Browsing by Subject "Mixed methods"

Behavioral symptoms of dementia cause considerable distress for persons with dementia and their caregivers and are related to adverse outcomes that have significant social and economic impact. Thus, behavioral symptoms represent one of the most challenging aspects of dementia care. Over the past three decades, research on behavioral symptoms of dementia has laid the foundation for development of non-pharmacological interventions by identifying underlying mechanisms of symptom development. However, the research has largely overlooked how the needs of military veterans may influence development and treatment of behavioral symptoms of dementia, including those needs associated with co-occurring dementia and posttraumatic stress disorder (PTSD). This dissertation aimed to develop knowledge related to behavioral symptoms of dementia among older veterans with and without PTSD by synthesizing current understanding of neurocognitive and psychiatric comorbidities of PTSD among veterans as well as explicating relationships among background factors, proximal factors, and behavioral symptoms of dementia among veterans living in residential care using the need-driven, dementia-compromised behavior (NDB) model.

This dissertation includes a systematic review in Chapter 2 that synthesized the patterns of neurocognitive and psychiatric comorbidities of PTSD in older veterans and revealed a substantial gap in the literature with regards to understanding manifestations and treatment of behavioral symptoms of dementia among older veterans with co-occurring dementia and PTSD. The primary study of this dissertation that encompasses Chapters 3 and 4 utilized an exploratory sequential mixed methods design using secondary data derived from the evaluation dataset of the STAR-VA training program. In Chapter 3, a qualitative study, as the first phase of the mixed methods study, analyzed text data that captured the interdisciplinary care team’s observation of behavioral symptoms of dementia and their circumstances for the subsample of 33 veterans from the STAR-VA dataset. This qualitative study described how behavioral symptoms of dementia are manifested among veterans with and without PTSD in the context of personal, interpersonal/social, and environmental factors that trigger the symptoms. Findings demonstrated that behavioral symptoms of dementia are heterogeneous, with distinct clusters of triggers that are multi-level, thereby warranting an interdisciplinary, multi-level approach to developing person-centered interventions. In addition, findings from this qualitative study informed the development of the second phase of the sequential mixed methods study in Chapter 4 that aimed to test hypothesized pathways between background factors, interpersonal triggers (proximal factors), and behavioral symptoms of rejection of care and aggression and to explore the moderating effect of PTSD on the hypothesized pathways. The mixed methods approach integrated quantitative data measured by standardized scales and text data for 315 veterans derived from the STAR-VA dataset. After converting text data into categorical variables, structural equation modeling (SEM) was performed to compare the patterns of relationships among background factors, interpersonal triggers, and behavioral symptoms of rejection of care and aggression between veterans with and without PTSD. The direct effect of interpersonal triggers and the indirect effect of background factors through interpersonal triggers on rejection of care and aggression emphasizes the importance of developing and implementing psychosocial interventions that improve interpersonal relationships. The multi-group SEM revealed that the full model was not moderated by PTSD. However, the differential direct and indirect effect of background factors and interpersonal triggers as a proximal factor on the behavioral outcomes between veterans with and without PTSD suggest potential different mechanisms of behavioral outcomes between veterans depending upon whether or not PTSD is present. Evidence for the PTSD-moderated mediating effect of interpersonal triggers on the relationship between depression and rejection of care was demonstrated, suggesting the need to develop targeted interventions for veterans with dementia and PTSD who have greater depressive symptoms.

The new knowledge generated from this dissertation helps to clarify complex patterns of associations among background factors such as PTSD and proximal factors and behavioral symptoms of dementia consistent with the NDB model, strengthening the foundation for development of novel approaches to designing and implementing person-centered care for veterans with co-occurring dementia and PTSD.

In this dissertation, I seek to understand the power of legal actors in determining punitiveness in plea bargaining in criminal courts. Using a unique combination of administrative court data and qualitative interviews, I evaluate the influence of the chief elected prosecutor, line prosecutors, and defense attorneys on plea bargaining practices and punitiveness in case outcomes across multiple local court systems. Chapter 2 presents an analysis of the association between the elected chief prosecutor and prosecution and active sentence rates in four types of criminal cases in nine districts in North Carolina. The study finds that chief prosecutors influenced punitiveness, but their influence was not aligned with their political party. Although Democratic and Republican chief prosecutors did not differ in levels of punitiveness, the one progressive prosecutor in the sample reduced punitiveness across most crime types to the lowest levels out of all nine study districts. Chapter 3 examines how line prosecutors working in one progressive prosecutor’s office reduced punitiveness in case outcomes, mainly by dismissing weak and low-priority cases even before they reached the plea bargaining stage. Finally, Chapter 4 explores the power of the defense attorney in plea bargaining, and shows how the legal actors and context of the plea bargaining interaction impacted defense attorneys’ leverage and negotiation strategies. These chapters provide insights into current movements to reform prosecution and reduce mass incarceration in the United States, and shed light on how punitiveness may be impacted through the complex process of plea bargaining.

Background: Harmful alcohol use and violence are both major contributors to global mortality and morbidity rates, despite being both predictable and preventable. This study seeks to quantitatively determine the scope of violence-related injury and Alcohol Use Disorders in a referral hospital in Moshi, and qualitatively determine 1) how violence-related injury patients perceive alcohol use influences the occurrence of violence and 2) how experiencing a violence-related injury influences patients’ subsequent alcohol use behavior.

Methods: This study was conducted at Kilimanjaro Christian Medical Center (KCMC). Survey data was obtained from a trauma registry including all injury patients ≥ 18 years admitted to the emergency room. Interview participants were included if they reported their injury was due to violence, tested positive for alcohol (by breathalyzer) upon admittance, medically stable, able to communicate and provide informed consent in Swahili or English, and clinically sober at the time of enrollment.

Results: From the 500 injury patients enrolled in the trauma registry from April 17, 2018 to January 12, 2019, 84 (16.8%) reported that their injury was due to violence. Patients with violent injuries were 2.21 times more likely to have a positive alcohol status compared to non-violent injuries (95% CI 1.36, 3.60, p<0.01). Among violent injuries, those with a positive alcohol status were 6.26 times more likely to have an Alcohol Use Disorder compared to those with a negative alcohol status (95% CI 2.13, 18.39, p<0.001). Interview respondents reported a perception that violent injuries were worse from other injuries, that the perpetrator was also under the influence of alcohol, that alcohol contributes to violence, and a desire to change alcohol use behavior following their injury.

Conclusion: Alcohol use and violence-related injury pose a significant threat to health and well-being globally. In Moshi, Tanzania, both issues are prevalent and contribute to a sufficient disease burden. This study has added to the data on alcohol-attributable harm, contributing to expanding information available on this issue from LMICs. To adequately reduce violence-related injuries in this setting, it is necessary to address harmful alcohol use as well.

In the United States, there has been over 1,000,000 deaths and more than 90 million cases of COVID-19. As of April 19, 2021, all adults aged 16 and older were eligible to receive vaccination. Nevertheless, young adults are being vaccinated at a slower rate than older adults. The current study aimed to identify potential factors associated with young adult vaccine hesitancy through a mixed methods approach comparing vaccinated and unvaccinated through both a quantitative survey and qualitative in-depth interviews. The survey captured 350 responses from young adults aged 20 to 30 living in four states: California, Mississippi, Oregon and Texas. The online survey differentiated between vaccinated and non-vaccinated individuals and analyzed different aspects of vaccine hesitancy from political trust to COVID-19 vaccine beliefs. Sixteen semi-structured in-depth interviews lasting 20 to 30 minutes were performed on Zoom. The main factors associated with vaccine hesitancy in young adults for both the survey and interviews were social drivers, trust in institutions, barriers to vaccination, perceptions of the vaccine, and COVID-19 vaccine information quality. Study findings will increase understanding of COVID-19 vaccination decision-making pathways of young adults with the purpose of informing future interventions and policy for promoting vaccination rates in young adults.

Background: Obstetric fistula is the development of a necrosis between the bladder and the vagina and/or the bladder and the rectum as a result of prolonged obstructed labor, resulting in urinary or fecal incontinence. In Tanzania surgical repair for obstetric fistula is provided freely by the government but it is estimated that there are over 25,000 women living with an untreated fistula. These women experience high degrees of psycho-social stresses exacerbated by the stigma surrounding their condition. There is a dire need to explore stigma within this population in order to better understand its impact, as stigma affects both treatment seeking behavior as well as long term recovery of those who access surgical repair.

Study Aims: This study aims to understand the experiences of stigma among women with obstetric fistulas by examining both internalized and enacted stigma, and by identifying pertinent correlates of internalized stigma.

Methods: This mixed-methods study utilized both quantitative and qualitative data collected in two related studies at a single hospital in Moshi, Tanzania. All study participants were women receiving surgical repair for an obstetric fistula. In the quantitative portion, cross-sectional survey data were collected from 52 patients. The primary outcome was fistula-related stigma, measured using an adaptation of the HASI-P stigma scale, which included constructs of both internalized and enacted stigma. In the qualitative portion, 45 patients participated in a semi-structured in-depth interview, which explored topics such as stressors caused by the fistula, coping mechanisms, and available support. The transcripts were analyzed using analytic memos and an iterative process of thematic coding using the framework of content analysis.

Results: Expressions of internalized stigma were common in the sample, with a median score of 2.1 on a scale of 0 – 3. Internalized was significantly correlated with negative religious coping, social participation, impact of incontinence and enacted stigma. Qualitative analysis was consistent and demonstrated widespread themes of shame and embarrassment. Experiences of enacted stigma were not as common (median score of 0), although some items, like those pertaining to mockery and blame, were endorsed by up to 25% of the study sample. Themes of anticipated stigma (isolation and non-disclosure due to the possibility of stigmatization) were also evident in the qualitative sample and may explain the low enacted stigma scores observed.

Conclusion: In this sample of women receiving surgical repair for an obstetric fistula, stigma was evident, with internalized stigma resulting in psychological impacts for patients. Experiences of both anticipated and enacted stigma were also observed. There is a need to explore interventions that would decrease stigma while also increasing support for these women, as stigma may be a barrier towards accessing surgical repair and reintegration following surgery.

Keywords: Tanzania, obstetric fistula, stigma, maternal health

In this dissertation, I propose a new framework for conceptualizing goal interdependence in teams and expand our understanding of team-related goal cognition. In Chapters 1 and 2, I propose that the goals of any one team can be viewed as being embedded a team goal system made up of the goals each member holds for the team as a whole, the individual goals that each member holds in relation to the team’s goal(s), the external, personal goals held by each member of a team (i.e., extra-team goals, ETGs), and the goals each member possesses for one another (i.e., relational goals). In the empirical part of my dissertation (Chapters 3 and 4) I use a mixed methods approach to investigate the role of team goal system awareness on individual and team processes and outcomes. In Chapter 3, I present findings from two qualitative studies and develop theory regarding the factors that influence the development and impact of team goal system awareness for individuals and teams. In Chapter 4, I present results from a laboratory experiment where I compare the effects of disclosing different types of extra-team goals on individual perceptions (commitment, trust, satisfaction, viability) and team performance. I find that, although there are efficiency and motivational benefits associated with team goal system awareness, teams must mitigate the perceived interpersonal costs that are associated with this awareness in order to benefit from it. In Chapter 5, I discuss implications of this work and avenues for future research.

Background: Each year, approximately 400,000 children are diagnosed with cancer with over 85% of new cases occurring in low- and middle-income countries (LMIC). Survival rates in LMIC are 25% compared to 85% in high-income countries (HIC). Undernutrition is a key factor contributing to this disparity. Children diagnosed with cancer are at a higher risk for undernutrition, especially in low resource settings, but nutritional status remains largely unrecognized and unmonitored in many pediatric oncology hospitals in LMICs. Study aims: This study aims to first, determine the prevalence and severity of undernutrition at diagnosis, and second, evaluate existing barriers and facilitators to optimal nutrition among children with cancer at a large specialty referral hospital in Mwanza, Tanzania.

Methods: A mixed methods approach was used including quantitative surveys, and semi structured interviews that were distributed to caregivers and medical providers for children with cancer treated at Bugando Medical Centre (BMC) from May to December 2019. Results: Quantitative surveys were completed by caregivers(n=65), with a sub group completing a second KAP survey (n=51). Both caregivers (n=10) and stakeholders (n=14) also completed in-depth qualitative interviews. Using Tanzanian nutrition guidelines, the majority of pediatric cancer patients (60%) were classified as undernourished and 78.4% of caregivers reported being food insecure. Key factors perceived to contribute to poor nutrition included 1) food insecurity; 2) lack of education; and 3) community support was reported as facilitator towards achieving optimal nutrition. Additionally, parents expressed interest in being involved in nutritional education and supplementation programs during treatment. Conclusions: The study addresses a major gap in understanding factors contributing to undernutrition among children with cancer in LMIC and provides strategy targets for future interventions and policies to promote nutrition for pediatric oncology patients in Tanzania.

Background

Methods

Discussion

Trial registration