Christine Holmberg

Charité Universitätsmedizin Berlin, Berlín, Berlin, Germany

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Publications (37)69.61 Total impact

  • M Stamer · C Güthlin · C Holmberg · U Karbach · C Patzelt · T Meyer
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    ABSTRACT: The third and final discussion paper of the German Network of Health Services Research's (DNVF) "Qualitative Methods Working Group" demonstrates methods for the evaluation and quality of qualitative research in health services research. In this paper we discuss approaches described in evaluating qualitative studies, including: an orientation to the general principles of empirical research, an approach-specific course of action, as well as procedures based on the research-process and criteria-oriented approaches. Divided into general and specific aspects to be considered in a qualitative study quality evaluation, the central focus of the discussion paper undertakes an extensive examination of the process and criteria-oriented approaches. The general aspects include the participation of relevant groups in the research process as well as ethical aspects of the research and data protection issues. The more specific aspects in evaluating the quality of qualitative research include considerations about the research interest, research questions, and the selection of data collection methods and types of analyses. The formulated questions are intended to guide reviewers and researchers to evaluate and to develop qualitative research projects appropriately. The intention of this discussion paper is to ensure a transparent research culture, and to reflect on and discuss the methodological and research approach of qualitative studies in health services research. With this paper we aim to initiate a discussion on high quality evaluation of qualitative health services research.
    No preview · Article · Dec 2015 · Das Gesundheitswesen
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    ABSTRACT: Background: Pharmaceutical promotion activities in low and middle-income countries are often neither regulated nor monitored. While Egypt has the highest population and per capita use of medicines in the Arab world, we know very little about pharmaceutical companies promotional activities in the country. Aim: To explore and analyze the perceptions of physicians towards promotional and marketing activities of pharmaceutical companies among physicians and pharmacists in Egypt. Methodology: Perspectives of different healthcare system stakeholders were explored through semi-structured, in-depth interviews conducted in 2014 in Cairo, Egypt. Interviewees were chosen via purposive sampling and snowball technique. Each interview was recorded and transcribed. Then qualitative, thematic analysis was conducted with the help of NVIVO software. Findings: The majority of physicians and pharmacists acknowledged exposure to pharmaceutical promotion. It was commonly believed that interaction with the pharmaceutical industry is necessary and both associated risks and benefits were acknowledged. The interviewed physicians considered themselves competent enough to minimize risks and maximize benefits to their prescribing habits. Views diverged on the extent and magnitude of the risks and benefits of pharmaceutical promotion, especially in regard to the influence on patients' health. Conclusions: Pharmaceutical promotion in Egypt is intensely directed at prescribers and dispensers. Physicians, pharmacists and policymakers expressed little skepticism to the influence of promotion towards their individual prescribing. Raising awareness of the pitfalls of pharmaceutical promotion is necessary, especially among the less experienced physicians.
    Full-text · Article · Oct 2015 · PLoS ONE

  • No preview · Article · Oct 2015 · Cancer Epidemiology Biomarkers & Prevention

  • No preview · Article · Sep 2015 · European Journal of Integrative Medicine
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    Susanne Blödt · Claudia M. Witt · Christine Holmberg

    Preview · Article · Sep 2015 · European Journal of Integrative Medicine
  • Christine Holmberg · Katie Whitehouse · Mary Daly · Worta McCaskill-Stevens
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    ABSTRACT: Concepts of disease risk and its management are central to processes of medicalisation and pharmaceuticalisation. Through a narrative perspective, this paper aims to understand how such macro-level developments may (or may not) be experienced individually, and how an algorithm that is used for recruitment into a clinical trial may structure individual notions of being 'at risk' and 'in need of treatment'. We interviewed 31 women participating in the Study of Tamoxifen and Raloxifene (STAR), a chemoprevention trial conducted in the US between 1999 and 2006. Interviews were thematically analysed. Women in the study had experienced the threat of breast cancer and felt vulnerable to developing the disease prior to STAR participation. The diagnosis of 'being at risk' for cancer through an algorithm that determined risk-eligibility for STAR, opened up the possibility for the women to heal. The trial became a means to recognise and collectivise the women's experiences of vulnerability. Through medication intake, being cared for by study coordinators, and the sense of community with other STAR participants, trial participation worked to transform women's lives. Such transformative experiences may nevertheless have been temporary, enduring only as long as the close links to the medical institution through trial participation lasted. © 2015 Foundation for the Sociology of Health & Illness.
    No preview · Article · Aug 2015 · Sociology of Health & Illness
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    ABSTRACT: Decision-making experts emphasize that understanding and using probabilistic information are important for making informed decisions about medical treatments involving complex risk-benefit tradeoffs. Yet empirical research demonstrates that individuals may not use probabilities when making decisions. To explore decision making and the use of probabilities for decision making from the perspective of women who were risk-eligible to enroll in the Study of Tamoxifen and Raloxifene (STAR). We conducted narrative interviews with 20 women who agreed to participate in STAR and 20 women who declined. The project was based on a narrative approach. Analysis included the development of summaries of each narrative, and thematic analysis with developing a coding scheme inductively to code all transcripts to identify emerging themes. Interviewees explained and embedded their STAR decisions within experiences encountered throughout their lives. Such lived experiences included but were not limited to breast cancer family history, a personal history of breast biopsies, and experiences or assumptions about taking tamoxifen or medicines more generally. Women's explanations of their decisions about participating in a breast cancer chemoprevention trial were more complex than decision strategies that rely solely on a quantitative risk-benefit analysis of probabilities derived from populations In addition to precise risk information, clinicians and risk communicators should recognize the importance and legitimacy of lived experience in individual decision making. © The Author(s) 2015.
    No preview · Article · Jul 2015 · Medical Decision Making
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    ABSTRACT: Spiritual healers in contemporary Germany comprise a heterogeneous and growing group, yet little data exists about them. Therefore, one aim of this study was to learn about which biographical aspects and events were important to the process of becoming a healer and which biographical aspects drove clients to consult a healer. The study was based on semi-structured interviews combined with participant observations. All data were recorded digitally, transcribed, entered into the software program MAXQDA and analysed subjected to Content Analysis. In total, 15 healers (nine male, six female) and 16 clients (13 female, three male) were included. According to the healers, a talent for healing can be inborn, inherited or developed through life experiences. Most of the healers experienced a crisis, which prompted their transformation to healers (the wounded healer type). A smaller group became healers mainly out of interest without going through crisis and by focusing on the spiritual attitude itself (the healer by interest type). The basis of healing is seen as a connection to a transcendent reality, which enables an open, loving and empathetic attitude. The experience of crises and illnesses and the importance of spirituality are major biographical similarities between healers and clients. Near-death experiences as an extreme form of crisis were reported from a few healers and clients. The connections between healing talents and crises, including a deepened exploration of near-death experiences and questions regarding inclining towards spirituality could be of interest in further studies.
    No preview · Article · Jun 2015 · Anthropology & Medicine
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    ABSTRACT: On 28–29 April 2014, the Qualitative Research Group on Cancer, based at the Berlin School of Public Health, Charité – Universitätsmedizin, in Berlin, Germany, hosted a two-day conference to review current perspectives in qualitative cancer research.[note 1] Such research has become a major focus of qualitative health research in recent decades, both challenging and supplementing studies grounded in the epistemology of biomedical sciences. Qualitative cancer research is committed to investigating various actors’ perspectives on and the implications of contexts, (power) relations, and processes related to a cancer diagnosis, and cancer prevention, treatment, and the experience thereof. The conference provided a rare opportunity to bring together a diverse group of researchers and clinicians engaging in qualitative cancer research from twelve countries, various career stages, and multiple disciplines, including biomedicine, social sciences, and public health. The conference included fifteen individual presentations grouped into five thematic sessions (see the list of presentations at the end of this report). http://www.medanthrotheory.org/read/4798/qualitative-cancer
    No preview · Article · Mar 2015
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    ABSTRACT: An increasing number of clinics offer complementary or integrative medicine services; however, clear guidance about how complementary medicine could be successfully and efficiently integrated into conventional health care settings is still lacking. Combining conventional and complementary medicine into integrative medicine can be regarded as a kind of merger. In a merger, two or more organizations - usually companies - are combined into one in order to strengthen the companies financially and strategically. The corporate culture of both merger partners has an important influence on the integration. The aim of this project was to transfer the concept of corporate culture in mergers to the merging of two medical systems. A two-step approach (literature analyses and expert consensus procedure) was used to develop practical guidance for the development of a cultural basis for integrative medicine, based on the framework of corporate culture in "mergers," which could be used to build an integrative medicine department or integrative medicine service. Results include recommendations for general strategic dimensions (definition of the medical model, motivation for integration, clarification of the available resources, development of the integration team, and development of a communication strategy), and recommendations to overcome cultural differences (the clinic environment, the professional language, the professional image, and the implementation of evidence-based medicine). The framework of mergers in corporate culture provides an understanding of the difficulties involved in integrative medicine projects. The specific recommendations provide a good basis for more efficient implementation.
    Full-text · Article · Jan 2015 · Patient Preference and Adherence
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    ABSTRACT: Purpose: Patients who need to make a major medical decision are often expected to understand and use probabilistic information well enough to be capable of evaluating a complex set of tradeoffs between the treatment’s risks and benefits. Much effort has been invested in creating materials to improve decision making in such situations, but patients vary in the extent to which they use probabilistic information even when it is provided to them in a way that is comprehensible. This study explored decision making, including the use of probabilities, from the perspective of women who were invited to participate in the Study of Tamoxifen and Raloxifene (STAR). Methods: We conducted in-depth one-on-one narrative interviews with 20 women who agreed to participate in STAR and 20 women who declined. The interviewer began with a single open-ended question (“You have done a statistical risk assessment. Can you tell me about that?”) and allowed interviewees to direct the conversation with minimal interviewer interference. Data were analyzed using an iterative process that included developing summaries of each interview, coding the transcripts, identifying themes, and ensuring validity by presenting and discussing the study in a qualitative research group. Results: Interviewees explained their decisions using a framework of lived experiences. They did not indicate that they used probabilistic information to weigh the risks and benefits of treatment. Rather, their decisions were embedded within experiences encountered throughout their lives. Such lived experiences included, but were not limited to, their family history of breast cancer, their personal history of breast biopsies, and their experiences and assumptions about the potential consequences of taking tamoxifen. Interviewees also discussed their decisions in the context of the challenges of using population-derived data, such as that used to calculate risk estimates, for making decisions and predicting health outcomes for individuals. Conclusions: Women’s explanations of their decisions about participating in a breast cancer chemoprevention trial were more complex than decision strategies that rely solely on a quantitative risk-benefit analysis of probabilities derived from populations. Recognizing that lay decision-making strategies may be reasonable may facilitate patient-provider communication about this challenging topic.
    No preview · Conference Paper · Oct 2014
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    ABSTRACT: Background: In Germany, many prostate cancer patients use complementary medicine (CM) or have an interest in these treatment approaches; however, the information and consultation situation of cancer patients is insufficient and therefore the Competence Network Complementary Medicine in Oncology (COCON) was launched by the German Cancer Aid Society. One of the projects of the COCON examines the use of CM and the information and counseling needs regarding these topics in various groups of cancer patients. The focus of this article is on the qualitative study reporting selected results for the subgroup of prostate cancer patients. Study design and study methods: A total of 19 semi-structured qualitative interviews with prostate cancer patients were conducted regarding the use of CM as well as their information and consultation needs. Results: It was found that the patients interviewed discussed various issues surrounding nutrition, particularly a healthy diet, the selective use of certain foods and the use of dietary supplements. Additional themes mentioned by interviewees were physical exercise, psychological well-being, mistletoe therapy, homeopathy and traditional Chinese medicine. Patients indicated that they wanted more information and counseling opportunities with regards to CM. They also expressed a desire for more holistic care. Conclusion: The results show that prostate cancer patients use a range of CM and have a need for information about CM. Prostate cancer patients are in a special situation because of a regular feedback on the prostate-specific antigen (PSA) value. This should be taken into consideration in consultation with prostate cancer patients regarding CM.
    Full-text · Article · Oct 2014 · Der Urologe
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    ABSTRACT: Background Utilisation of multidisciplinary teams is considered the best approach to care and treatment for cancer patients. However, the multidisciplinary approach has mainly focused on inpatient care rather than routine outpatient care. The situation in private practice care and outpatient care is gradually changing. We aimed to 1), investigate interdisciplinary cooperations in the care of tumor patients among urologists and oncologists in the community setting, 2), establish an estimate of the prevalence of cooperation among oncologists and organ-specific providers in community settings in Germany and 3), characterise existing cooperations among oncologists and urologists. Methods We conducted simultaneously a cross-sectional survey with private practice urologists (n = 1,925) and a qualitative study consisting of semi-structured interviews with urologists and oncologists (n = 42), primarily with private practices, who had indicated cooperation the care of urological tumor patients. Results Most of the participants (66%) treated their own tumor patients. When physicians referred patients, they did so for co- and subsequent treatments (43%). Most cooperating urologists were satisfied with the partnership and appreciated the competency of their partners. Qualitative interviews revealed two types of collaboration in the community setting: formal and informal. Collaborations were usually ongoing with many physicians and depended equally on both patient preference and diagnosis. Conclusion Joint patient treatment requires clear delineation of roles and responsibilities and simple means of communication. Formal frameworks should allow for incorporation of patients’ critical role in collaboration decisions in treatment and care.
    Full-text · Article · Oct 2014 · BMC Cancer
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    ABSTRACT: Ovarian cancer is a malignant entity typically diagnosed in advanced stages, with concomitant poor prognosis. Delayed healthcare seeking is commonly explained by the ‘vague’ character of the disease's symptoms combined with a lack of awareness among patients. However, research on the social contexts of ovarian cancer patients' pre-diagnostic illness experiences and healthcare seeking is scarce. To explore these topics, we initiated a qualitative interview study guided by the principles of grounded theory and based on interviews with 42 ovarian cancer patients. The study was conducted in Germany from September 2011 to February 2013. Our analysis illustrates how, in the narratives, the interviewees struggled to balance specific bodily sensations with aspects of their life-worlds prior to consulting a biomedical professional. We propose a three-phase model to capture these experiences and demonstrate how the developments of pre-diagnostic sensations were catalysed by the dynamic and complex interplay of the sensations with a variety of individual and socio-cultural factors. To conceptualize these interplays, we introduce the analytical notion of a triggering process, and we elaborate on the different ways in which such a process conditioned the transformation of a sensation into a symptom and decisions to seek healthcare. We finally discuss our findings both in relation to current research on sensations, symptoms and healthcare seeking and in their relevance for understanding diagnostic delays in ovarian cancer.
    No preview · Article · Oct 2014 · Social Science & Medicine
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    ABSTRACT: This paper aims to understand the influence of welfare institutions on illness experiences, particularly health insurance and income compensation policies, by comparing narrative interviews with breast- and prostate cancer patients in Germany (n=90 for both cancers) and Japan (n=97 for both cancers). Both countries have a comprehensive social security system. Using the data collected for the project Database of Individual Patient Experiences (DIPEx), two levels of comparison will be sought: 1) country, and 2) disease type, resulting in four analytic groups. Due to language constraints, cross-national comparisons will be based on the analysis within each country is complete with regards to the study question: How do health insurance systems and income compensation policies such as sick leave and disability benefits affect the experience of having cancer? Preliminary findings show that in both countries breast cancer patients who are generally younger and thus still in the workforce tend to express financial concerns more than prostate cancer patients. However, the impact of financial pressure is more apparent in Japan where out-of-pocket copayments are higher and the terms for sick leave are less favorable to employees, affecting patients’ treatment decisions and the timing of return to work. For German patients who are eligible for early retirement and disability benefits, the diagnosis in many cases does not present financial disaster. However, receiving disability benefits led to stigmatization through the bureaucratic mechanism in place. Subsequently women discussed feelings of shame and worthlessness induced by bureaucratic mechanisms. The present study will be one of the first studies in which international comparisons on qualitative interview materials that have been collected in different languages and by different interviewers are analyzed within the same research framework. Thus the paper presents important findings on production of inequality in high-income countries, and provides a new methodology for cross-cultural secondary analysis.
    No preview · Conference Paper · Jul 2014
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    ABSTRACT: Background Limited research has been conducted on contemporary spiritual healing in European countries. The aim of this article is to report how German healers and their clients experienced and perceived the outcomes of spiritual healing and which explanations they use to describe the perceived effects. Methods Semistructured interviews and participatory observation was used to collect data from spiritual healers and their clients. Analyses were based on the methodological concept of directed qualitative content analysis. Data was analyzed using MAXQDA software, discussed and reviewed by a multidisciplinary research team consisting of medical anthropologists, medical doctors and a religious studies scholar. Results In total 15 healers and 16 clients participated in this study, 24 interviews with healers, 20 interviews with clients and 8 participatory observations were analyzed. Healers and clients reported outcomes as positively perceived body sensations, increased well-being, positive emotions and symptomatic relief of medical complaints. Clients often described changes in their self-concepts and adapted life values. Explanations for perceived effects included connecting with transcendent sources, construction of meaning, as a result of the client-healer relationship, and as empowerment to make changes. Because the interviewed clients were recruited by the healers, a selection bias towards positive healing experiences is possible. Conclusion We hypothesize that concepts of meaning construction, resource activation and the utilization of the clients’ expectations help to explain the data. Grounded in the emic perspective, we propose to use the following outcomes for further prospective studies: positive body sensations, changes of self-concepts and values, changes of medical symptoms and complaints. From the etic perspective, physical, emotional, social and spiritual wellbeing, sense of coherence, meaningfulness of life, empowerment, resource activation, change and symptom control should be further explored as potential outcomes.
    Full-text · Article · Jul 2014 · BMC Complementary and Alternative Medicine
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    ABSTRACT: Background Policy efforts focus on a reorientation of health care systems towards primary prevention. To guide such efforts, we analyzed the role of primary prevention in general practice and general practitioners’ (GPs) attitudes toward primary prevention. Methods Mixed-method study including a cross-sectional survey of all community-based GPs and focus groups in a sample of GPs who collaborated with the Institute of General Practice in Berlin, Germany in 2011. Of 1168 GPs 474 returned the mail survey. Fifteen GPs participated in focus group discussions. Survey and interview guidelines were developed and tested to assess and discuss beliefs, attitudes, and practices regarding primary prevention. Results Most respondents considered primary prevention within their realm of responsibility (70%). Primary prevention, especially physical activity, healthy eating, and smoking cessation, was part of the GPs’ health care recommendations if they thought it was indicated. Still a quarter of survey respondents discussed reduction of alcohol consumption with their patients infrequently even when they thought it was indicated. Similarly 18% claimed that they discuss smoking cessation only sometimes. The focus groups revealed that GPs were concerned about the detrimental effects an uninvited health behavior suggestion could have on patients and were hesitant to take on the role of “health policing”. GPs saw primary prevention as the responsibility of multiple actors in a network of societal and municipal institutions. Conclusions The mixed-method study showed that primary prevention approaches such as lifestyle counseling is not well established in primary care. GPs used a selective approach to offer preventive advice based upon indication. GPs had a strong sense that a universal prevention approach carried the potential to destroy a good patient-physician relationship. Other approaches to public health may be warranted such as a multisectoral approach to population health. This type of restructuring of the health care sector may benefit patients who are unable to afford specific prevention programmes and who have competing demands that hinder their ability to focus on behavior change.
    Full-text · Article · May 2014 · BMC Family Practice
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    Christine Holmberg · Julia Rappenecker · Julia J Karner · Claudia M Witt
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    ABSTRACT: Chronic pain is prevalent in elderly populations. The goals of this study were 1) to understand the results of a randomized clinical trial - Qigong and Exercise Therapy for Elderly Patients with Chronic Neck Pain (QIBANE) - that showed no difference between qigong, exercise therapy, and no-treatment on quality of life, and 2) to understand how elderly individuals with chronic pain experience interventions of qigong and exercise therapy. A qualitative interview study was conducted with 20 QIBANE participants. Interviews asked about motivation for and expectations of trial participation, experiences with the exercise classes (qigong or exercise therapy), and changes in pain experience. Interviews were transcribed, entered into the software program ATLAS.ti, and coded thematically by two coders. Content analysis was performed. All interviewees reflected positively on their QIBANE experience and described their participation in QIBANE as helpful. However, what was discussed in both groups when they talked about "positive experiences" in the study differed between the two groups. For example, themes that emerged in the exercise-therapy group related to difficulties associated with aging and staying physically active. In the interviews with qigong group members, emergent themes related to qigong as a method that improved bodily experiences and influenced daily activities. The effects that exercise therapy and qigong have on an elderly population cannot be captured by health-related quality-of-life measurements, such as the Short Form (36) Health Survey. Broader concepts of quality of life that include the concepts of self-efficacy and positive affect may be more appropriate. The results presented in this study suggest that for this population group, the approach of patient-centered outcomes is especially pertinent in order to design meaningful intervention studies in the elderly. This means that research questions, interventions, and outcome measurements need to take into account the special situation of elderly people.
    Full-text · Article · Mar 2014 · Clinical Interventions in Aging
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    Christine Holmberg · Julia J Karner · Julia Rappenecker · Claudia M Witt
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    ABSTRACT: To improve clinical study developments for elderly populations, we aim to understand how they transfer their experiences into validated, standardised self-completed study measurement instruments. We analysed how women (mean 78±8 years of age) participating in a randomised controlled trial (RCT) cognised study instruments used to evaluate outcomes of the intervention. The interview study was nested in an RCT on chronic neck pain using common measurement instruments situated in an elderly community in Berlin, Germany, which comprised of units for independent and assisted-living options. The sample (n=20 women) was selected from the RCT sample (n=117, 95% women, mean age 76 (SD±8) years). Interview participants were selected using a purposive sampling list based on the RCT outcomes. We asked participants about their experiences completing the RCT questionnaires. Interviews were analysed thematically, then compared with the questionnaires. Interviewees had difficulties in translating complex experiences into a single value on a scale and understanding the relationship of the questionnaires to study aims. Interviewees considered important for the trial that their actual experiences were understood by trial organisers. This information was not transferrable by means of the questionnaires. To rectify these difficulties, interviewees used strategies such as adding notes, adding response categories or skipping an item. Elderly interview participants understood the importance of completing questionnaires for trial success. This led to strategies of completing the questionnaires that resulted in 'missing' or ambiguous data. To improve data collection in elderly populations, educational materials addressing the differential logics should be developed and tested. Pilot testing validated instruments using cognitive interviews may be particularly important in such populations. Finally, when the target of an intervention is a subjective experience, it seems important to create a method by which participants can convey their personal experiences. These could be nested qualitative studies. ISRCTN77108101807.
    Full-text · Article · Mar 2014 · BMJ Open
  • Christine Holmberg · Christine Bischof · Susanne Bauer
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    ABSTRACT: Statistics constitute the social universe of which they are gathered. The foundation necessary to develop quantified knowledge about society is the population. If quantified knowledge changes society, the question arises on how individuals become to be represented as population. The population has to be extracted from individuals in a process that we call "populationisation." This encompasses the development of the individual into a segment of a population through the compilation of individual data into population data and its analysis. To describe the process of populationisation, we follow a statistical risk assessment tool, the German Diabetes Risk Score, from its inception in a cohort study to its entry into the public sphere of German society. The population is extracted from individuals that function as research subjects through an identification number. Preprocessed information is entered into a dynamic database that enables its rearrangement according to main aggregates. Through populationisation, a signified is enacted that can be sliced up and that is equal in all its parts. Now predictions can be computed and fed back to society as tools of moral judgment. The acting individual and "society" are—numerically and literally!—entangled in the production and enactment of risk knowledge.
    No preview · Article · May 2013 · Science, Technology & Human Values