received GBP (400 mg to 800 mg 3 times a day) then PGB (150 mg to 300 mg twice daily) or vice versa, each taken for 8 weeks. Crossover followed a 1-week washout. Main Outcomes and Measures The primary outcome was pain intensity (10-point visual analog scale) at baseline and 8 weeks. Secondary outcomes included disability (using the Oswestry Disability Index) and severity/frequency of adverse events. Results The total trial population (N = 18) consisted mostly of men (11 [61%]) with a mean (SD) age of 57 (16.5) years. A third of the cohort were smokers (5 [28%]), and more than half consumed alcohol (12 [67%]). Gabapentin was superior to PGB, with fewer and less severe adverse events. Both GBP (mean [SD], 7.54 [1.39] to 5.82 [1.72]; P < .001) and PGB (mean [SD], 7.33 [1.30] to 6.38 [1.88]; P = .002) displayed significant visual analog pain intensity scale reduction and Oswestry Disability Index reduction (mean [SD], 59.22 [16.88] to 48.54 [15.52]; P < .001 for both). Head to head, GBP showed superior visual analog pain intensity scale reduction (mean [SD], GBP: 1.72 [1.17] vs PGB: 0.94 [1.09]; P = .035) irrespective of sequence order; however, Oswestry Disability Index reduction was unchanged. Adverse events for PGB were more frequent (PGB, 31 [81%] vs GBP, 7 [19%]; P = .002) especially when PGB was taken first. Conclusions and Relevance Pregabalin and GBP were both significantly efficacious. However, GBP was superior with fewer and less severe adverse events. Gabapentin should be commenced before PGB to permit optimal crossover of medicines. Trial Registration anzctr.org.au Identifier: ACTRN12613000559718

Improvements in the diagnosis and disclosure of dying mean that nowadays dying people typically live with an awareness of their status for longer than they have previously.However, little is known regarding how transitions between living and dying roles occur during this time.In this grounded theory study, we investigated role transitions at end-of-life.We found that dying people periodically foreground and background living and dying selfhoods, focus on living day-by-day and goal-by-goal and reframe dying roles with an orientation to living.We argue that with better understanding of role transitions at end-of-life more compassionate and responsive care becomes possible.

Objective This paper provides a narrative overview of the literature concerning clinical decision-making processes when staff come under pressure, particularly in uncertain, dynamic and emergency situations. Methods Studies between 1980 and 2015 were analysed using a six-phase thematic analysis framework to achieve an in-depth understanding of the complex origins of medical errors that occur when people and systems are under pressure and how work pressure affects clinical performance and patient outcomes. Literature searches were conducted using a Summons Search Service platform; search criteria included a variety of methodologies, resulting in the identification of 95 papers relevant to the present review. Results Six themes emerged in the present narrative review using thematic analysis: organisational systems, workload, time pressure, teamwork, individual human factors and case complexity. This analysis highlights that clinical outcomes in emergency situations are the result of a variety of interconnecting factors. These factors may affect the ability of clinical staff in emergency situations to provide quality, safe care in a timely manner. Conclusions The challenge for researchers is to build the body of knowledge concerning the safe management of patients, particularly where clinicians are working under pressure. This understanding is important for developing pathways that optimise clinical decision making in uncertain and dynamic environments. What is known about the topic? Emergency departments (EDs) are characterised by high complexity, high throughput and greater uncertainty compared with routine hospital wards or out-patient situations, and the ED is therefore prone to unpredictable workflows and non-replicable conditions when presented with unique and complex cases. What does this paper add? Clinical decision making can be affected by pressures with complex origins, including organisational systems, workload, time constraints, teamwork, human factors and case complexity. Interactions between these factors at different levels of the decision-making process can increase the complexity of problems and the resulting decisions to be made. What are the implications for practitioners? The findings of the present study provide further evidence that consideration of medical errors should be seen primarily from a ‘whole-of-system’ perspective rather than as being primarily the responsibility of individuals. Although there are strategies in place in healthcare organisations to eliminate errors, they still occur. In order to achieve a better understanding of medical errors in clinical practice in times of uncertainty, it is necessary to identify how diverse pressures can affect clinical decisions, and how these interact to influence clinical outcomes.

There is currently an absence of high-grade evidence regarding the treatment of chronic sciatica (CS). Whilst gabapentin (GBP) and pregabalin (PGB) are both currently used to treat CS, equipoise exists regarding their individual use. In particular, no head-to-head study of GBP and PGB in CS exists. Despite equipoise, most countries’ formulary regulatory authorities typically favour one drug for subsidy over the other. This hinders interchange wherever the favoured drug is either ineffective or not tolerated. The primary aim of this study is to conduct a head-to-head comparison of the efficacy of PGB versus GBP for CS based on outcomes on a visual analogue scale (VAS) and the Oswestry Disability Index (ODI).

This article was migrated. The article was marked as recommended. Clinical reasoning is fundamental to medical education and clinical practice (Schmidt & Mamede, 2015). Despite its centrality, clinical reasoning is often regarded as difficult to conceptualise and teach (Charlin, 2012; Pinnock & Welch, 2014). The pivotal role of clinical reasoning constitutes a compelling case for better understanding, more efficient teaching and practice that is more systematic and evidence-based. Clinical reasoning has been regarded as an art rather than a science (Braude, 2012) and has attracted less research effort than befits its important function. The authors examined the suitability of grounded theory methodology to provide a more complete understanding of the clinical reasoning process. Grounded theory and clinical reasoning are processes which both qualitatively evaluate and analyse information from an interview subject as well as additional sources and arrive at a robust, defensible theory to explain their findings. Grounded theory offers considerable utility for (i) understanding and modelling clinical reasoning, (ii) researching clinical reasoning and (iii) as a heuristic for teaching clinical reasoning skills. This paper explores the parallels between grounded theory methodology and clinical reasoning, as well as the suitability of grounded theory as a framework for informing and transforming our understanding of clinical reasoning.​

BACKGROUND:Papua New Guinea (PNG) is a diverse and culturally-rich country with severe infrastructural and health problems. Tuberculosis (TB) is widespread, and the number of cases with drug resistance is rising. Treatment adherence is known to be important for both effective treatment and limiting the emergence of drug resistance. The aim of this study was to construct a matrix of the factors that act as facilitators or barriers to TB treatment adherence in a remote region of PNG.METHODS:The study was based in the Balimo region of the Western Province. People known to have undergone TB treatment, as well as staff involved in managing people with TB, were asked to participate in an in-depth interview about their experiences. Purposive sampling was used to identify a diverse range of participants, from different geographic locations, social backgrounds, and with successful and unsuccessful treatment outcomes. The interview data was analysed based on grounded theory methodology.RESULTS:The study identified a range of factors that influence TB treatment adherence, with these being classified as personal, systems, and sociocultural. These factors are presented along with suggested recommendations for adaptations to DOTS-based treatment in this region. Barriers included the challenges associated with travel to treatment sites, and the difficulties of undertaking treatment alongside the daily need to maintain subsistence food production. However, facilitators were also identified, including the positive influence of religious beliefs, and high confidence in the ability of DOTS-based treatment to cure TB.CONCLUSIONS:Documenting the wide range of factors that influence treatment adherence in a severely affected remote population will assist in improving TB control. These results provide impetus for further community-based efforts aimed at improving access to TB diagnosis and treatment, and maintaining successful treatment outcomes in the face of emerging drug resistance.

In Australia, approximately 30% of people diagnosed with HIV are not accessing treatment and 8% of those receiving treatment fail to achieve viral suppression. Barriers limiting effective care warrant further examination. This mixed-methods systematic review accessed health and social sector research databases between November and December 2015 to identify studies that explored the perspective of people living with HIV in Australia. Articles were included for analysis if they described the experiences, knowledge, attitudes and beliefs, in relation to treatment uptake and adherence, published between January 2000 and December 2015. Quality appraisal utilised the Mixed Methods Appraisal Tool Version 2011. Seventy-two studies that met the inclusion criteria were reviewed. The interplay of lack of knowledge, fear, stigma, physical, emotional and social issues were found to negatively impact treatment uptake and adherence. Strategies targeting both the individual and the wider community are needed to address these barriers.