Qualitative Health Research recent issues

Mixing Qualitative Methods

Morse, J. M. — Tue, 20 Oct 2009 16:47:03 PDT

Being There for Another With a Serious Mental Illness

Champlin, B. E. — Tue, 20 Oct 2009 16:47:03 PDT

In this article I describe the unique caring and caretaking relationship between a mentally ill person and the nonprofessional caretaker in his or her life. Stressing the perspective of the caretaker, I call this relationship "being there" for the mentally ill person. I collected the data through in-depth interviews and used a descriptive phenomenological approach to unveil the general structure of the experience. Eight constituents emerged as central to the general structure of this experience: (a) accepting the changed other and grieving the loss of who the other once was; (b) taking action in challenging circumstances; (c) recognizing the ongoing, never-ending, and sometimes unpredictable nature of the experience; (d) feeling isolated; (e) having ambiguity of the heart; (f) experiencing the tension of waiting; (g) knowing the other well; and (h) caring for the other. Knowledge gained from the study findings will help health care professionals understand and support people who are in this experience from a more caring paradigm.

Dignity Violation in Health Care

Jacobson, N. — Tue, 20 Oct 2009 16:47:03 PDT

In this grounded theory analysis I sought to understand dignity violation in health care and to explore the context in which such violations take place. I found that dignity violation in health care occurs through processes of rudeness, indifference, condescension, dismissal, disregard, dependence, intrusion, objectification, restriction, labeling, contempt, discrimination, revulsion, deprivation, assault, and abjection. The conditions that promote these processes reside in the positions of the actors involved; in the asymmetrical relationships between the actors; in the health care setting itself, which is characterized by multiple tensions—including those between needs and resources, crisis and routine, experience and expertise, and rhetoric and reality; and in the embeddedness of health care in a broader social order of inequality. These findings suggest several interventions that might mitigate dignity violation in health care.

Incomprehensibility in the Narratives of Individuals With a Diagnosis of Schizophrenia

Saavedra, J., Cubero, M., Crawford, P. — Tue, 20 Oct 2009 16:47:03 PDT

The fact that individuals with a diagnosis of schizophrenia have difficulties in terms of ordering and communicating their life stories is well known, and undoubtedly these dysfunctions are linked to the experience of alienation and isolation. In this article we contribute to the debate by studying life narratives of ten patients with a diagnosis of paranoid schizophrenia living in care homes in Andalusia, Spain. Patients were selected through meetings held with the directors of the care homes and data obtained from narrative, semistructured interviews. Thematic self-positioning and structure analysis identified four types of clearly distinctive narratives: delusive episodes with invasive voices, delusive episodes with no invasive voices, absence of delusive episodes or invasive voices and domination of self-position as patient, and complexity and articulation of self-positions.

Perspectives of Colorectal Cancer Risk and Screening Among Dominicans and Puerto Ricans: Stigma and Misperceptions

Goldman, R. E., Diaz, J. A., Kim, I. — Tue, 20 Oct 2009 16:47:03 PDT

Colorectal cancer is the second most common cancer among Latinos, but a lower percentage of Latinos are screened than Whites and Blacks. Along with recognized economic barriers, differences in knowledge and perceptions might impede colorectal screening among Latinos. We conducted 147 individual, qualitative interviews with Dominicans and Puerto Ricans in the northeastern United States to explore their explanatory models for colorectal cancer and screening barriers. Many participants had not previously heard of colorectal cancer. The most commonly mentioned cause of colorectal cancer was anal sex. Also considered risks were "bad food," digestion leading to constipation, and strained bowel movements. Screening barriers included stigma, misperceptions, embarrassment, and machismo. Progress toward increasing colorectal cancer screening requires normalization of this screening among Latinos. Higher patient familiarity, along with improved physician counseling and referral, might contribute to reducing stigma and other barriers, and to enhancing knowledge and Latino community support of colorectal cancer screening.

Women's Accounts of Their Decision to Quit Taking Antidepressants

McMullen, L. M., Herman, J. — Tue, 20 Oct 2009 16:47:03 PDT

Over the past 15 years, the rates at which antidepressants are prescribed have increased dramatically. Adherence, however, is often low and considered to be problematic. Using a discursive approach to analyzing interviews with six Canadian women who chose unilaterally to discontinue their use of antidepressants, we focus on three rhetorical strategies used to justify their actions: (a) referencing the actual or potential effects of antidepressants, (b) positioning lay knowledge as superior to expert medical knowledge, and (c) denigrating medical authorities. We argue that these women drew on the responsible-use-of-drugs framework as a way of positioning themselves against potential charges of having engaged in an irrational act.

Experiencing "The Other Side": A Study of Empathy and Empowerment in General Practitioners Who Have Been Patients

Tue, 20 Oct 2009 16:47:03 PDT

Work-related pressures and susceptibility to health problems mean that many general practitioners (GPs) will, at some stage, experience the role of patient. However qualitative evidence about their experiences of illness and patienthood is sparse. Our study offers an interpretative perspective on GPs’ experiences of illness and the influence that this has had on their practice. Seventeen GPs who had experienced significant illness took part in semistructured interviews. Data were analyzed using interpretative phenomenological analysis (IPA). The findings highlight the relationship between empathy and empowerment and explore the role of self-disclosure of GP status by GPs in consultations. We make suggestions as to how empathy in doctor—patient relationships can be developed through consideration of power and status as well as through interaction with patients from similar backgrounds. Future research should focus on more specific ways to integrate these ideas into medical training.

African American Women's Beliefs, Coping Behaviors, and Barriers to Seeking Mental Health Services

Ward, E. C., Clark, L. O., Heidrich, S. — Tue, 20 Oct 2009 16:47:03 PDT

Little is known about African American women’s beliefs about mental illness. In this qualitative study we employed the Common Sense Model (CSM) to examine African American women’s beliefs about mental illness, coping behaviors, barriers to treatment seeking, and variations in beliefs, coping, and barriers associated with aging. Fifteen community-dwelling African American women participated in individual interviews. Dimensional analysis, guided by the CSM, showed that participants believed general, culturally specific, and age-related factors can cause mental illness. They believed mental illness is chronic, with negative health outcomes. Participants endorsed the use of prayer and counseling as coping strategies, but were ambivalent about the use of medications. Treatment-seeking barriers included poor access to care, stigma, and lack of awareness of mental illness. Few age differences were found in beliefs, coping behaviors, and barriers. Practice and research implications are discussed.

Ethical Dilemmas: The Experiences of Israeli Nurses

Shapira-Lishchinsky, O. — Tue, 20 Oct 2009 16:47:03 PDT

In this study I explored ethical dilemmas in nursing to gain a better understanding of nurses’ work and their professional status. Qualitative data on ethical dilemmas were collected by interviewing 52 nurses in 18 hospitals and health maintenance organizations. The transcribed interviews were analyzed using a stepwise method. Results indicate a large number of dilemmas that can be divided into five main categories: caring vs. following formal codes; fair process vs. fair outcome; organizational standards vs. family agenda; autonomy vs. deference to higher authority, and guarding secrecy vs. duty to report. The study findings might enhance nurses’ ability to cope with ethical dilemmas and bring about change in their professional status. In addition, the results might guide nurses and their supervisors toward developing practitioner programs for nurses that deal with ethical aspects. All these might reduce the expected shortage of nurses and improve the ability of the system to provide quality health care.

Recovery From Total Hip Replacement Surgery: "It's Not Just Physical"

Grant, S., St John, W., Patterson, E. — Tue, 20 Oct 2009 16:47:03 PDT

In this grounded theory study we explored the process of recovery following total hip replacement (THR) surgery from the perspective of the older adult. In-depth interviews were conducted with 10 patients aged more than 65 years who had been discharged from hospital for a period of 4 to 6 months following THR surgery. Findings showed that three distinct but interrelated processes constitute the physical, psychological, and social recovery process: reclaiming physical ability, reestablishing roles and relationships, and refocusing self. Intervening conditions affecting the recovery process include comorbid conditions, the personal outlook of the patient, patients’ relationships, and social support. The recovery process can lead to changes in personal and social functioning that patients might not anticipate. Awareness of potential changes will inform patient education and enable clinicians to develop strategies that facilitate THR patients’ return to health.

Positions in Doctors' Questions During Psychiatric Interviews

Ziolkowska, J. — Tue, 20 Oct 2009 16:47:03 PDT

In this article I apply the concept of positioning to the analysis of 15 initial psychiatric interviews. I argue that through their questions the psychiatrists-in-training impose positions requiring the patients to gaze at themselves and their actual problems from particular perspectives. I point to three such positions: (a) the position of the observing assessor, from which it is expected that the patients will make a detached assessment of themselves or their problems, (b) the position of the informing witness, which requires the patients only to verify the information about themselves, and (c) the marginal one, the position of the experiencing narrator, from which talk about experiences and problems is expected. I explore the roots and consequences of the positions, with particular attention toward objectivization of the patients’ experiences in the dominant witness and assessor positions. I conclude with a discussion about the medical model in psychiatry.

Protecting Respondent Confidentiality in Qualitative Research

Kaiser, K. — Tue, 20 Oct 2009 16:47:03 PDT

For qualitative researchers, maintaining respondent confidentiality while presenting rich, detailed accounts of social life presents unique challenges. These challenges are not adequately addressed in the literature on research ethics and research methods. Using an example from a study of breast cancer survivors, I argue that by carefully considering the audience for one’s research and by reenvisioning the informed consent process, qualitative researchers can avoid confidentiality dilemmas that might otherwise lead them not to report rich, detailed data.

Practicing the Awareness of Embodiment in Qualitative Health Research: Methodological Reflections

Sharma, S., Reimer-Kirkham, S., Cochrane, M. — Tue, 20 Oct 2009 16:47:03 PDT

Although the importance of the researcher’s embodiment has been noted in health and social sciences research, in many instances, more attention has been paid to the embodiment of the researched. Thus, more in-depth analysis of the embodied researcher can illuminate qualitative inquiry. The influence of the embodied researcher became visible in a recent critical ethnographic study examining the negotiation of religious, spiritual, and cultural plurality in health care. In this article, we do not present research findings per se, but rather methodological reflections. As researchers, we highlight emotional and bodily ways of knowing and experiences of difference such as culture, race, and religion as embodied and a part of researcher—participant encounters. We aim to elucidate the awareness of being embodied researchers, and with this elucidation, we consider implications for knowledge generation for health and social sciences.

The Case of the Proliferating Paradigms

Coulehan, J. — Mon, 05 Oct 2009 15:29:09 PDT

Patient Real-Time and 12-Month Retrospective Perceptions of Difficult Communications in the Cancer Diagnostic Period

Mon, 05 Oct 2009 15:29:09 PDT

Communication is a notoriously complex challenge in the cancer care context. Our program of research involves exploration of patient—provider communications across the cancer trajectory from the patient perspective.Toward this end, we have been following a cohort of 60 cancer patients, representing a range of tumor sites, from immediately after diagnosis through to recovery, chronic, or advanced disease. Drawing on interpretive description analytic techniques, we documented patterns and themes related to various components of the cancer journey. In this article, we report on findings pertaining to poor communication during the initial diagnostic period, as described by patients at the time of diagnosis and 1 year later.These findings illuminate the dynamics of communication problems during that complex period, and depict the mechanisms by which patients sought to confront these challenges to optimize their cancer care experience. On the basis of these findings, considered in the context of the body of available evidence, suggestions are proposed as to appropriate directions for system-level solutions to the complex communication challenges within cancer care.

Accounts of HIV Seroconversion Among Substance-Using Gay and Bisexual Men

Aguinaldo, J. P., Myers, T., Ryder, K., Haubrich, D. J., Calzavara, L. — Mon, 05 Oct 2009 15:29:09 PDT

Statistical associations between substance use and seroconversion among gay and bisexual men abound. However, these associations often ignore men’s own interpretations of their seroconversion. Using in-depth interviews with gay and bisexual men who reported using drugs or alcohol at the time of their seroconversion, we identify how these men explain the events that led to HIV transmission. Whereas a small minority of respondents reported substance use to explain their seroconversion, the majority reported three competing explanations. These participants claimed that they lacked sufficient knowledge about the behavioral risks that led to their seroconversion; that their decision to engage in unsafe sex was because of negative personal affect; and that they "trusted the wrong person." We link these findings to prevention and suggest that gay and bisexual men who use substances for recreational purposes will benefit from prevention efforts designed to address issues of gay and bisexual men rather than substance-using men.

Experiencing Out-of-Hospital Cardiac Arrest: Significant Others' Lifeworld Perspective

Bremer, A., Dahlberg, K., Sandman, L. — Mon, 05 Oct 2009 15:29:09 PDT

When patients suffer out-of-hospital cardiac arrests (OHCA), significant others find themselves with no choice about being there. After the event they are often left with unanswered questions about the life-threatening circumstances, or the patient’s death, or emergency treatment and future needs. When it is unclear how the care and the event itself will affect significant others’ well-being, prehospital emergency personnel face ethical decisions. In this article we describe the experiences of significant others present at OHCA, focusing on ethical aspects and values. Using a lifeworld phenomenological approach, 7 significant others were interviewed. The essence of the phenomenon of OHCA can be stated as unreality in the reality, which is characterized by overwhelming responsibility. The significant others experience inadequacy and limitation, they move between hope and hopelessness, and they struggle with ethical considerations and an insecurity about the future.The study findings show how significant others’ sense of an OHCA situation, when life is trembling, can threaten values deemed important for a good life.

Relationships Between Humor, Subversion, and Genuine Connection Among Persons With Severe Mental Illness

Kidd, S. A., Miller, R., Boyd, G. M., Cardena, I. — Mon, 05 Oct 2009 15:29:09 PDT

Although humor has been linked to resilience among many populations, little is known regarding the role of humor in the coping of individuals with severe mental illness (SMI). In this study, a series of interviews focused on humor was completed by 15 individuals with SMI, with narratives analyzed using grounded theory methods.The marginalized and stigmatized social position occupied by persons with SMI was found to affect both the use and meanings of humor. Humor was described as being the subject of clinical scrutiny. Humor was also emphasized as a means of subverting power differentials revolving around the identity of SMI with, for many, the primary goal being the development of "real" and genuine connections with service providers.

Family Presence During Resuscitation and Invasive Procedures: The Nurse Experience

Miller, J. H., Stiles, A. — Mon, 05 Oct 2009 15:29:09 PDT

The purpose of this study was to understand the experiences of nurses who participate with families during resuscitation and invasive procedures in the hospital. Seventeen nurses in a large metropolitan area in the northeastern United States were interviewed about their thoughts and feelings about participating with families during these procedures. Conversations were audiotaped and transcribed verbatim for analysis. Transcripts were analyzed using van Manen’s technique of isolating thematic statements. Four main themes were identified from the data: forging a connection, engaging the family, transition to acceptance, and a cautious approach.The experience of participating in family presence during resuscitation or invasive procedures can be a positive experience for the nurse by forging a connection with family.The experience for the nurse might include a transition to acceptance and a committed change in practice.

"I've Never Not Had it So I Don't Really Know What it's Like Not to": Nondifference and Biographical Disruption Among Children and Young People With Cystic Fibrosis

Williams, B., Corlett, J., Dowell, J. S., Coyle, J., Mukhopadhyay, S. — Mon, 05 Oct 2009 15:29:09 PDT

The relevance of biographical disruption and loss of self for children and young people is unclear, particularly in cases of congenital illness such as cystic fibrosis, where no prior period of wellness, stability, or perceived normality might exist. We explored the meaning, importance, and forms of maintenance of ideas of normality among 32 children and young people with cystic fibrosis. We examine the ways in which normalcy is produced, maintained, and threatened, and discuss the implications for the applicability and relevance of these traditional sociological concepts. Analysis of children’s and young people’s accounts resulted in a conceptualization of four forms of normalcy based on personal and social definitions and audiences. Biographical disruption appeared relevant but in a more nuanced form than its usual conceptualization when applied to adult populations. Maintaining normality within the family resulted in continual biographical revision in anticipation of future illness trajectory and life course.

From Trauma to PTSD: Beliefs About Sensations, Symptoms, and Mental Illness

Mon, 05 Oct 2009 15:29:09 PDT

Despite the ongoing debate about its legitimacy as a diagnostic entity, posttraumatic stress disorder (PTSD) continues to be the prevailing model for posttrauma suffering in Western societies. In this article, we examine how U.S. veterans came to conceptualize their posttrauma suffering as reflecting the mental disorder of PTSD. We describe the criteria veterans used to evaluate the potential clinical importance of their posttrauma reactions, and the process by which they came to label these reactions as PTSD. Difficulties that veterans experienced in evaluating their posttrauma reactions and in labeling them as PTSD mirror issues that have been raised about the diagnosis of PTSD in the professional literature.

Navigating Between Illness Paradigms: Treatment Seeking by Samoan People in Samoa and New Zealand

Norris, P., Fa'alau, F., Va'ai, C., Churchward, M., Arroll, B. — Mon, 05 Oct 2009 15:29:09 PDT

There are substantial Samoan communities in New Zealand. Most Samoan people use both palagi (Western) and traditional Samoan health care. Western practitioners sometimes comment on Samoan patients’ seemingly erratic patterns of seeking and using health care. Within a larger study on knowledge and the use of antibiotics, we carried out semistructured interviews with 31 Samoan people in Samoa and New Zealand.Accounts of participants’ responses to illness and patterns of treatment seeking reveal how Samoan people draw on traditional and Western models of treatment and healing resources. Samoan people are very active interpreters of illness symptoms, using (at least) the two illness paradigms they know of to make sense of symptoms.These paradigms and systems of treatment are sometimes used experimentally, to determine whether illnesses are Samoan or Western. Symptom interpretation and decision making about treatment are done at the family level as well as the individual level. The individual might hold a particular view of what symptoms mean and what to do about them, but might not act on this if overruled or persuaded by other family members.

"Making it All Normal": The Role of the Internet in Problematic Pregnancy

Lowe, P., Powell, J., Griffiths, F., Thorogood, M., Locock, L. — Mon, 05 Oct 2009 15:29:09 PDT

Women are actively encouraged to educate themselves about pregnancy from formal sources (e.g., information leaflets, antenatal classes, books). In addition, informal stories of pregnancy and birth are routinely told between women. However, increased prenatal testing means that more fetuses are diagnosed with abnormalities, shifting the information requirements during pregnancy. Traditional sources of information cannot cover all possible outcomes, and the Internet is beginning to fill this gap. In this article, we draw from interviews about experiences of antenatal screening and pregnancy to explore how the Internet provides a unique resource for problematic pregnancies. It allows access to information about rarer conditions beyond standard pregnancy texts, as well as personal narratives about conditions. Learning how others have coped or are coping in similar situations can help alleviate feelings of isolation, and also places women back in a familiar territory of shared pregnancy narratives.

Adjusting to Life After Esophagectomy: The Experience of Survivors and Carers

McCorry, N. K., Dempster, M., Clarke, C., Doyle, R. — Mon, 05 Oct 2009 15:29:09 PDT

Following surgery for esophageal cancer, patients can experience complex physical, social, and emotional changes. Investigation of these challenges, particularly from the perspective of the patient and his or her carer, has been limited. The current study explored the emotional and cognitive experiences of esophageal cancer survivors and those of their carers, using focus groups conducted with members of a patient support group. Analysis of the patients’ data yielded three themes: coping with a death sentence, adjusting to and accepting an altered self, and the unique benefits of peer support. Analysis of the carers’ data also yielded three themes: the carer as buffer, representations of recovery and recurrence, and normalizing experiences through peer support. Esophageal cancer patients and their carers require holistic support in their efforts to adjust to the social, emotional, and physical consequences of esophagectomy. Peers could be an effective channel for the support of patients and carers.

Understanding the Ecological Validity of Neuropsychological Testing Using an Ethnographic Approach

Gioia, D. — Mon, 05 Oct 2009 15:29:09 PDT

Neurocognitive impairment is a defining and disabling feature of schizophrenia and other physical disorders. Most of our understanding about neurocognitive deficits comes from laboratory-based testing in research protocols. There has been little research using direct behavioral community observation over a prolonged period to understand the association of daily functioning with cognitive performance.The purpose of this study was to develop an observational method that could be replicated by researchers interested in viewing cognitive deficits in vivo, and then comparing this data to laboratory measures to affirm the ecological validity of those measures.The eight-step method explained here was developed from the targeted ethnographic study of 10 persons with schizophrenia. Obtaining real world context with this method will help to increase the generalizability of effective cognitive treatments, create improved interventions for this population, and bring into greater relief the coping and compensatory strategies already used by individuals to complete daily tasks.

Toward an Agenda for Evaluation of Qualitative Research

Stige, B., Malterud, K., Midtgarden, T. — Mon, 05 Oct 2009 15:29:09 PDT

Evaluation is essential for research quality and development, but the diversity of traditions that characterize qualitative research suggests that general checklists or shared criteria for evaluation are problematic. We propose an approach to research evaluation that encourages reflexive dialogue through use of an evaluation agenda. In proposing an evaluation agenda we shift attention from rule-based judgment to reflexive dialogue. Unlike criteria, an agenda may embrace pluralism, and does not request consensus on ontological, epistemological, and methodological issues, only consensus on what themes warrant discussion. We suggest an evaluation agenda—EPICURE—with two dimensions communicated through use of two acronyms.The first, EPIC, refers to the challenge of producing rich and substantive accounts based on engagement, processing, interpretation, and (self-)critique. The second—CURE—refers to the challenge of dealing with preconditions and consequences of research, with a focus on (social) critique, usefulness, relevance, and ethics. The seven items of the composite agenda EPICURE are presented and exemplified. Features and implications of the agenda approach to research evaluation are then discussed.

Is the Story Enough?

Thorne, S. E. — Tue, 18 Aug 2009 11:41:50 PDT

The Significance of Social Engagement in Relocated Older Adults

Dupuis-Blanchard, S., Neufeld, A., Strang, V. R. — Tue, 18 Aug 2009 11:41:50 PDT

Social networks and social support are recognized as important determinants of health. Relocation is a common transition in older adults’ lives that can disrupt existing social networks and challenge seniors to reconstitute these networks. Social engagement is a required component of the process of reconstituting social relationships and of feeling connected. The purpose of this focused ethnographic study was to develop an understanding of the experience of social engagement in relocated residents of a senior-designated apartment building. Data generation included interviews with 19 older adults. Transcribed interviews were analyzed using thematic analysis. Seniors developed four types of relationships for provision of feelings of security, casual interactions, opportunity to be supportive, and friendship. The findings of this research provide a better understanding of the relationships seniors developed in a new community as a result of the process of social engagement.

Hooking Up and Sexual Risk Taking Among College Students: A Health Belief Model Perspective

Downing-Matibag, T. M., Geisinger, B. — Tue, 18 Aug 2009 11:41:50 PDT

"Hooking up" with friends, strangers, and acquaintances is a popular way for college students to experience sexual intimacy without investing in relationships. Because hooking up often occurs in situations in which prophylactics against sexually transmitted infections (STIs) are not available or in which students’ judgment is impaired, it can involve risky behaviors that compromise student health. As such, in-depth studies of the factors related to sexual risk taking during hookups are needed, to advance preventive research and programming. Based on semistructured interviews with 71 college students about their hooking-up experiences, the findings of this study demonstrate that the Health Belief Model can serve as a useful framework for understanding sexual risk taking during hooking up, and offers suggestions for sexual risk-prevention programs on college campuses. The results demonstrate why students’ assessments of their own and their peers’ susceptibility to STIs are often misinformed. The findings also show how situational characteristics, such as spontaneity, undermine students’ sexual self-efficacy.

Pubertal Development in Mexican American Girls: The Family's Perspective

Thelus Jean, R., Bondy, M. L., Wilkinson, A. V., Forman, M. R. — Tue, 18 Aug 2009 11:41:50 PDT

Mexican American (MA) girls are entering puberty earlier than in the past, yet few studies have explored the perceptions surrounding puberty among this group. We conducted separate focus groups for fathers, mothers, and daughters aged 6 to 12 years to explore perceptions of body image, pubertal development, communications, and sources of puberty-related information in MA participants. Our results revealed parental concerns about daughters’ weight and pubertal development, as well as differences in their communication with their daughters. Although both parents willingly discussed pubertal issues concerning their daughters, mothers had a more active role in conveying pubertal information to daughters. Among the girls, there was a gap in knowledge about the pubertal process between the younger and older girls. Our findings present opportunities and challenges for addressing obesity as a pubertal risk factor in MA girls; however, more studies are needed to understand family beliefs and sociocultural dynamics surrounding puberty in MAs.

Competing Motivational Discourses for Weight Loss: Means to Ends and the Nexus of Beauty and Health

Kwan, S. — Tue, 18 Aug 2009 11:41:50 PDT

Western cultural discourses generally deem fat unhealthy and unattractive, providing strong motivation for body nonconformists to lose weight. Semistructured interviews with 42 overweight and obese participants illuminate how individuals understand health and beauty weight-loss motivations and the relationship between the two. Interviews indicate that health and beauty motivate because they are seen as means to various ends. Specifically, participants aspire to health to fulfill various social roles and to live long, meaningful lives. Moreover, they aspire to conventional beauty ideals hoping that aesthetic conformity will elicit benefits, both psychological and social. Interviews also illustrate an intertwining of discourses in which participants conflate beauty and health in three ways: indicating that depictions of the beauty ideal are depictions of the health ideal; using beauty indicators as health indicators; and employing beauty as a motivator for health goals. This article concludes with a discussion of the health, social, and policy implications of these findings.

"Overeating is Not About the Food": Women Describe Their Experience of a Yoga Treatment Program for Binge Eating

McIver, S., McGartland, M., O'Halloran, P. — Tue, 18 Aug 2009 11:41:50 PDT

As part of a larger mixed-methods study, data from 20 personal journals were analyzed to examine the experience of a 12-week yoga treatment program for binge eating among a sample of 25 women who were obese. Qualitative analysis revealed a positive shift experienced by the women during the program, summarized by a general structural description: disconnection versus connection. Women’s comments suggested that the program appeared to encourage a healthy reconnection to food, as well as the development of physical self-empowerment, through cultivating present-moment awareness. Specifically, women perceived an overall reduction in the quantity of food they consumed, decreased eating speed, and an improvement in food choices throughout the program. The women also reported feeling more connected to and positive about their physical well-being. These evolving outcomes were summarized through two major themes: the way their physicality changed, and the way their food consumption changed over time. Findings provide insights relevant to therapeutic processes that might occur within eating disorder interventions that draw on meditation-based approaches.

Professional Satisfaction and Dissatisfaction Among Fiji Specialist Trainees: What Are the Implications for Preventing Migration?

Oman, K. M., Moulds, R., Usher, K. — Tue, 18 Aug 2009 11:41:50 PDT

The migration of doctors from developing countries threatens the health status of the populations left behind. This qualitative study was conducted to explore why an unexpected number of Fiji specialist trainees left the public sector, often to migrate, using a lens of professional satisfaction. Forty seven Fiji doctors, including 36 of 66 who undertook specialist training in Fiji, were interviewed about the factors that led to their own professional satisfaction and dissatisfaction. Three major components of professional satisfaction emerged: professional growth, service, and recognition, with considerable overlap between categories. The aspects of professional dissatisfaction were more varied but could be categorized as the absence or blocking of the elements of professional satisfaction. From the interviews, a professional satisfaction model was developed featuring the three overlapping central elements of satisfaction on a background of an enabling health system. This model might have implications for health systems seeking to retain their workers.

Health Materials and Strategies for the Prevention of Immigrants' Weight-Related Problems

Ferrari, M., Tweed, S., Anneke Rummens, J., Skinner, H. A., McVey, G. — Tue, 18 Aug 2009 11:41:50 PDT

Existing health education materials dealing with healthy eating, active living, and body image were examined by immigrant parents of elementary school children to determine their relevance, cultural competence, and accessibility. A total of 13 immigrant mothers from Sri Lanka and China participated in a series of three focus groups. Study findings indicate that the present health education materials intended to help prevent weight-related problems could be improved to better meet the needs of new immigrant families. Immigrant mothers who participated in the study expressed their preferences for health education materials and prevention interventions undertaken in a culturally relevant/competent, knowledge-sharing, participatory manner. Acting on these suggestions could help practitioners and public health agencies develop more effective strategies that meet the requirements of ethno-cultural immigrant communities.

Using Narratives to Understand Older People's Decision-Making Processes

Tetley, J., Grant, G., Davies, S. — Tue, 18 Aug 2009 11:41:50 PDT

Despite the availability of health and social care services designed to support people in their own homes, older people often underuse or refuse these services. It is now acknowledged that this phenomenon contributes to older people being admitted to hospital and long-term care in circumstances that could be avoided. To understand how the uptake of supportive and preventative services can be improved, the first author, supervised by the second and third authors, developed a constructivist inquiry to explore what factors enhance or bar service use. This article describes how narratives were used not only to help identify decision- and choice-making influences, but also as a way of enhancing the hermeneutic processes associated with constructivism.

Strengths and Challenges in the Use of Interpretive Description: Reflections Arising From a Study of the Moral Experience of Health Professionals in Humanitarian Work

Hunt, M. R. — Tue, 18 Aug 2009 11:41:50 PDT

Interpretive description is a qualitative research methodology aligned with a constructivist and naturalistic orientation to inquiry. The aim of interpretive description, a relatively new qualitative methodology, is to generate knowledge relevant for the clinical context of applied health disciplines. To date there has been little discussion in the literature of the particular merits and limitations of this methodological framework. In this article I draw on my experience of using interpretive description as methodology for an inquiry into the moral experience of clinicians in humanitarian work. I identify and discuss strengths and challenges that can arise in the application of interpretive description. Strengths identified include a coherent logic and structure, an orientation toward the generation of practice-relevant findings, and attention to disciplinary biases and commitments. Challenges include limited resources for situating the methodology, challenges in employing a lesser-known methodology, and uncertainty regarding the degree of interpretation to seek.

Participatory Action Research: Practical Strategies for Actively Engaging and Maintaining Participation in Immigrant and Refugee Communities

van der Velde, J., Williamson, D. L., Ogilvie, L. D. — Tue, 18 Aug 2009 11:41:50 PDT

In this research we examined the processes involved in implementing and maintaining a participatory action research (PAR) project by uncovering how theoretical PAR tenets hold up in the reality of a community-based project addressing immigrants’ and refugees’ mental health needs. Qualitative data from focus groups with these newcomers were analyzed for thematic content. Findings reveal that active participation is seen as the gateway into a PAR project, whereas knowledge attainment and empowerment are the stimuli for continued participation. The data also suggest that newcomers’ motivations to participate in a PAR-oriented project might vary across ethno-cultural groups. Practitioners working in community-based initiatives would do well to appeal to the diversity of motivational factors, while endorsing individual and group strengths.

A Cooperative Inquiry Into Action Learning and Praxis Development in a Community Nursing Module

Jenkins, E. R., Mabbett, G. M., Surridge, A. G., Warring, J., Gwynn, E. D. — Tue, 18 Aug 2009 11:41:50 PDT

As nurse lecturers we investigated practice development and action learning approaches aimed at enabling postregistration bachelor’s- and master’s-level nursing students (Community Health Studies, Nursing in the Home) to advance practice in the context of policy and professional developments. A patchwork text was used to assess summatively what students achieved (practice change/development) and how this was informed critically, via an extended epistemology. First-person inquiry supplemented by cooperative inquiry postcourse completion (including reflective discussions with 16 students and 16 practice mentors) were used to assist coresearcher constructions of meaning. A relational, tripartite approach to learning and assessment (students’, teachers’, and practice mentors’ collective contributions) depends on continuing reflective attention. Action learning enhances interrelation of experience with dialectic thinking. The patchwork text functions to promote creative writing, evaluative thinking, and praxis development. Role modeling by all, being genuine and not just "talking" genuine, is challenging yet crucial if people are to function as mutual resources for learning.

The Lived Experience of Hepatitis C and its Treatment Among Injecting Drug Users: Qualitative Synthesis

Treloar, C., Rhodes, T. — Tue, 18 Aug 2009 11:41:50 PDT

Hepatitis C virus infection is a stigmatized condition because of its close association with injecting drug use. There is a need to explore how people who inject drugs (IDUs) perceive hepatitis C, including in relation to treatment experience. We undertook a review, using a qualitative synthesis approach, of English-language qualitative research focusing on the lived experience of hepatitis C among IDUs. The review included 25 published articles representing 20 unique studies. A synthesis of this literature generated three interplaying themes: social stigma, biographical adaptation, and medical and treatment encounters. Interactions with health systems can reproduce stigma linked to drug injecting and hepatitis C, as well as trivialize the lived experience of diagnosis and illness. Hepatitis C can be biographically reinforcing of socially accommodated risk and spoiled identity, as well as disruptive to everyday life. We hypothesize hepatitis C as a liminal illness experience, oscillating between trivial and serious, normalized and stigmatized, public and personal. We conclude by emphasizing the disconnects between the lived experience of hepatitis C among IDUs and Western health care system responses.

Data Expressions or Expressing Data

Morse, J. M., Coulehan, J., Thorne, S., Bottorff, J. L., Cheek, J., Kuzel, A. J. — Tue, 28 Jul 2009 13:43:16 PDT

Mind and Body Management Strategies for Chronic Pain and Rheumatoid Arthritis

Shariff, F., Carter, J., Dow, C., Polley, M., Salinas, M., Ridge, D. — Tue, 28 Jul 2009 13:43:16 PDT

Chronic pain (CP) and rheumatoid arthritis (RA) pose particular challenges for the individual. Although biomedicine inevitably plays a role in the reduction or control of some symptoms for people living with chronic pain, directed self-management is also increasingly recognized as an important tool. Self-management can address pain-associated symptoms of CP and RA, and often has broader aims, such as promoting positive well-being. Forty-six interviews with people experiencing CP and 46 interviews with those living with RA-associated pain were analyzed. Our analysis uncovered three broad strategies adopted by participants: body management, mind-management and mindbody management. The analysis demonstrated that for those living with pain, a sense of well-being is achieved not through pain control alone, but also through various mind/body techniques for managing pain, accepting new limits, and adjusting the way people relate to themselves. These self-management strategies are an important adjunct to biomedical care for those experiencing chronic pain.

Intuition, Subjectivity, and Le Bricoleur: Cancer Patients' Accounts of Negotiating a Plurality of Therapeutic Options

Broom, A. — Tue, 28 Jul 2009 13:43:16 PDT

Cancer patients are now combining complementary and alternative medicine (CAM) with biomedical cancer treatments, reflecting an increasingly pluralistic health care environment. However, there has been little research done on the ways in which cancer patients juggle multiplicity in claims to expertise, models of disease, and therapeutic practice. Drawing on the accounts of cancer patients who use CAM, in this article I develop a conceptualization of therapeutic decision making, utilizing the notion of bricolage as a key point of departure. The patient accounts illustrate the "piecing together" (or bricolage) of therapeutic trajectories, drawing on intuitive, embodied knowledge, as well as formalized "objective" scientific expertise. Le bricoleur, as characterized here, actively mediates, rather than accepts or rejects CAM or biomedicine, and utilizes a combination of scientific expertise, embodied physicality, and social knowledge to make decisions and assess therapeutic effectiveness. Although these "border crossings" are potentially subversive of established biomedical expertise, the analysis also illustrates the structural constraints (and penalties) associated with bricolage, and furthermore, the interplay of a repositioning of responsibility with neoliberal forms of self-governance.

Coping With HIV: Caribbean People in the United Kingdom

Anderson, M., Elam, G., Solarin, I., Gerver, S., Fenton, K., Easterbrook, P. — Tue, 28 Jul 2009 13:43:16 PDT

Although Caribbean people in the United Kingdom are increasingly being affected by HIV/AIDS, there has been no examination of how they are coping with the illness. We investigate the coping strategies of HIV-positive Caribbean people using in-depth interviews with a purposively selected group of 25 residents of South London. The main coping strategies were more cognitive than behavioral: restricted disclosure, submersion, faith, and positive reappraisal. These strategies were intertwined in complex ways, and most were rooted in contextual factors, particularly cultural ones. Themes of loss, silence, and reinvention suffused respondents' narratives. Interventions should consider the high degree of stigmatization of HIV/AIDS in the Caribbean community, reluctance to disclose, the likelihood of an initial severe reaction to diagnosis, and external stressors. HIV-positive Caribbean people who are coping well could serve as mentors and role models for poor copers and newly diagnosed patients; establishing Caribbean-specific support groups might also assist coping.

Making New Meanings of Being in the World After Treatment for Oral Cancer

Roing, M., Hirsch, J.-M., Holmstrom, I., Schuster, M. — Tue, 28 Jul 2009 13:43:16 PDT

When the mouth is affected by cancer, difficulties in satisfying basic human needs such as eating, tasting, swallowing, and speaking might arise, and the existential significance of the mouth might become obvious. How does it feel to live with these difficulties? What does it mean to be a human being living with the consequences of oral cancer? Five patients with oral cancer were interviewed a median time of 4 years after the beginning of treatment. A hermeneutic research approach was used to understand, explain, and interpret the transcribed interviews and showed how the consequences of oral cancer affected the being-in-the-world of the participants in three ways: existing as oneself, existing in the eyes of others, and existing with others. Against the background of the philosophy of Martin Heidegger, these findings illuminate how essential the mouth is to a human being's identity and existence.

Examining the Meaning Attached to Mental Illness and Mental Health Services Among Justice System-Involved Youth and Their Parents

Watson, A. C., Kelly, B. L., Vidalon, T. M. — Tue, 28 Jul 2009 13:43:16 PDT

A large percentage of youth involved in the juvenile justice system experience mental health problems, yet many do not receive mental health care. In this study, we used a process-focused framework of mental health decision making to gain insight into the use of mental health services among these youth. In-depth interviews were conducted with nine youth and nine parents participating in a program servicing youth with mental health problems who have been in detention. Themes related to problem recognition, the decision to seek and participate in services, subjective norms, and juvenile justice system involvement emerged. Most families acknowledged their youth was having problems, but few defined those problems in mental health terms. This did not prevent them from seeking services, although some were not able to access adequate services until the justice system became involved. Participants were aware of negative attitudes about mental illness, and might have limited their social networks to shield themselves.

Hospitalization for Type 2 Diabetes: The Effects of the Suspension of Reality on Patients' Subsequent Management of Their Condition

Balcou-Debussche, M., Debussche, X. — Tue, 28 Jul 2009 13:43:16 PDT

Hospitalization still plays a major part in the management of uncontrolled type 2 diabetes and its complications. In this article, we assess the effects of self-management education on the individual practices of 42 patients after discharge from specialized diabetes units on the French island of Reunion. Hospitalization offers respite and temporarily suspends the realities of daily life. When patients leave the unit where they have acquired new knowledge and practices, the extent to which the latter can be maintained depends on the practice in question, the individual's circumstances, and his or her social relationships and support systems. In the longer term, therefore, the effects of self-management education interventions can be weak. The study findings reveal the complexities surrounding the acquisition of habits that maintain health and prevent illness. The article makes a significant contribution to the debate on patient support and the role of inpatient educational units.

Making Sense of Living Under the Shadow of Death: Adjusting to a Recurrent Breast Cancer Illness

Kenne Sarenmalm, E., Thoren-Jonsson, A.-L., Gaston-Johansson, F., Ohlen, J. — Tue, 28 Jul 2009 13:43:16 PDT

Women with recurrent breast cancer face many difficulties and challenges, from clinical symptoms of disease progression and treatment to a range of emotional responses. Guided by grounded theory methodology, we explored the main concerns of women with recurrent breast cancer, and how they were dealing with their situations. Data were collected from 40 in-depth interviews with 20 women diagnosed with recurrent breast cancer. The core category illustrated the process of "making sense of living under the shadow of death," and was based on the women's experiences of adjusting to living with a persistent life-threatening illness. Confronting a recurrence of breast cancer was a life-altering event. Moving through a difficult and challenging time, women eased their distress by letting go of losses and reassessing important values. Through a personal transition women transcended living with a life-threatening illness. These findings emphasize the importance of recognizing existential distress in clinical practice.

The Experience of Kidney Graft Failure: Patients' Perspectives

Ouellette, A., Achille, M., Paquet, M. — Tue, 28 Jul 2009 13:43:16 PDT

In this article we describe the phenomenon of kidney graft failure from the unique perspective of patients. Fifteen patients took part in semistructured interviews. We analyzed interviews using interpretative phenomenological analysis. The content analysis yielded five main emergent themes: life disruption, suffering, meaning making, resistance/acceptance, and social comparison. These results are discussed within the theoretical framework of psychosocial transition put forward by Parkes. A comprehensive description of the experience of kidney graft failure emerging from the patients' perspectives can provide a better understanding of the psychosocial aspects— not only the body aspects—of the phenomenon. It can help health care professionals better address patients' suffering, which is experienced by a person as a whole, and to offer support that promotes adaptation to kidney graft failure.

Experiencing Cancer in Old Age: A Qualitative Systematic Review

Hughes, N., Closs, S. J., Clark, D. — Tue, 28 Jul 2009 13:43:16 PDT

Our purpose in this study was to find, report, and interpret the results of qualitative studies which investigated the experiences of older people living with cancer. We conducted systematic literature searches, identified and extracted the findings from 11 studies, and analyzed them systematically. We interpreted the findings to suggest that living with cancer in old age is to live in a perpetual state of ambiguity. The experience is characterized by a sense of disintegration, diminished identity, suffering, and social retraction. These experiences are balanced by sources of comfort and strength found within the self and among diverse relationships. The results of our study illuminate the complex, multidimensional character of living with cancer in old age. They show that older people living with cancer are resilient as well as vulnerable. We argue for changes in attitudes and behavior that will enable health care professionals to foster older peoples' resilience.

Studying Narrative-in-Action in Women With Chronic Rheumatic Conditions

Alsaker, S., Bongaardt, R., Josephsson, S. — Tue, 28 Jul 2009 13:43:16 PDT

In this article we aim to sculpt a possible methodology for studying how a good everyday life comes about when living with chronic rheumatic conditions (CRC). Our "how" focus acknowledges a woman with CRC as one member of a diverse population, whereby we question the biomedically based view that she differs from the population. The more frequently asked "what" question colors study designs and results in categories and characteristics regarding what she is able to do and what adaptations she has made in everyday life as a consequence of her disease. Adopting a narrative approach, we ask how a good everyday life comes about, and illustrate this with ethnographic material of the everyday activities of women living with CRC. We conceptualize narrative as embedded in the process of enacting activities. Furthermore, we highlight hermeneutical interpretative processes of how meaning works in the stream of everyday action.

Turning Adolescents Into Analysts of Their Own Discourse: Raising Reflexive Awareness of Everyday Talk to Develop Peer-Based Health Activities

Lamerichs, J., Koelen, M., te Molder, H. — Tue, 28 Jul 2009 13:43:16 PDT

Adopting principles applied in discursive psychology and translated to suit the practice of participatory health education, we describe in this article the five steps of the discursive action method (DAM). With this method, adolescents are stimulated to explore their own everyday conversations to become consciously aware of how they talk about health issues with their peers. Using detailed accounts of adolescents' experiences with the method, we present some first indications of the kinds of results this method can achieve. We show that the strength of the method specifically lies in two closely related domains: (a) stimulating adolescents' attentiveness to interactional problems and strategies as they occur in their own everyday talk, and (b) operating as a catalyst for developing participatory health activities aimed at peers.