Browsing by Subject "Qualitative"

This dissertation encompasses three essays which examine the development of obesity in black and white girls and its responses to interventions.

The first chapter asks the question, how does obesity develop in girls? Using the National Growth and Health Study (NGHS), a longitudinal study of 2400 girls from age 9 to age 18, this chapter aims to address gaps in knowledge about the development and persistence of obesity in girls. Analyses using multivariate regression and growth-mixture modeling describe trajectories of body mass change in children and their correlates. Results suggest that obesity in children begins early and persists in most cases--BMI at age 17 is, on average, 1.3 times BMI at age 9. However, change does occur; 0.8 percent of the sample move from being obese at age 9 to healthy weight at age 17, and 2.2 percent of the sample make the reverse journey from healthy weight to obese. Where change occurs, it is most commonly seen among those who socio-demographically were anomalies among their body mass cohort at age 9. These results emphasize the importance of early interventions as well as the need for more study into body mass mutability in population subsamples.

The second chapter investigates 1) what motivates children to pursue weight loss; and 2) what aspects of interventions may most effectively support healthy child motivations and program success. These questions are qualitatively studied among a sample of 45 obese girls aged 9 to 13 girls participating in a behavior modification intervention. In total, 106 interviews were conducted. All of the girls in the study were interested in losing weight, most commonly in order to fit in (n=11), reduce teasing (n=10), or express particular social identities (n=6). However, not all of the girls were able to translate this desire to lose weight into a healthy and effective lifestyle change motivation. Several factors were associated with adopting healthy motivation and behavior, including familial involvement, self-regulation skills, non-social weight desires, realistic weight loss goals, and clear messages about body ideals. Other program protocols also supported motivation during difficult periods for those who adopted healthy motivation, including nutrition information, incentives, lack of physician judgment, and patient autonomy. Finally, two other potential program protocols were mentioned by girls in the study as useful aids. More support services, particularly during the summer, and more information on the expected course of weight loss could, these girls argued, help sustain motivation. Together, these findings suggest a role for self-regulation theory in the design of lifestyle change motivation and for more directly addressing expectations in weight loss treatment.

The third chapter investigates the relationship between self-worth and obesity among girls, again using the National Growth and Health Study. Results indicate a negative relationship between self-worth and obesity across all participants. However, this relationship only has predictive power from early body mass to later self-worth and self-worth trajectories. That is, higher body mass at age 9 predicts lower self-worth at age 17 and decreases in self-worth from age 9 to age 17. The effect is larger for Caucasians and for those in young adolescence but persists across the sample. Mechanisms for this relationship are also investigated, and some support found for stigma. Analyses using self-worth components suggest most of the self-worth effects are driven by social concerns, while mediational analyses suggest social body image pressures explain the relationship between global self-worth and body mass. Overall, the findings suggest a complex interrelation between self-worth and body mass in girls, meriting further investigation as well as a more nuanced discussion in the public realm.

The exposure to chronic interpersonal trauma during developmentally critical periods can have pervasive impacts on social, psychological, biological and cognitive functioning. Interpersonal trauma has been associated with a complex range of risk factors at the individual, family, community, and societal levels. However, little research has focused on the interplay between culture and trauma, especially in low- and middle-income countries. The current study is a qualitative investigation to develop a culturally grounded model of interpersonal trauma in Kenyan adolescents. Fourteen focus groups were conducted in three ethnically diverse communities surrounding Eldoret, Kenya with adolescents ages 12 to 18 (n=67) and caregivers (n=54). Focus Group participants identified community leaders and providers and three additional focus groups were conducted with these key informants (n=28). A grounded theory approach was used for data collection and analysis. A culturally grounded model of interpersonal trauma exploring both exposure and symptomatic presentation is proposed. From this investigation, it is apparent that adolescents who experience chronic interpersonal trauma in these communities experience dysregulation symptoms similar to those described in complex trauma theory. However, poverty, martial conflict, caregiver stress, caregiver substance abuse and favoritism emerged as risk factors for interpersonal trauma and indicate measures and interventions developed for the assessment and treatment of symptoms resulting from interpersonal trauma must be adapted for use in this population.

Abstract

INTRODUCTION

Clergy are a dynamic group of the population: they point people to God, navigate social and spiritual waters, provide advice and guidance, and teach and visit parishioners. Research has shown that caregivers often neglect their health to tend to the health and well-being of others. Because of their unique role in society, the health and well-being of the clergy themselves is an important subject of research. While clergy health is a growing topic of interest in the Western world, very little is known. The few studies conducted on the health of clergy have found that in some areas, this group is less healthy than the general population due to their hectic schedules, lacking social support, and job-related stressors. With the exception of the United States, Canada, and Great Britain, almost nothing has been studied internationally regarding clergy health. In Africa, religion is known to play an important role in the daily life of its inhabitants; however, the overall well-being of clergy including mental, spiritual, and physical health remains under-studied. To date, nothing has been reported regarding the health of pastors in Kenya. This exploratory study sought to better understand how United Methodist Church (UMC) clergy in Western Kenya conceptualize health and how that relates to their health seeking behaviors.

METHODS

This study partnered with religion and public health researchers at Moi University in Eldoret, Kenya, and utilized qualitative methodology to gather information on the conceptualization of health among UMC clergy in Western Kenya. One hour in-depth oral interviews with seven clergy and two Associate District Superintendents and four focus group discussions were conducted with a total of 52 United Methodist Church clergy in Nyanza Province, Kenya in June and July 2012.

ANALYSIS

All transcripts were entered into QSR International's NVivo 10 qualitative data analysis software and coded. Two members of the research team coded an in-depth oral interview and focus group transcription to ensure replicability. A combination of Grounded Theory (GT) analysis and Interpretative Phenomenological Analysis (IPA) was used to interpret the data.

CONCLUSION

UMC clergy define health holistically as the complete well-being of a person in their mind, body, and spirit. Indigenous cultural traditions are still present within the UMC; pastors and parishioners will seek care from a magician rather than a medical doctor if they believe the disease stems from evil spirits. Religious beliefs relate to health seeking behavior in one of two ways: first, clergy believe God alone heals, and thereby view medical seeking behavior as unnecessary and second, clergy believe God alone heals, but view the doctor as a permitted conduit of healing. This knowledge learned from this exploratory study may help inform future interventions.

The family of patients hospitalized in an intensive care unit (ICU) after a neurological event often immediately assume the role of caregiver to an individual with significant health care needs. Family/caregivers act as patient advocates and members of the care team, yet their experiences accompanying neurocritical care patients in Argentina and assuming the caregiving role are not well understood. The purpose of this study is to investigate the experiences of family members/caregivers during the time in which they assume the caregiving role as a means to better understand the relationship between patient, family/caregiver, provider, and health system in the ICU to potentially inform the development of appropriate interventions.

This study explores the use of Bronfenbrenner’s Ecological Systems Theory to ethnographically investigate the perceptions and attitudes of family/caregivers regarding their experience and relationships and interactions between patient, family, provider, and health system after an acute neurological event in Argentina. Study implementation occurred over the course of eleven weeks and included direct observation and semi-structured interviews. The initial two-week direct observation period was used to determine study feasibility and provide contextual understanding. Family/caregiver experience was investigated using 9 qualitative, semi-structured interviews with family/caregivers. Participants were selected using purposive sampling of family/caregivers of patients in a hospital ICU. Family/caregivers were unpaid family members, at least 18 years of age, and self-identified or elected by the family to speak on behalf of the family for the patient admitted to the ICU for an acute neurological event. Direct observation continued throughout the nine weeks of participant identification and interviewing after the initial two-week period to aid the investigator’s comprehensive understanding of patient and family/caregiver experience. Interviews were transcribed verbatim and translated line-by-line from Spanish to English. Iterative thematic analysis using a grounded theory approach was used to code and analyze interview transcripts. Thick description and comparison and categorization of themes were used to identify, explain, and verify patterns and develop broad themes.

Nine themes emerged based on iterative thematic analysis, including: adjusting to a changed life, managing emotions, changing role, relying on faith, redefining recovery, participating in patient care, depending on clinical experts, el trato humano, and finding unity in purpose. Patients, family/caregivers, and medical providers often interact in the ICU. While patients rely upon both providers and family/caregivers for care, family/caregivers also rely upon providers to explain prognosis and next steps, including plans for rehabilitation. Medical providers have the power to affect patient and family/caregiver experience through more than just medical care – family/caregivers perceive and place importance on interactions with providers.

Family members/caregivers form an integral part of the care team. The centrality of the patient to both family/caregiver and provider unites these two groups and emphasizes the need for recognition of the role that family/caregivers play in patient experience as a mediator between provider and patient. Exploration of family/caregiver experience can help improve patient- and family-centered care and mitigate disability and other negative health outcomes through deeper understanding of the needs and concerns of family/caregivers as they support the patient across the care continuum.

Background: Cancer is grossly underreported and underdiagnosed in Africa, as only an estimated 57% of childhood cancers are diagnosed and survival rates for children with cancer are very low; an estimated 20% of children survive cancer in Africa. Several factors can lead to delays in treatment and discontinuing treatment such as lack of knowledge about cancer and negative beliefs or stigma about cancer. The research objective of this paper is to explore the types of stigmas faced by pediatric cancer patients and their families to inform interventions to reduce cancer stigma and increase survival rates of pediatric cancer patients in Tanzania.Methods: The study took place at Bugando Medical Centre (BMC) in Mwanza, Tanzania. The study sample included more than 300 patients who had completed treatment for pediatric cancer at Bugando Cancer Centre. This qualitative study was conducted using structured focus group discussions (FGD) and in-depth interviews (IDI) with patients and caregivers. Data was transcribed and translated into English and NVivo12 was used for qualitative data analysis and coding through an inductive and deductive approach. Results: The main themes of stigma found in both the FGDs and IDIs were severity of condition, avoidance, financial discrimination, beliefs about causes of cancer and stigma due to physical changes. These themes were found among all age groups and were experienced by both caregivers and patients. Conclusions: The results and data gathered from this study illustrate that cancer stigma is still an issue faced by pediatric cancer patients and their families. It also illustrates that, although some aspects of stigma have been described and addressed in the literature through adult stigma studies, there are aspects of stigma for pediatric cancer patients specifically that should be addressed. The data gathered here can be used to develop interventions targeted towards cancer stigma for pediatric populations, to reduce cancer stigma and increase survival rates of pediatric cancer patients in Tanzania.

Background: Outbreaks of infectious diseases such as Ebola have dramatic economic impacts on affected nations due to significant direct costs and indirect costs, as well as increased expenditure by the government to meet the health and security crisis. Despite its dense population, Nigeria was able to contain the outbreak swiftly and was declared Ebola free on 13th October 2014. Although Nigeria’s Ebola containment success was multifaceted, the private sector played a key role in Nigeria’s fight against Ebola. An epidemic of a disease like Ebola, not only consumes health resources but also detrimentally disrupts trade and travel to impact both public and private sector resulting in the ‘fearonomic’ effect of the contagion. In this thesis, I have defined ‘fearonomics’ or the ‘fearonomic effects’ of a disease as the intangible and intangible economic effects of both informed and misinformed aversion behavior exhibited by individuals, organizations, or countries during an outbreak. During an infectious disease outbreak, there is a significant potential for public-private sector collaborations that can help offset some of the government’s cost of controlling the epidemic.

Objective: The main objective of this study is to understand the ‘fearonomics’ of Ebola in Nigeria and to evaluate the role of the key private sector stakeholders in Nigeria’s Ebola response.

Methods: This retrospective qualitative study was conducted in Nigeria and utilizes grounded theory to look across different economic sectors in Nigeria to understand the impact of Ebola on Nigeria’s private sector and how it dealt with the various challenges posed by the disease and its ‘fearonomic effects'.

Results: Due to swift containment of Ebola in Nigeria, the economic impact of the disease was limited especially in comparison to the other Ebola-infected countries such as Liberia, Sierra Leone, and Guinea. However, the 2014 Ebola outbreak had more than a just direct impact on the country’s economy and despite the swift containment, no economic sector was immune to the disease’s fearonomic impact. The potential scale of the fearonomic impact of a disease like Ebola was one of the key motivators for the private sector engagement in the Ebola response.

The private sector in Nigeria played an essential role in facilitating the country’s response to Ebola. The private sector not only provided in-cash donations but significant in-kind support to both the Federal and State governments during the outbreak. Swift establishment of an Ebola Emergency Operation Centre (EEOC) was essential to the country’s response and was greatly facilitated by the private sector, showcasing the crucial role of private sector in the initial phase of an outbreak. The private sector contributed to Nigeria’s fight against Ebola not only by donating material assets but by continuing operations and partaking in knowledge sharing and advocacy. Some sector such as the private health sector, telecom sector, financial sector, oil and gas sector played a unique role in orchestrating the Nigerian Ebola response and were among the first movers during the outbreak.

This paper utilizes the lessons from Nigeria’s containment of Ebola to highlight the potential of public-private partnerships in preparedness, response, and recovery during an outbreak.

Background: Hospital adoption of health information technology (HIT) systems is promoted as essential to decreasing medical error and their associated 44,000 annual deaths and $17 billion in healthcare costs (Institute of Medicine, 2001; Kohn, Corrigan, & Donaldson, 1999). Leading national healthcare groups, such as the Institute of Medicine, Agency for Healthcare Research and Quality, Institute for Healthcare Improvement, and the Leap Frog Group continue to advocate for increased use of HIT (AHRQ, 2010; Beidler, 2010; Institute of Medicine, 2001; Page, 2003; The Leapfrog Group, 2009), such as provider order entry and electronic health record systems, as a way to improve healthcare quality in hospitals. Even under intense pressure to adopt HIT, however, a mere 2% of US hospitals report having a comprehensive electronic health record system. Further, more than 50% of US hospitals have only rudimentary HIT systems (Jha et al., 2009). With the ARRA HITECH Act of 2009, the pressure on hospitals to quickly adopt HIT and achieve meaningful use is mounting.

While a large body of literature exists about HIT implementation, the majority is anecdotal case reports. The remaining studies investigated attitudes about HIT or the impact of HIT on patient care processes and outcomes. Thus, best strategies for implementing HIT in hospitals remain unknown. Study design choices, such as the use of self report data, retrospective data collection methods, subjects from single care units or single healthcare professions further limit our understanding HIT implementation in complex hospital care settings.

Methods: This prospective, longitutdinal case study used a novel approach, sensemaking, to understanding how project teams may work to implement HIT in an academic medical center. Sensemaking, defined as the social process of establishing the meaning of events and experiences (Weick, 1995), is associated with learning and problemsolving in research studies of healthcare and nonhealthcare settings. Through direct observation and document review I observed project team social interaction and activities over the course of the 18 month preimplementation phase of an HIT implementation project in a single tertiary care hopsital.

Conclusions: In this study, I described team actions and activities that enhanced clinician team member sensemaking including: frequent, collective interaction with HIT and focusing team members' attention on specific aspects of HIT function. Further, study findings demonstrated that team members' perceptions of HIT and care processes varied across healthcare professions, management levels, and departments. Supportive social interaction from team leaders and members encouraged team member participation and resulted in members' voicing observations, perceptions and attitudes about the HIT and hospital care processes. Sensemaking of HIT teams not only resulted in identification of needed HIT design changes, but also revealed assumptions and information which may prove critical to successful HIT implementation in hospital care environments. Based on study findings, I suggested strategies for selecting and preparing HIT team members as well as for HIT team activities. This study advanced our understanding of how project teams function and bring about change in complex hospital care environments by not only identifying HIT implementation issues within but also describing the link between team member social interaction and implementation actions.

Political upheaval in Syria makes Jordan a temporary home to over one million Syrian refugees. More than half of these individuals, due to limited resources and challenging financial circumstances, do not have adequate access to reproductive health and family planning mechanisms. Among pregnant refugee women in Jordan, approximately one in five are at risk for poor obstetrical outcomes, including premature and underweight births. Due to increased rates of birth in humanitarian and lower resource settings, and the crucial need for addressing sexual and reproductive health in these settings, this study conducted a comparative analysis of the sexual and reproductive health climate among Syrian refugee and Jordanian men and women.

Using a case study research design, semi-structured qualitative interviews were conducted with 34 study participants, including 15 Syrian women, 8 Jordanian women, 6 Syrian men, and 5 Jordanian men. These interviews examined participants’ migration experiences, pregnancy outcomes, influencers for reproductive decisions, and gaps in sexual and reproductive health care.

Qualitative interviews revealed that Syrian refugees indicated greater reproductive and sexual health need than Jordanians, more specifically related to education on reproductive health and contraceptive methods. Syrian refugees were married at earlier ages than Jordanians, and, overall, had more children. Additionally, Syrian refugees confirmed that healthcare in Syria was more accessible, affordable, and comprehensive in comparison to Jordan. The greatest contributors to gaps in care for both Jordanians and Syrians were financial constraints and apathy regarding refugee welfare among providers in public facilities.

Increasing access to comprehensive sexual and reproductive healthcare among refugees in low-resourced, humanitarian settings, while also continuing to meet the needs of the nation’s own population, is a healthcare priority. The findings of this study have the potential to guide and influence policy affecting family planning mechanisms afforded to migrants in Jordan in both public and private facilities. Action is required immediately by policymakers and government officials to create budgetary resources for sexual and reproductive health education programs in Jordan in order to meet the family planning needs of refugee and migrant populations residing there.

Young Black men in neighborhoods with high levels of poverty and intensive policing have a greater risk of violent death—both at the hands of civilians and police—than any other demographic group in the United States. Yet, there is a dearth of academic research that examines safety and what constitutes legitimate policing from this demographic’s perspective. In this dissertation, I conduct two-hour qualitative interviews of 21 young Black men living in Durham, NC to examine how they assess police and their desired police reforms. Chapters focus on participants’ (1) criteria for judging how well police are doing; (2) ideal attributes of officers well-suited to carry out their vision of policing; and (3) standards for building and maintain trust. I find that participants are principally concerned with the unpredictable nature of policing. Their reforms center on forging a police force that is predictable and reliable, and whose actions reflect a government contract they are owed as American citizens and, more importantly, human beings. Findings enrich our theoretical understanding of what this population believes would need to change to ensure their communities are and feel safe. Each substantive chapter concludes with policy recommendations for police departments and municipal leaders.

Background: Indonesia has a population of over 69 million women of reproductive age and struggles to reduce national maternal mortality rates. The transitioning health system must contend with improving the quality of maternity care. This study aimed to investigate the provision of maternity care from the perspective of two key stakeholders: providers and clients. Methods: We conducted individual, in-depth qualitative interviews with 31 pregnant and postpartum mothers and held two focus group discussions with 10 midwives in a community health center to examine attitudes and perceptions of quality maternity care. We then analyzed data through mapping emergent themes to the WHO QMNC framework. Results: Participants across both groups most frequently referenced interpersonal relationships, more than physical or human resources, as the main determinate to perceptions of quality care. Additionally, socioeconomic, religious and cultural factors also played a significant role in the provision of care; yet, was not fully captured in the definition of quality care. Conclusions: Interpersonal relationships are critical components to the provision of quality care. Investments in further fostering these relationships are important in strengthening the capability of the health system to provide safe, effective and high quality maternity care.