Abstract
Abstracts, Oral Presentations: Listed alphabetically by first author
Health Communication Experiences in an Arab Community in British Columbia
Hana Al-Banay
University of British Columbia
This study examines the intercultural barriers Arab immigrants encounter when they access the Canadian health system. It was based on 25 individual interviews with Arab immigrants residing in Victoria, British Columbia. Participants were selected by snowball sampling from the Greater Victoria Arab community. Thematic analysis was used to identify four themes from the interview data: the basic philosophy underlying the Canadian health system, gender sensitivity issues, social support networks, and trust between Arab patients and Canadian doctors. The theoretical background of the analyzed data was underlined by the theory of a culture-centered approach. This egalitarian approach enhanced its rigor in this study by allowing the participants to provide suggestions for improving the level of cultural sensitivity in the health care system.
Dental Health Needs of New Immigrant and Refugee Children
Maryam Amin
University of Alberta
Children of immigrant and refugees have higher rates of dental decay and lower rates of dental visits than Canadian-born children. A community-based participatory study has been conducted in collaboration with Multicultural Health Brokers Co-operative and Alberta Employment and Immigration to explore the dental health needs of refugee and new immigrant preschoolers and to identify the barriers to access to dental care services experienced by their families. The feasibility of developing and implementing a community participatory oral health promotion program was explored in focus group interviews with 22 health brokers from 13 refugee and new immigrant communities. The interviews were recorded, transcribed, and analyzed. Health brokers were concerned about high levels of need for dental health care in their communities and perceived the currently available services inadequate. They believed that dental care is a low priority for most refugee and new immigrant families when they are struggling with their basic needs. Although the cost of dental care was predominantly identified as the most significant barrier, English language skills, transportation, parents' time constraints, and lack of knowledge about existing services were also identified as important by brokers. Additional barriers indentified for refugee families included low literacy skills in their original language, number of children in a family, and reluctance of dentists to visit refugee children. Increasing government funding for dental services for refugee and new immigrant children, enhancement of interpreter services, and development of more community-based oral health promotion programs were recommended. The information derived from this phase of the study will be used as part of a needs assessment for an oral health promotion program to promote children's oral health in high-risk populations.
Family Care as Borderless and Timeless Mini-Multi-Cultures
Cynthia Lee Andruske
University of Houston Clear Lake
Deborah O'Connor
Centre for Research on Personhood in Dementia
Daniel W. L. Lai
Despite Canada's reputation as a culturally diverse country, little research exists about the relationship between family care and culture. To investigate this, a qualitative study has commenced in Vancouver, BC, and Calgary, AB, to explore the meaning of culture in the lives of Latin American, Chinese, and South Asian caregivers and its influence on health. Using the grounded theory approach, preliminary findings from qualitative interviews with 6 Latin American women in Vancouver unpacked the relationship between family, “culture,” and social support networks in these women's experiences of caring for an elderly family member. The intent here is to begin developing a framework for conceptualizing and understanding culture and caregiving. Two key findings emerged. The first was the implicit importance placed on preserving microcultural practices in the daily lives of the older adult. This was especially important when the older adult was institutionalized with family members visiting almost daily to help care for aging parents by bringing special foods, music, and stories reflective of the home country. The second unanticipated finding related to the absence of geographic boundaries in the family's experiences of caring: Irrespective of the older adult's immigrant status in Canada, these older adults frequently returned to their home countries to stay with family members for extended periods, moving between the Canadian context and their original homeland. For health providers and policymakers, these findings emphasize the family's role and influence is even more significant as it transcends geography in the care and health of Latin American older adults.
How Does Place Matter in Cardiovascular Risk Modification? A Photo-Elicitation Study in Two Regions of Ontario, Canada
Jan Angus
University of Toronto
Ellen Rukholm
Lauentian University
Isabelle Michel
Sudbury & District Health Unit
Sylvie Larocque
Laurentian University
Lisa Seto
University of Toronto
Jennifer Lapum
Ryerson University
Katherine Timmermans
Laurentian University
People at high risk for coronary heart disease (CHD) may benefit from multiple risk factor interventions but find it difficult to change established lifestyle patterns. This study examined contextual constraints and supports in the maintenance of health-related behavior change. Working from the tenets of critical ethnography, we employed photo elicitation to examine and contextualize the health-related experiences of 38 people who had received information about cardiovascular risk modification. Men and women were recruited from two regions of Ontario, Canada: a large metropolitan center in the south of the province (20 participants) and a small city in the sparsely populated northern region (12 anglophone, 6 francophone participants). Individual interviews focused on the contextual issues and personal meanings represented in participants' own photographs. Interviews with francophones were conducted and analyzed in French. The analysis was attentive to the places or physical locations of everyday life as well as participants' spatial practices or activities within these places. Participants' photographs and interviews demonstrated how places contribute to cardiovascular risk modification. All participants described the effort involved in initiating and maintaining recommended lifestyle changes, but different patterns of barriers and resources were seen between regions and subgroups. However, even within regions, individual risk modification efforts were not fixed in place and time. Participants moved through several places in the course of daily activity, creating “itineraries” or chains of spatial practice where constraints and supports to healthy behavior shifted continually. Health behaviors were integral within these itineraries and were continuously challenged and reconstituted.
Revisiting the Qualitative Research Mandate in the Context of the Wider Evidence Base
Rosaline Barbour
University of Dundee
As qualitative researchers we often claim the “moral high ground,” describing our endeavors as “giving voice” to previously marginalized or muted groups. Even research that appears innocuous or harmless may merit more critical examination.
This paper reflects on the experience of carrying out two studies aimed at designing interventions: with a respective focus on improving uptake of folic acid and addressing weight management postpartum. Ethical and political issues abound, ranging from implications of seeking to access “hard-to-reach” groups (who may have legitimate reasons for avoiding practitioners and researchers); sampling by deficit; use of respondents' insights and “misconceptions”; and our implicit role as “marketers of health promotion.” Both studies have highlighted the relatively firm basis for many lay misgivings and the lack of critical focus we, as qualitative researchers, often bring to such work, preferring to accept professional justifications at face value. Our attempts to elicit users' perspective may not be as benign as we imagine, particularly if we neglect to engage critically with the quantitative evidence base in such contested areas as fetal development and obesity and the “industries” that attend these.
Finally, the paper will discuss our role and responsibilities and our mandate as researchers within the wider professional and political context, arguing that we cannot afford to ignore professional, political and policy initiatives, and that we need to remain alert lest we unwittingly become “agents of control” rather than empowerers.
Reclaiming the Life They Were Not Supposed to Have: Women's Experiences Living Long Term with HIV/AIDS
Donna B. Barnes
California State University, East Bay
Audrey A. Thomas
Harvard University
In countries with resources, HIV is now considered a chronic illness for those with routine health care, including antiretroviral therapies. The complexities of living long term with HIV have not yet been well described in women. In this paper we examine the experiences of women who have survived through the changing contexts of AIDS as a death sentence toward living with HIV as a chronic illness.
Sixty women living with HIV, from Oakland, California (n = 30), and Rochester, New York (n = 30) participated in an initial study on reproductive decisions between 1995 and 2001. Of these original 60 women, 51 women were living. In this follow-up study we have completed interviews between 2005 and 2009 with women (n = 36) from Oakland (n = 16) and Rochester (n = 20). Grounded theory techniques were used in both studies.
Participants were living an unexpected and reclaimed life, having survived an average of 14.8 years, ranging from 8 to 25 years. New longevity offered possibilities for making a life participants were not supposed to have, though complicated with reconciling past experiences and choices, given various, often limited resources and opportunities to make life changes. Participants' fear of illness and death, and living with secrecy, loss, and isolation influenced this process. Perceived stigma along with efficacy of antiretroviral therapy disturbed and changed the social contexts of participants' reclaimed lives.
Results suggests the continued need for social support programs that assist with housing, employment, and reconnecting with children, especially for those women who face punitive regulations due to past jail records.
How Did I Get from Structural Equation Modeling to Axial Coding?
Bruce Bidgood
University of Northern British Columbia
What started as positivistic research on the characteristics of treatment group attendees was transformed at the hand of emergent design into a grounded theory study of the processes used by male abusers to construct/deconstruct more positive social images. The paper chronicles the author's frequently ambivalent methodological journey as he learns to convince himself of the epistemological value of naturalistic inquiry; focus the inquiry as process, not outcome; establish strategies to enhance trustworthiness; develop analytic techniques; and convey the products of the inquiry. Particularly instructive is the author's use of structural equation modeling as a figurative illustration of not only the observed change processes but more broadly for the teaching of qualitative data analysis. The utility of this selective coding metaphor is illustrated in the elaboration of a substantive theory of image transformation that is grounded in the discourses of male batterers and systematically related to the literature on stigma, deviance theory, linguistic accounts, and group identity transformation. The potential of the theory to serve as a formal grounded theory of image restoration for other negatively labeled populations is also explored. The lessons learned from this case study for the conduct, teaching and supervision of naturalistic inquiry are discussed.
Child Legal Representation: Young Adults Report on their Experiences with Child Lawyers
Rachel Birbaum
King's University College, University of Western Ontario
Purpose: Across the globe, the argument from a practice and policy point of view is that children and youth are important social actors in their parents' separation and/or divorce and should have a voice in the decisions that affect their lives. One way of providing their voice is through child legal representation. Yet, very little has been documented about hearing the voices of those children who had a lawyer represent them in a child custody dispute as a result of their parents' separation. Method: Audio-taped telephone interviews were conducted with 11 young adults. Themes were generated that explored the experiences of the youths with having a lawyer represent them, advice they would give to other young people in similar situations, and advice to lawyers who represent children in these disputes.
Results: Most young adults liked the idea of having a neutral person represent them. The majority felt that their lawyer did not spend enough time with them and most wanted their lawyers to provide follow-up with them about what happened in court.
Conclusions: From a practice perspective, child lawyers need education and training regarding age and stage of child development. From a research perspective, there needs to be more collaboration between researchers, legal service providers and with children to understand how children's voices can be heard in the context of parental separation. From a policy perspective, there needs to be a discussion in Canada about the role of child's counsel in custody disputes and their effectiveness.
A Demonstration of Educational Craft: An Outdoor Educator's Autoethnography
James Borland
Brock University
As an outdoor educator I use the outdoors to teach what is best learned in nature. However, I began to question the nature of my personal educational philosophy: the statement of beliefs I use to guide my craft. Defining craft as the creative synergy between an educator's educational philosophy and his actions in practice, I began asking myself, how does what I do as an outdoor educator, shape my educational philosophy? What influences drive my actions in the field? How can reflective practice as a form of research improve a practitioner's craft? I decided to conduct an autoethnographic inquiry about my craft, outdoor education (OE). Autoethnography is a methodology that begins with the researcher as a cultural insider. Implementing a storytelling approach, it elicits a relationship between the audience and the research, encouraging readers to apply the story to their experiences, provoking reflective knowledge development. Analyzing my reflective journal, three other outdoor educators' narratives, and a review of newspaper articles about Ontario-based OE, I used fictional critical writing (FCW) to create an academic discussion between four outdoor educators sharing stories around a campfire. Using fictional writing reflectively to critique critical incidents in my practice, I identified five fault lines shaping my craft. Fault lines are areas of ideological tension between groups where there exists the potential for a social shift in power. This study illustrates how reflective practice can help practitioners evaluate critical incidents in practice, identify fault lines in their craft, and construct a personal education philosophy to negotiate those fault lines.
Understanding Existential Suffering in Serious Illness Using Situational Analysis
Anne Bruce
University of Victoria
Rita Schreiber
University of Victoria
Patricia Boston
University of British Columbia
Olga Petrovskaya
University of Victoria
Existential suffering is a frequently occurring and highly distressing experience that accompanies a diagnosis of serious illness. Recent studies show that existential concerns are of great importance to aging patients approaching the end of their lives. Prolonged existential suffering is acknowledged to be debilitating with a significant impact on quality of life. Nevertheless, existential issues are seldom brought into focus. Empirical inquiries into existential suffering are few, and findings report diverse conceptual ideas. There is no clear theoretical framework for understanding how existential suffering is managed by patients with serious illness, family, and health care providers.
A grounded-theory methodology using in-depth interviews with constant comparative analysis is employed. In addition, analysis is extended using situational analysis to examine major human, discursive, and material elements shaping how people engage with existential suffering. Both the method and findings of the situational analysis are presented with a focus on the relationships between and among these elements. Understanding how people work with experiences of being shaken to the core, groundlessness, and learning to live within in-between spaces of “as if, and yet” will be presented. Through theorizing how older adults, families, and health professionals manage existential suffering, a clearer framework is being created to assist those developing interventions and clinical approaches to confront existential challenges presented by serious illness.
“Something I Enjoy Doing and That I Can Do”: Older Adults with Multiple Chronic Conditions and the Meaning of Physical Activity
Andrea Bundon
University of British Columbia
Laura Hurd Clarke
University of British Columbia
William Miller
University of British Columbia
There is an extensive literature documenting the biomedical benefits of physical activity in later life, including the mitigation of the physical effects of chronic conditions and the prevention of comorbid conditions. Additionally, there is research analyzing the perceived environmental, health, and social barriers and facilitators to engaging in physical activity programs among older adults. Despite reports that older individuals with multiple chronic conditions are frequently inactive, there has been little exploration of their experiences. This paper draws on data from in -depth interviews with 5 men and 5 women aged 72 to 87, with between 4 and 18 chronic conditions. Recruited from a longitudinal study of physical activity and chronic conditions (N = 200), the primary inclusion criteria was a marked decrease of functional abilities in a 2-year period (as determined by the TUG, 6-minute walk test, and pedometer performance over a 3-day period). Our analysis reveals the following three findings: (a) pursuits currently defined as physical activity differed from the definitions utilized earlier in life; (b) although they were engaging in adapted physical activity programming, participants placed a higher value on informal activities such as housework, hobbies, and volunteer work; and (c) although environmental barriers to physical activity existed, the participants' own comorbid health issues were experienced as the most constraining and debilitating factors that deterred and prevented them from being active. We discuss our findings in relation to the need for physical activity programming to remain congruent with individuals' valuation of activities and physical impairments.
Discourses and Silences: How Social Position Affects Youth's Negotiations about Safer Sex
Catherine Chabot
University of British Columbia
Jean Shoveller
University of British Columbia
Judith Soon
University of British Columbia
Joy Johnson
University of British Columbia
Jennifer Reade
University of British Columbia
Sexual health education emphasizes shared responsibility and negotiation about safer sex practices. However, youth's ability and willingness to do so is influenced by a variety of factors related to social position, including age, gender, sexual identity, ethnicity, religious beliefs, and socioeconomic status. Drawing on data from in-depth, semistructured interviews with 114 youth (aged 15 to 24 years) and service providers, as well as field notes collected during community-based fieldwork in two northern British Columbian communities, we use a Foucaultian analysis to examine how social position affects young women's discourses (and silences) regarding sexual health issues with their male sex partners. Our analysis demonstrates how power imbalances in many sexual relationships fail to position many young women—especially those who are low-income, Aboriginal, and/or early-age mothers—in ways that allow them to realistically challenge dominant discourses about stereotypical gender roles while assigning them responsibility for sexual health. Many women, particularly those in more marginalized social positions, told us that they were reluctant to discuss contraception, condom use, or sexual history with male partners for fear of being judged as promiscuous or “easy.” These apprehensions were linked with inconsistent use of contraception. To address sexual health inequities, we argue that sexual health educators need to acknowledge and address the impact of social position on power differentials. It is not enough to teach about safer sex; we must also challenge assumptions about the power to negotiate it.
Hey Look! Youths' Photographs and Their Families' Narratives Provide Insight into the Complex Relationship of the Built Environment and Youth Obesity in Nova Scotia.
Andrea Chircop
Dalhousie University
Jill Grant
Dalhousie University
Renee Lyons
Dalhousie University
Robert Pitter
Acadia University
Patricia Manuel
Dalhousie University
Laurene Rehman
Dalhousie University
The purpose of this study is to provide better understanding of the complex interactions between the built environment (urban and rural), public policy, physical activity, nutrition, and socioeconomic status of youths and their families and youth obesity. This study is a collaborative project involving community partners, provincial policy decision-makers and academic researchers. The focus of our presentation will be on the qualitative dimension of the overall project, specifically on photovoice focus groups with youth and on family interviews of youths' families in grades 7 to 9 in Nova Scotia, Canada.
Youth photovoice focus groups and family interviews provided rich, contextualized sociocultural data and insights into youths' and their families' perceptions about the link between obesity and the built environment from an everyday perspective of living in a certain neighborhood. Questions were aimed at why and how youth engage in physical activity and healthy eating. Family interviews allowed for insight into the dynamics of decision-making concerning physical activity and healthy eating at the family level that would otherwise not be captured.
Preliminary themes of 24 family interviews and 26 photovoice participants include busy family schedules, accessibility and distance, safety concerns within the neighborhoods, and family finances. Unique differences related to urban vs. rural; and low vs. high socioeconomic backgrounds are emerging. Challenges of the photovoice method with youth and family interviewing will be discussed. Results of the study are intended to inform meaningful public policy to reduce youth obesity.
A Proposal to Explore the Dimensions of Secondary HIV-Related Stigma in Partners of Men with HIV/AIDS
Jon Christensen
University of San Diego
Few diseases exemplify the disenfranchised status of stigma more than HIV/AIDS. Those living with HIV/AIDS are particularly prone to societal stigmatization. HIV stigma has its roots in societal beliefs, attitudes, and policy that are detrimental to those living with the disease. This specific type of stigma affects not only those living with HIV disease but also family members, partners, caregivers, and those associated with that person. This phenomenon was defined by Erving Goffman as “secondary” or “courtesy stigma.” HIV stigma is well described in the literature, and research indicates that where stigma exists, people are reluctant to seek testing or participate in education and prevention activities. Secondary HIV stigma has been poorly described in the literature and, when addressed, is usually done so only in a tangential manner. Some research has looked at secondary HIV-related stigma in family members, but there is a dearth of research looking at partners and how they are affected by secondary HIV stigma. In the discipline of nursing scant literature exists that looks empirically at secondary HIV stigma and its effects on those to whom it is directed. This proposal advocates an exploratory descriptive study to better identify the phenomenon of secondary HIV stigma experienced by partners of men with HIV/AIDS. Qualitative methods of data collection and analysis will be used. It is hoped that findings from this research will be helpful to nurses as they focus on holistic treatment of patients and their partners.
Mindfulness-Based Practices for Children: The Usefulness of Holistic Arts-Based Methods
Diana Coholic
Laurentian University
Sean Lougheed
Laurentian University
Our research explored the helpfulness of holistic arts-based group methods for the development of self-awareness, self-esteem, and resilience (foundations for healthy development) in children living in foster care. Our research reflects the burgeoning interest in holistic health/helping practices, and in arts-based methods.
The group that we developed is experiential, and art materials/games are used to assist children to resolve issues that are interfering with healthy development. Facilitating mindfulness, which is activity that encourages awareness to emerge through paying attention on purpose in the present moment, is an important part of the group. Mindfulness has been studied for its effectiveness with adult populations and problems and has been found to foster health benefits. Until recently, there were no studies that extended these findings to children. However, recent findings indicate that mindfulness holds promise as an intervention for children.
We found that mindfulness helped children learn to relax, pay attention, become more self-aware, better use their imaginations, develop relationships with family and peers, and cope positively. These findings emerged from the analysis of 17 six-week groups with almost 40 children. All of the groups were video-recorded, transcribed, and analyzed. The research was guided by a grounded theory strategy, which was suited for exploring the process and usefulness of the holistic methods.
The research results are promising and we have developed creative dissemination tools such as an instructional film. We will discuss the results and show part of the film that will bring the methods to life.
Women with Incarcerated Partners: Examining Health Concerns and Challenges
Cheryl Cooke
University of Washington Bothell
Wadiya Udell
University of Washington Bothell
Claude Weadon
University of Washington Bothell
Jessica Bell
University of Washington Bothell
There is little research focused on the health risks and current health conditions of women with incarcerated partners. Until now, research on women with incarcerated partners has primarily concentrated on risky sexual behaviors and interpersonal violence between partners. As more than 2 million individuals are incarcerated in the United States and more than 50% of the men in prison are married with children, understanding the challenges of maintaining and/or improving health while a partner is incarcerated is essential to keeping these vulnerable women healthy and available as caregivers for their children.
In this study, we explore the effects of incarceration of a male partner on maternal physical and mental health. Using structured and semistructured interviews, we examine the lives of 50 women whose male partners are incarcerated. Content analysis is used to uncover themes related to health, including the range of health problems encountered by these women, barriers to health care access and maintenance, and issues that arise while trying to maintain their health as well as a relationship with their partner.
Future research efforts will be targeted at a more in-depth investigation into how health problems (substance use, chronic disease) can be mitigated using a community-based intervention focused on improving the health of women with incarcerated partners.
Too Much, or Just Right? Methodological Pluralism in Knowledge Translation Research
Ryan DeForge
University of Western Ontario
His mentor exclaimed, “Social network analysis, critical ethnography, and participatory action research?!? I'd advise you against doing that!”
This presentation features the considerations of a doctoral student in health promotion who feels troubled by the blurry lines between and among methodological choices. In proposing a knowledge translation (KT) research process that aims to empower practitioners (in a hospital-based, specialized geriatric services program) to participate in the improvement of the delivery of their health care services, the researcher is faced with two methodological dilemmas.
The first is, How can social network analysis be employed as a tool to complement a critical ethnographic situational analysis? Second, could/should the critical ethnography extend itself into the realms of participatory action research? The former engages issues of mixing methods and of paradigmatic congruency; the latter necessitates consideration of feasibility (especially in a dissertation project), as well as consideration of the (supposed) need for methodological purism.
This presentation invites others' consideration of these (potential) methodological tensions. Scholars (particularly other doctoral students) with an interest in paradigmatic and methodological consistency and congruency, will find this presentation, couched as it is in consideration of issues of rigor, to be of great interest. Simultaneously, practitioners with an interest in KT will be afforded an opportunity to consider alternative modes of inquiry as a basis for understanding and evaluating possible mechanisms that trigger or impede the translation of knowledge into practice.
Muddying the Waters: The Complexities of Engaging with/in Relational Critical Reflexivity
Ryan DeForge
University of Western Ontario
Jodi Hall
University of Western Ontario
As second-year doctoral students in the field of health and rehabilitation sciences with interests in qualitative inquiry related to supporting knowledge translation (KT) and change, we have come to understand the importance of reflexively acknowledging our values and assumptions. Consistent with our paradigmatic positioning that draws on the tenets of critical feminist theories and postmodernism, and consistent with our valuing of the relational processes within the fields of health promotion and health professional education [HP(E)], we have pushed ourselves beyond reflective/reflexive practice to engage in relational critical reflexivity (RCR). Our conceptualization of RCR is characterized by reflexive, dialogic exchange between/among peers as an enhanced way of examining and understanding oneself.
An issue of rigor, such a courageous opening of self to other(s), makes space for prior beliefs to be questioned and for the discovery of the underlying aspects of ourselves that remain hidden. Such discovery is essential to the vigilant subjectivity that critical qualitative research demands. In our presentation, our introduction of RCR will serve as a point of departure in our effort to extend the practice into the fields of HP(E).
Specifically, we will story how extending our inward gazes toward one another has served to help us more readily identify: the ways in which our ideologies shape our personal and professional identities/practices; how we hold one another up for scrutiny and collective (re) visioning; and what benefits such relational scholarship has for the fields of KT and HP(E), all of which hinge on particular, situated intersubjectivities.
People from the Former Yugoslavia and Their Lived Experiences of War, Exile, and Resettlement
Branka Djukic
University of British Columbia
Most people from the former Yugoslavia were severely traumatized in the last war that ended most than a decade ago. A considerable number of these people resettled in Canada and probably adjusted to various degrees. Can we assume they are doing just fine? What are the changes due to living through multiple traumas and how these people make meaning in the face of negative events? No study has been done in Canada.
In my research study, I explored and analyzed the stories people from the former Yugoslavia construct about their lived experiences of war, exile, and resettlement to arrive at better understanding of meaning making process and changes in the aftermath of severely disturbing events. I used the narrative research design, as it seemed particularly suitable for a study that deals with the personal construction of past experiences and for research questions that ask about life experiences of an individual and how they unfold over time.
The results indicate that after a more than a decade past since the end of the war in the former Yugoslavia, people who resettled in Canada, still experience a considerable amount of distress. Panic attacks, dissociation, and depression are difficulties that my participants talked about in their stories. The ways in which counselors can reach out to this population that suffer silently will be discussed. Also the ways how to better facilitate the integration of negative experiences and promote positive changes in people who were exposed to traumatic events will be highlighted.
An Intersectional Approach to Understanding Cultural Meanings of Mothering in African American Adolescent Mothers: Through Their Own Eyes
Debora Dole
University of Cincinnati
Donna Shambley-Ebron
University of Cincinnati
Mothering practices of African American women have been affected by social, political, race, and gender issues that have altered the ways in which cultural practices are transferred generationally. Traditional biomedical research has focused on the African American adolescent mother as pathologic in her ability to parent effectively, failing to consider the effects of the alteration in generational transfer of traditional mothering practices. The continued disparity in infant mortality between African American infants and all other races illustrates the need to explore health disparities using a multiple determinants of health model that considers the effect of socially constructed determinants on the health of individuals and communities.
Theoretical framework: An intersectional approach using an integrated conceptual framework including critical feminist theory, critical social theory and critical race theory provides theoretical support for exploring mothering practices through the socially constructed concepts of gender, class and race.
Methodology: Using photovoice, a participatory research methodology in which participants are given cameras to document their own experiences, this study explored the cultural meanings of mothering of 12 African American adolescent mothers and how cultural mothering practices are being transferred generationally. Themes uncovered were analyzed using culturally appropriate interpretive theories including Africana Womanism, Black Feminist Thought, and Womanism.
Discussion: The approach and process itself provided participants with a forum to identify and share their own cultural strengths and positive mothering practices with each other. Themes of building a network, seeing the future and sharing responsibilities emerged as an avenue for the intragenerational transfer of positive mothering practices.
“Falling through the Net”: Health Professionals' Views about Perinatal Mental Health Care for Black and Minority Ethnic (BME) Women
Dawn Edge
University of Manchester
To investigate health professionals' views about perinatal mental health care for Black and minority ethnic (BME) women, a range of health care professionals (N = 42) were recruited from antenatal community clinics, a large teaching hospital, general practice, and a specialist voluntary sector agency in the north of England, United Kingdom. Qualitative data were collected via individual interviews and focus groups.
Participants reported inadequacies in training and lack of confidence both in identifying the specific needs of Black women and for managing perinatal depression more generally, particularly in women with mild-to-moderate or “subthreshold” depression. Failure to screen routinely, confusion about professional boundaries, and poorly defined care pathways increased the likelihood of women “falling through the net,” thus failing to receive appropriate care and treatment.
This study highlighted gaps between the rhetoric of U.K. policy, which espouses equality of access for all sections of society, and the reality of everyday practice. The evidence suggests that although suboptimal detection and treatment of perinatal depression (particularly among “high-risk” women) applies to women from all ethnic groups, minority women might be particularly vulnerable to deficiencies in service provision.
A Relational Decision-making Model for the Resuscitation of Extremely Premature Infants
Marilyn Evans
University of Western Ontario
Kevin Coughlin
St. Joseph's Health Care London
Decisions regarding resuscitation of extremely premature infants often present with ethical dilemmas and result in significant moral distress and residue for health care providers and parents. With advances in medical technology comes the obligation to ensure that they are used appropriately. Is survival the most important factor or does quality of life take precedence? How do we define quality of life, and what degree of handicap is unacceptable? How do differences in ethical, cultural, and spiritual beliefs factor into the decision? The current literature focuses primarily on how physicians rationalize these decisions. Using grounded theory, the values, thoughts processes, and reasoning of parents, physicians, and other health care professionals involved in this difficult decision-making process were explored. This paper presents a theoretical model derived from an analysis of in-depth individual interviews (with obstetrical and neonatal physicians, residents, advanced practice, and resuscitation room nurses), focus groups (with allied health care professionals, staff nurses), and interviews with parents (hospitalized women with threatened preterm labor and their partner). Data collection and analysis employed a constant comparative method. Open, axial, and selective coding was used to identify the key themes arising from the discussions. A family-focused relational model emerged that illustrates the complex and iterative process that health providers and parents engage in when making decisions regarding the resuscitation of extremely premature infants. Strategies to decrease moral distress for families and health care providers, guidelines and policy development addressing resuscitation practices in this population will be discussed.
Estrangement and Alienation in Chronic Illness Experience
Adi Finkelstein
Hebrew University, Jerusalem, Israel
“Physical pain has no voice” writes E. Scarry (1985) in the beginning of her book (p. 3).
This study deals with the narratives of women suffering from chronic fatigue syndrome or fibromyalgia syndrome. Its unique contribution consists in the attempt to provide an interpretive analysis of the language used by female patients when they describe their physical pain and their fatigue.
Some of the images used by those women are identical to images described in the phenomenological literature as characteristic of the “pain language.” I broaden the understanding of the women's language by using the metaphors formulated by Irigaray. By using special images and metaphors, the women express their body experience as an encounter with anything external as an invasion by foreign entities, which mix inside their body, thus weakening it and causing it to sicken. This experience clearly relates to the biomedical discourse, but the women narrate a much broader story, relating to additional aspects concerning their lifestyle, their relationship with others, and their living priorities. What the interviewed women want is a recognition of their state as an inseparable component of an ordinary, normative condition.
In conclusion, I propose the main message, which, in my opinion, also concerns any broadly generalized discourse about chronic diseases. As far as the two diseases discussed are concerned, a decided change is required from the social and political body, as represented by physicians and by social institutions: a conceptual modification of the medical-scientific discourse from dichotomy and omniscience into flexibility and transformation.
Follow the Leader? Identity Construction, Control, and the Health Service Manager
Tim Freeman
University of Birmingham
Helen Dickinson
University of Birmingham
Suzanne Robinson
University of Birmingham
We make an empirical contribution to the identity regulation literature by qualitatively exploring U.K. health care managers' responses to a leadership development program.
Drawing on Foucault (1977, 1979) and Townley (1993), the theoretical literature on the role of identity regulation in organizational control (Alvesson, 2001; Alvesson & Wilmott, 2002; Ford et al., 2008) is well developed. Collinson (2003, 2005) suggested that although the use of surveillance-based human resource management techniques, such as 360° feedback and personal development planning, might encourage individuals to develop “conformist” selves, their effects might also be less predictable, resulting in “resistant” or “dramaturgical” selves (Collinson, 2003), in which individuals seek to engage with and/or variously resist attempts to shape their identities. However, empirical studies of these concerns remain relatively rare, especially in health care.
The leadership role of health care managers is far from straightforward, as they work in organizational environments in which corporate and professional agendas may conflict. Managers are required to be both followers and leaders—the former to the extent that they must comply with the demands of corporate hierarchies and the latter to the extent that they are able to influence service delivery and service improvement interventions within their areas of responsibility. Drawing on semistructured interviews, we explore respondents' narratives of exposure to, and situated engagement with, surveillance-based techniques of identity management during a leadership development program. We reveal a rich picture of the way that they use, and are shaped by, such technologies.
Accounts of Filial Care: The Ideal of “Delayed Reciprocity”
Laura Funk
University of Victoria
Adult children play key roles in supporting their aging parents, and there is considerable attention to exploring their motivations for providing filial care. An idealized sense of indebtedness or “paying back” those who cared for us (“delayed reciprocity”) has often been highlighted as providing justification to the moral imperative of care. Drawing on data from multiple, in-person interviews with 28 adult children, the authors examined accounts of support and responsibility for aging parents to understand their use of the concept of reciprocity. If participants did not mention the concept unprompted, they were asked whether it had personal resonance. Talk about reciprocity was identified and further analyzed in the context of the interview as well as by particular subthemes. Participants positioned themselves in various ways in relation to reciprocity. Comments ranged from those strongly supportive; those initially supporting but then qualifying the concept; to those “somewhat” supportive or rejecting the concept at the level of their filial relationships. Overall, few comments (or participants) reflected unequivocal acceptance, and most represented qualification, contradiction, or rejection. In particular, reciprocity was often qualified by prioritizing other motivations for parent care based in love or affection, or by interpreting it as less calculated and contractual. Participant accounts suggest that some filial caregivers experience difficulties with the individualistic principle of contractual exchange, as well as the familialistic principle of “paying back” as implying an automatic obligation. The realities of their personal feelings about parent care are far more complex than either ideal might specify.
Widows of Kilimanjaro
Connie Geekie
University of Alberta
This ethnographic research examines how social structure constrains the well-being of widows in the Kilimanjaro region of Tanzania, explores the role of women's agency in bettering their lives, and looks at tension between international and local development projects. Widows identify several issues that make them vulnerable to social, political, and economic marginalization: widow inheritance, inheritance and land ownership laws, limited access to capital, lack of education, and AIDS. The research is a collaborative project involving the Moshi Widows Education and Counseling Centre (MOWECCE), an organization that provides community sensitization seminars, individual counseling, social support, legal advice, and a small-loans program. Focusing on gender equality, the organization promotes widows' rights to raise their children, to protect themselves from AIDS, to economic security, and to respect within their communities. Factors that appear to mitigate the structural challenges of widowhood in Tanzania include education, social support, employment out of the home, having children, and strong relationships between the widow and her husband's clan. Although social structure influences outcomes, understanding the role of social action in constructing healthy communities offers insight into the process of social change.
The Coffee Room: An essential Part of Family Practice Prescribing
Aileen Grant
University of Dundee
Prescribing consumes 12% of the United Kingdom's National Health Service budget and is rising rapidly. Although numerous initiatives are targeted as family practitioners to encourage the application of research evidence, the significant variation is difficult to explain.
This ethnographic study of three different family practice cultures in the United Kingdom, involved participant observation, documentary review, and semistructured interviews. Analysis was an iterative process conducted in Atlas.ti by grounded theory techniques. Practices were selected using prescribing quality indicators developed by Audit Scotland via PRISMS (Prescribing Information System for Scotland), which collects prescribing data for all practices in Scotland. Two practices with high-quality prescribing and one with lower quality were observed.
Practices with higher quality prescribing value face-to-face communication, collective learning and decision-making, practice protocols, and consistency in prescribing. These principles were absent from the lower quality practice. Experience had the greatest influence on behavior in all practices. In the high-quality prescribing practices the majority of face-to-face communication was in the coffee room, where prescribers would discuss difficult decisions and prescribing issues, seek advice, and discuss research evidence. Sharing experiences and engaging in discussion and debate increased ownership of decision-making, and practices were able to adapt to change quickly. This led to consistency in behavior and validated practice norms. Humor was used to address rogue behavior.
Time spent in the coffee room improved communication and consistency in behavior by modifying and validating norms. As fewer practitioners practice on their own, occupying the coffee room is a valuable use of time.
A Health Setting-Based HIV Stigma Reduction Intervention in South Africa
Minrie Greeff
North-West University
A group of researchers in five African countries designed a HIV stigma reduction intervention based on their experiences and results (quantitative and qualitative) over 3 years in Perceived AIDS Stigma: A Multinational African Study. The HIV stigma reduction intervention was the last phase in the 5-year study. This presentation focuses on the HIV stigma reduction intervention in South Africa as well as the results obtained after implementing a HIV stigma reduction project it in a specific health care setting.
A case study design was used. One health care setting was selected for the intervention and 10 nurses and 7 PLHA included through purposive voluntary sampling. The intervention combined three strategies: (a) sharing information based on the findings of the larger study and the understanding of stigma, (b) increasing contact with the PLHA by bringing PLHA and nurses together, and (c) improving coping through empowerment in a planned and implemented stigma reduction project by the group. A nurse and a PLHA facilitated the workshop. The case record included naïve sketches of the participants during the workshop, field notes of observations made by the researchers, a detailed description of the stigma reduction project, a project evaluation report by the participants, and recorded interviews with management in the health care setting after the stigma reduction project. The findings showed that the tenets on which the intervention was built (improved knowledge, contact between nurses and PLHA, and empowerment) did make a difference in reducing HIV stigma.
The Challenges of Conducting a Systematic Review on Communicating Environmental Health Risk Uncertainty
Cindy Jar dine
University of Alberta
Lisa Given
University of Alberta
S. Michelle Dredger
University of Manitoba
Alison McMillan
University of Alberta
The need for evidence-based recommendations for communicating the uncertainty associated with environmental health risks is becoming increasingly evident to health practitioners. A systematic review of the literature in various health-related and communication disciplines (including public health, psychology, sociology, education, business, agriculture, and environmental science) was conducted to consolidate and integrate the knowledge currently available on this area. However, carrying out this review in a rigorous and appropriate manner presented many challenges, both anticipated and unforeseen. In particular, the inclusion of qualitative, interdisciplinary articles in the process raised a number of issues for the effective review of this content. Additional challenges include (a) the multiple disciplines, indexing databases, and types of evidence on this subject area; (b) the enormous volume of applicable peer-reviewed literature obtained in the initial search; (c) establishing acceptable and clear definitions of the key concepts of risk communication, uncertainty, and environmental health; (d) “calibrating” reviewers from different backgrounds; (e) conducting a true systematic review versus the tendency toward purposive selection of papers; (f) establishing criteria for incorporating the gray literature; and (g) achieving knowledge translation that will meet the needs of diverse stakeholders. Strategies for meeting these challenges will be explored. The use of advanced electronic databases (i.e., Wikis and SRS Database) for accessing and managing the systematic review process will also be discussed.
Arduous Access: A Look at the Primary Health Care Crisis in Quebec, Canada
Tania Jenkins
McGill University
With nearly 25% of Quebecers lacking a family doctor, compared to the national average of 14%, the situation regarding access to primary health care (PHC) is critical. Montrealers and low-income individuals are particularly known to suffer the worst access in the province. In response to these quantitative findings from the first half of my mixed-methods master's thesis, this study will be the first to delve qualitatively, from the perspective of the medical profession, into the reasons why access to PHC is so strained and stratified in Quebec.
To do this, 24 respondents, including family physicians, union leaders, and government officials, were interviewed over 8 months. Two major Quebec policies meant to restrict both the nature and locations of family physicians' practices were identified as major reasons for the crisis: specific medical activities (AMPs) and regional manpower plans (PREMs). AMPs require physicians to work a minimum number of hours in understaffed areas of medicine or with vulnerable patients, such as in emergency departments or with pregnant mothers, but this takes time away from their regular practices. PREMs have successfully redistributed doctors to rural areas but only by depleting the supply of physicians in cities. Because of this, social connections (which vary positively with SES) have become invaluable resources for accessing family physicians. In conclusion, while AMPs and PREMs have indeed reallocated family physician services, they might have had the inadvertent effect of making access to PHC in Quebec even more arduous, especially for the poorest members of society.
“It Isn't Pot, It's My Medicine”: Interviewing Individuals Living with Chronic Illness and Using Marijuana as Medicine
Bindy Kang
University of British Columbia
John Oliffe
University of British Columbia
Lynda Balneaves
University of British Columbia
Joan Bottorff
University of British Columbia-Okanagan
The qualitative interview serves as a powerful research tool that allows for the complexities inherent to lived realities. Within these communications, the interviewee's voice is emphasized, whereas the peripheral interactions around the dialogue often receive limited attention. This presentation emerges from the qualitative data collected for the Health Effects of Medical Marijuana Project (HEMMP) in which 25 individuals shared their experiences of using marijuana for medicinal purposes.
During data collection, interviewers recorded field notes to highlight issues embedded in the participants' narratives but moreover to reveal “peripheral” contextual issues. For example, scheduling field notes were compiled to uncover how participants negotiated their chronic illnesses, use of marijuana and involvement in the study. Despite, the participants' best intentions around scheduling their interviews, the burden of their chronic illnesses complicated their ability to engage in the interview process. Although these types of variations could be interpreted as “unnecessary” data, these interviews illuminated the complex day-to-day issues that arise for individuals living with chronic illnesses, particularly when using treatment modalities “outside of the medial box.” Additionally, how participants mechanically constructed their narratives further illustrates the challenges they face within their social domains. Relocating this peripheral data as complementary to the interview narratives better informs “hopeful” practices around interviewing individuals living with chronic illnesses, emphasizing the need for greater reflexivity and flexibility from qualitative researchers when they coproduce chronic illness narratives.
Looking beyond the “No”: Evaluating Participant Refusals while Recruiting Marginalized “Ethnic” Communities
Bindy Kang
University of British Columbia
Paul Galdas
University of British Columbia
This presentation emerges from the Dhil Dhee Sehayth Cardiac Rehabilitation project, a qualitative research study exploring the cardiac rehabilitation experiences of Canadians with Punjabi ancestry. The majority of individuals approached to take part in the study agreed to be contacted to schedule an interview. However, a significant proportion of the sample population unequivocally refused to participate. The following themes emerged from participants' rationale for nonparticipation: (a) belief that their experiences lacked value, (b) distrust in the research process, (c requirement for tangible deliverables, and (d) situational constraints.
The rate and reason for participant refusals in qualitative research warrant considerable attention, particularly in studies with marginalized communities. Based on the colonial past, distrust of institutional bodies remains a reality for those who experienced colonization. A refusal, when constructed as resistance, can promote empowerment within the postcolonial context. When the refusal emerges from disengagement because of an inherent belief that marginalized individuals cannot contribute, researchers have to incorporate opportunities to position participants' voices as valued by developing empowering recruitment methods. Our experience suggests that for participants who require tangible “deliverables” in exchange for their contributions, there is a need to deliver effective, sustainable knowledge translation projects. It is therefore necessary to integrate reflexive, postcolonial, feminist qualitative methodologies to include marginalized voices to better represent “ethnic” and cultural diversity in Canadian health care studies.
Why Collaborate? Exploring Collaborative Practice among Health and Social Care Academics
Karen Kniveton
University of Salford
The paper will present the findings of a qualitative research project that addressed the question, Why collaborate? Using a constructivist-grounded theory approach, the research project explored collaboration between academics in health and social care faculties in England. Focus was on their experiences of collaborating to develop interprofessional and interdisciplinary initiatives, including interprofessional education (IPE). The project was based on the premises, first, that academics need to collaborate effectively if initiatives like IPE are to develop and be sustained and, second, that theory building in relation to collaboration will assist our understanding of why collaborations are formed and why some are sustained and some are not. Research focus in this field has mostly focused on student experiences and the desire to identify the impact of IPE. The project aimed to address the under-researched area of collaboration between the academics concerned. Data has been generated from individual interviews and focus groups with academics from six universities. Respondents have shared their experiences of collaborating with colleagues from a range of professions and disciplines. The paper will outline the four emergent categories—motivation orientation, shifting identities, personal relationships, and situational influences—which assist our understanding of what helps and what hinders collaboration. The interrelationships between the four emergent categories will be outlined. A model to assist our understanding of why academics collaborate will be presented with discussion about application of the model. The project will be reported in a doctoral thesis in the summer of 2009.
Canada-South Africa Collaboration on Understanding Homelessness and Putting Knowledge to Action
Katharina Kovacs Burns
University of Alberta
Solina Richter
University of Alberta
The local and global implications of homelessness are enormous and costly in terms of health, social, and other negative outcomes for individuals and families who are homeless, stakeholders attempting to provide appropriate health and social services, policy decision makers weighing the evidence needed to support funding decisions, and local and global communities dealing with concerns. To make any positive transformation in the outcomes for homeless people and other stakeholders, it is essential to observe, gather and analyze “real” experiences and evidence regarding health and social interventions that can be translated and used to inform or improve programs, practices and policy decisions.
Cross-sectoral stakeholders in Canada and South Africa participated in a qualitative case study in which they engaged in three stages of evidence gathering, analyses, and dialogue. Stage 1 focused on identifying and summarizing the research conducted by governments, community services, universities, and homeless or low-income communities. Stage 2 consisted of reviewing, analyzing, and discussing the strengths, gaps, needs, and opportunities related to existing health and social services and policies for low income and homeless people. Stage 3 was the identification of priorities for research and strategies for knowledge translation of selected evidence from Stages 1 and 2 into practice/action.
Results included the identification of stakeholders' needs including to clearly define and understand homelessness as well as to build their research and KT application and evaluation capacities. The intent is to follow up on progress made at the end of one year by Canadian and South African stakeholders.
Focus Group Dynamics: Changes in Participant Behavior when the Facilitator is a Wheelchair User
Denise Lawler
Trinity College Dublin
Roisin Kavanagh
Trinity College Dublin
Joan Lalor
Trinity College Dublin
In a qualitative descriptive study commissioned by the National Disability Authority, four exploratory focus groups were conducted with health professionals to ascertain information on maternity services provided to women with disabilities (WWD) in Ireland. The authors will discuss how the dynamics of conducting a focus group for this study were affected when the moderator is a WWD and the facilitator is able bodied.
The focus group was facilitated by two of the authors, one a wheelchair user and the other without a disability. The participants were asked to comment on their experience of providing care to childbearing women with a physical or sensory disability. Issues such as access to the environment and compliance with legislative requirements were also addressed.
Having a moderator with a disability had the effect of ensuring the discussion remained focused. Each moderator noted that the participants directed the discussion and their responses towards the moderator who was a wheelchair user and were more inclined to engage with this person throughout the duration of the discussion often to the exclusion of the non wheelchair user.
The participants seemed to have a heightened level of sensitivity to questions regarding access to the service facility in which they were located. In this study, participants were keen to demonstrate sensitivity towards WWD and were apologetic for any gaps in the service they offered. This might have had an effect on the data obtained as responses were influenced by a desire to receive approval for their practice from the moderator.
Interviewing Women with a Sensory Disability: Reflections on the Impact of the Disability on the Interaction
Denise Lawler
Trinity College Dublin
Joan Lalor
Trinity College Dublin
In a qualitative descriptive study commissioned by the National Disability Authority, face-to-face interviews were undertaken with 12 women with an auditory disability regarding their experiences of maternity care in Ireland. Data collection in face-to-face interviews is undoubtedly influenced by the rapport established between the researcher and the participant. This paper presents reflections on the process of undertaking interviews with women where the presence of a sign language interpreter was required.
Examples are given of how the structure of the interview is altered in terms of language and the required positioning of the researcher to facilitate lip reading and the transmission of nonverbal cues. When the researcher and participant cannot communicate directly with each other, using an interpreter can be problematic. For example, the interpreter might misinterpret the researcher if he/she is not familiar with the subject matter or terminology. This might lull the novice researcher to dire ct communication toward the interpreter, making it difficult to establish a rapport with the participant. The relationship might be undermined if the interaction appears cold or clinical as it is challenging to translate the tone and empathy in the researcher's voice.
Consequently, suggestions are made regarding a range of strategies within the interview process that will assist the researcher to establish and maintain a direct connection with the participant. Taking cognizance of the physical environment is essential when facilitating the exchange of information for women who lip read. This paper uses personal reflections to illustrate the challenges in fieldwork.
Patients' Key Experiences after Coronary Artery Bypass Grafting: A Synthesis of Qualitative Studies
Marit Leegaard
Oslo University College
May Solveig Fagermoen
Institute of Nursing and Health Science
Ischemic coronary heart diseases are the most common reasons for admittance for patients 40 years and over in European and North American hospitals. Metaanalysis of randomized controlled trials has proven that coronary artery bypass grafting (CABG) is the most effective treatment for ischemic coronary heart diseases when other treatments are ineffective. However, health personnel require the additional knowledge base offered by patients' perspectives on illness and treatment.
The aim of this study was to integrate and explore qualitative studies regarding patients' post-CABG experiences. Electronic searches were carried out in four databases using search terms for CABG combined with key search terms associated with qualitative research. Nineteen of 45 qualitative studies identified met the inclusion criteria. The included studies were appraised by a reading guide developed to identify, describe, and systematize findings from qualitative studies. Raw data or direct citations were not considered as findings. Relevant findings where subsequently thematically analyzed in line with principles of qualitative descriptive research.
The following key concepts described patients' experiences after CABG: the paradox of surviving alone with supportive relations, sense of self disrupted, losses, rears, and getting on with life. The synthesis revealed that patients' postoperative experiences influence their existential aspects of life long after surgery. Surprisingly, few studies treated suffering from postoperative pain as a specific topic. This underlines the need for more qualitative research exploring specific postsurgical experiences for CABG patients such as postoperative pain.
Hurting to Care: The Experience of Older Nurses Working with Health Problems
Susan Letvak
University of North Carolina at Greensboro
The purpose of this qualitative, phenomenologic study was to describe the experiences of older nurses who work at the bedside who suffer from their own health problems of depression or musculoskeletal pain. Specifically, Merleau-Ponty's (1994) philosophical view that meaning is existential and created through an individual's interconnectedness with others was the phenomenologic perspective. Bedside nursing has become increasingly stressful, and health has an important influence on an older person's ability to work. Two health problems known to affect work productivity are pain and depression. The study was guided by Mayeroff's framework of caring. Care for another requires empathy and helping another grow. Fourteen nurses over the age of 50 (mean age = 57 years) who worked directly at the bedside participated in in-depth face-to-face interviews. Analysis was guided by Moustakas's phenomenological method. Four themes emerged from the nurses' voices: it hurts every day, nursing changed, learning to cope, and team support. Study findings demonstrate the need for increased caring for nurses who work with their own health problems and have spent their careers caring for others.
The Abstinent and Spiritual–Based and Detoxification Rehabilitation Protocol (Short-Term Residential Rehabilitation and Detoxification Program)
Masoomeh Maarefvand
Ministry of Welfare and Social Security
Abbas Deilami Zadeh
Rebirth Charity
Addiction is a multidimensional phenomenon that various methods have been used to treat it, but they have never been fully successful. The number of addicts is increasing in Iran, and also poverty jointly acts as a resonantly important factor which causes continuation and increase in addiction-related problems. In Iran, considering two points in treating addiction is important: much more variety in methods and treatment conditions to cover different and various target groups and considering reducing treatment costs by applying self-help group experiences. Of course, some of treatment-effect factors have been considered more in any method. In this study 25 recovered persons participated in an action research about the abstinent and spiritual–based treatment, and after focus group discussions and workshops they finalized a protocol that has some major features, including
proposing a definite kind of short–term residential programs,
proposing a compound kind of residential detoxification without drug and quick beginning of rehabilitation,
applying participation factor in recovery and keeping it, according to the experience of ex-addicts, and
considering the effect of spirituality on treatment. For the first time in Iran a local protocol has been introduced according to the experiences of a rebirth institution, with circumstances to increase recovery (continuity) by observing two main factors of abstinent-based consideration.
Experiences of Stigmatization by Women Whose Partners Died of AIDS
Eva Manyedi
North West University
Minrie Greeff
Africa Unit for Transdisciplinary Health Research
Stigma of HIV and AIDS causes concern because of the fact that it affects not only those who are infected but also their spouses, children, close family members, and those closely associated with them. Women, as the gender that is culturally dominated by men, are found to be the most affected by stigma. The focus of this study is on the experiences of women who lost their partners to AIDS and who are stigmatized due to the fact that both widowhood and AIDS carry stigma. A qualitative design was followed to explore and describe the experience of stigmatization of women whose partners died of AIDS. Findings revealed that women experience stigma that manifests in three forms; namely, received, internal, and associated stigma. Received stigma was reported as experiences of gossip, rejection, avoidance, blame, abuse, neglect, fear of contagion, and pestering. Participants also experienced internal stigma in the form of self-perception, fear of disclosure, social withdrawal, and self-exclusion. Additional categories that could not be directly linked to stigma are experiences of deterioration in physical status leading to physical weakness, helplessness, and preoccupation with and fear of anticipated death. Associated stigma of children and families of these women was also reported to a lesser extent. Guidelines were formulated for women whose partners died of AIDS to cope with the stigma associated with their having had a relationship with an infected partner who died of AIDS.
Healthy Possible Selves: Aboriginal and Non-Aboriginal Youth Narratives
E. Anne Marshall
University of Victoria
Francis Guenette
University of Victoria
Suzanne Stewart
OISE/University of Toronto
There is increasing evidence that youth in rural areas have been catching up to and even surpassing their urban counterparts with respect to health risk behaviors such as substance use, depression, and high-risk sexual practices. One possible explanation for this shift is the increasing stress associated with widespread social and economic restructuring that has particularly affected rural communities. Aboriginal youth have been identified as a particularly vulnerable population, with challenges related to differences between western and indigenous views of health and health interventions. This paper focuses on rural adolescent narratives related to health risk and protective factors.
We present findings from two ethnographic narrative studies conducted with Aboriginal and non-Aboriginal participants in five rural costal communities in British Columbia. Adopting a community partnership model within a social constructivist theoretical framework, our team has conducted focus group and in-depth individual interviews with more than 65 youth. We used innovative methodological techniques, life space and possible selves mapping, that we have found to be successful in engaging youth participants in the research process. Health risks and barriers identified included economic hardship, family and individual stress, substance use, low self-efficacy, cultural disconnect, inadequate and inappropriate health services, and isolation. Protective and support factors included health education, family and peer support, cultural identity, healthy dating relationships, sports involvement, school engagement, and community engagement. The findings underscore the need for culturally appropriate and community-based physical and mental health services for Aboriginal and non-Aboriginal youth.
Older Women's Experience of Disclosure of Nonheterosexual Orientation: Challenging Categories and Assumptions
Carol McDonald
University of Victoria
Marjorie McIntyre
University of Victoria
Lyn Merryfeather
University of Victoria
Middle-aged and older nonheterosexual women have rarely been the focus of research initiatives exploring disclosure experiences apart from those of nonheterosexual men, a gap that impairs policy development, program planning, and service provision for health and social services. This 3-year, SSHRC-funded hermeneutic study was undertaken to generate new understandings of experiences of self-disclosure of sexual orientation by nonheterosexual older women. The authors conceptualize this work as cutting-edge qualitative research with a near invisible population.
Disclosure, the experience of revealing sexual orientation, is not a one-time event. It is usually a choice, though not always, and it happens many times every day. Decisions to disclose and to conceal orientation contribute to the constitution of quality of life. Like the general population of older adults, these aging women represent a heterogeneous group of individuals with diverse experiences based on race, ethnicity, abilities, physical and mental health, social class, and material resources. The purpose of this research was to develop knowledge that does not essentialize the experience of aging nonheterosexual women but, rather, speaks of their experiences in the social and cultural context of their lives.
Quality and Qualitative Methods in Health Services Research
Eva Meyers
Hollywood Presbyterian Medical Center
Martha Ann Carey
Maverick Solutions
Connie Brehm
Ethnic disparities in provision of health care and in health status are well documented, and although remedies have received some attention, there remains a huge gap. The health system in the United States has traditionally focused mainly on illness treatment, with providers as the center. More effective use of the always limited resources would involve prevention and community based centers as service delivery sites. With the patient and family as the focus of planning, and prevention as the goal for this component of the research, this study's objectives were to develop information that would assist in advancing the health services research agenda and provide recommendations for service system changes and the educational preparation needed for the new roles. Guided by the Melnyk and Fineout-Overbolt (2005) conceptual model of health services research, this study explored the perspectives of four groups of stakeholders: the public, providers, researchers, and payers. By exploring experiences of people directly involved, a multiple case study approach (Stake, 2006) was used to identify common tenets and to make recommendations. Advanced practice nurses from three different care settings, nursing services research experts, and extant literature were the sources of the data. Findings, described as “assertions,” involved medical record system improvement, the need for a new mix of providers, empowerment of the client (patient and family) in their care, necessity of population level interventions, and the necessity of advocating for this expanded approach using the evidence base. This unique qualitative method and documentation for each assertion will be presented.
From Professionals' Interpretations of Policy to Patients' Embodied Experience: A Discussion of Care for Type 2 Diabetes in Scottish General Practice
Heather Milne
University of Edinburgh
In 2001–2002 each nation of the United Kingdom published a national service framework for diabetes care. The Scottish Diabetes Framework (2002) emphasized a collaborative approach to care and accelerated an established trend of moving care for type 2 diabetes into primary care. The subsequent U.K.-wide introduction of a new General Medical Services (GMS) contract in 2004 has, however, prompted significant changes in primary care by linking clinical targets to financial rewards on a larger scale than any previous approach. Diabetes is one of 19 financially incentivized clinical areas under the revised GMS contract (2006).
That professionals act as “street level bureaucrats” (Lipsky, 1980) has long been recognized and is discussed in relation to the implementation of the GMS contract by Checkland (2004). Research has also shown that the organization of health services can have a significant influence both on patients' daily experience of their chronic illness and how they perceive that illness (Hart, 2001; Lawton et al., 2005). Until now, however, the relationship between these two research fields has received little attention.
This presentation outlines how professionals' various interpretations and enactments of diabetes policy within differing general practice contexts are interpreted and given meaning by patients, informing their perceptions of their own health and their desire to be involved in diabetes management. The research presented here is based on focused ethnographic case studies of three GMS contracted general practices in Scotland: one small, remote and rural (c. 1,000 patients), one village based (c. 3,000 patients), and one large urban practice (c. 18,000 patients).
Investigating Knee Pain Patients' Health Priorities and Use of Self-Care. A Qualitative Exploration
Andrew Morden
Keele University
Clare Jinks
Keele University
Bie Nio Ong
Keele University
Self-care is key to current health policy for the management of long-term conditions. However, the best model for self-care remains unclear; first, the United Kingdom's national evaluation of the Expert Patient Programme (EPP) highlights that the EPP appeals to White, middle-class, female patients and existing self-managers. Second, research shows mixed benefit from arthritis self-management programs. Third, research shows that self-care is being underused in primary care. Fourth, lay people who work with our center want to adopt self-care but are unsure of what to do.
This study explores the prioritization of health problems for self-care alongside an investigation of the drivers and barriers to self-care for knee pain. Thirty people who suffer from knee pain, who do not consult with their general practitioner, and who suffer from comorbidities participated in the study. The sample was split into two groups of 15: those who self-care and those who do not. Three stages of data collection were used: baseline in-depth interviews, a diary and camera study for 6 months, and a follow-up interview at 6 months. Grounded theory analysis was employed.
The presentation will report the findings from the baseline interviews undertaken to explore patients' rationales for taking up self-care for knee pain. The findings will provide new evidence on whether support from health care professionals is required and, if support is needed, what form this should take.
Understanding the Significant Effects of a Participatory Intervention in Rural Nepal on Newborn Survival
Joanna Morrison
University College London
Rita Thapa
MIRA
Dharma Manandhar
MIRA
Sally Hartley
University of East Anglia
Rigorous evaluation of community-based interventions is necessary to build the evidence base to improve global maternal and child survival. We describe a participatory women's group intervention implemented in rural Nepal, which was evaluated through a randomized controlled trial. We observed a 29% reduction in newborn mortality in intervention areas and significant positive changes in care behaviors. We describe process data that enables increased understanding of the effect of context and mechanisms of change that led to the trial result. Data were collected from field reports, meeting minutes, focus groups, interviews, and observations. Group members, health workers, men, mothers-in-law, facilitators, and community leaders were purposively sampled. Data were tape-recorded, transcribed, translated, and analyzed using “framework.” Women's groups managed stretchers, community funds, and conducted health promotion activities. Home delivery kits were made and sold. Groups initiated meetings with health workers, men, and local leaders. The intervention enabled group members and communities to develop knowledge of neonatal and maternal health problems. Implementing strategies to address problems enabled community participation in group activities and dissemination of knowledge. This was also important in developing the capacity and confidence of group members. Health services tended not to be trusted, and a plural belief system was maintained. Positive attitudes to nongovernmental organizations prevailed and communities were receptive to social change. Process evaluations of randomized controlled trials are important in enabling exploration contextual effects and of mechanisms of change. Our findings inform the replication and scale-up of community-based participatory approaches to improve maternal and neonatal health.
Photography as a Data Collection Method in Intensive Care
Sepideh Olausson
Borås University/Jönköping University, Sweden
Terese Bondas
University of Borås, Sweden
The suffering patient is thrown into a strange and unfamiliar environment of different technological devices in an intensive care unit (ICU). The room is a place for care and treatment, for rest and recovery, a visiting room, and a working place for the staff. In this context patients and relatives are very vulnerable and are in a great need of support. Patients might suffer from unreal experiences, often very traumatic during their stay in ICU, many patients also suffer from unpleasant memories, and some develop posttraumatic stress after their discharge. To design optimal rooms in ICU, it would be important to identify factors that are meaningful for the patients and relatives. The aim of this study, as part of a larger research project, is to illuminate patients' and relatives' experiences of the physical room, the design, and the interior in the ICU. Photographs combined with interviews are used as data collection methods within the ICU context. Relatives and former patients are asked to photograph different aspects of the room that they remember or associate with a feeling. The pictures are used later during an interview with the informants. In total the researcher meets the informants three times, first time to inform, the second time to take the photos, and a third time for the interview. This method gives the researcher an opportunity to deepen the understanding and capture aspects of the room that otherwise might be hidden. The presentation will focus on photography as a research method.
“Suddenly in an Instant Your Life Is Just So Different … and You Want the Old Life Back”
Tracey O'Sullivan
University of Ottawa and the Elisabeth Bruyère Research Institute
Regine Amani-Yao
Grant Russell
Elisabeth Bruyère Research Institute, Faculty of Medicine University of Ottawa
Hillel Finestone
Elisabeth Bruyère Research Institute
Louise Lemyre
Faculty of Social Sciences and Institute of Population Health, University of Ottawa
Andrea Ghazzawi
Elisabeth Bruyère Research Institute
Extensive literature highlights common challenges families face when providing care for a family member who has survived a stroke. Although cross-sectional and retrospective studies have found depression and fatigue to be prevalent in family caregivers of stroke survivors, little is known how quality of life changes over time. In this study the researchers used a grounded theory approach to explore quality of life among primary caregivers in the 6 months following discharge from a stroke rehabilitation unit. A maximum variation sample of 15 primary family caregivers of adult stroke survivors was recruited by referral from social workers in three rehabilitation centers in eastern Ontario. Each participated in three semistructured interviews in the 6 months following the care recipient's discharge from the rehabilitation center. Interview transcripts and field notes were coded using NVivo 7. Emergent themes were identified following content analysis and multiple discussions between the analysis team, using a consensus approach. All care recipients were > 55 years of age, and the mean age of the primary caregivers was 65.9 years. The results provide longitudinal evidence of reduced quality of life among family caregivers, with particular realism and challenges occurring at 3 months. Emotional strain (e.g., worrying about leaving their loved one alone or feeling guilty about using respite services), personal health limitations, and reduced social and leisure opportunities emerged as key influences on caregiver quality of life. The identification of a critical time period, postdischarge, when caregiving becomes more difficult, is an important finding of potential benefit to service providers and program planners.
Delusions and Qualitative Confusions: A Dialogic Collaborative Exploration
Sue Patterson
Imperial College, London
Tim Weaver
Imperial College, London
This presentation is grounded in two observations: the increasing pressure on collaborative team work in qualitative health research and the tendency of qualitative research to focus on articulate, reflective, and well-educated respondents. Although shared authorship and thus shared ownership of ideas is increasingly common, the inherently complex politics, process, and procedures of development of ideas are seldom made explicit. We describe application of a dialogic collaborative process (DCP) to exploration of issues arising from our interview-based research in populations prone to delusions, commonly understood as false beliefs (can a subjective belief be false?) inconsistent with the person's culture. We used the DCP to investigate and develop a shared understanding of ethical and epistemological tensions associated with research with people who hold “unusual beliefs” and explore implications for practice. In this presentation we present both a discussion of the process and the “meanings” we developed. Although our “meaning making” involved agreement to disagree in relation to specific approaches, we are united in the view that full reporting and individual and team reflexivity, both positional and relational, are the hallmarks of quality for research with these populations. In a context in which qualitative research is increasingly conducted by multidisciplinary and hierarchical teams, we take the view that the DCP offers an effective and efficient means to construction of evidence-based knowledge. However, we caution that to maximize benefits, the process must be underpinned by clarity of purpose, self awareness, and the roles and commitment of each participant in the dialogue.
Criminal Stories: Analyzing Media Representations of the Warrior Gene
Suzanne Phibbs
Massey University
Christine Kenney
Massey University
Drawing on media representations and scientific texts, this presentation provides a discourse analysis of the “warrior gene” and traces the emergence of the “crime gene” as a potential explanation for antisocial human behavior. Media publicity surrounding research that linked criminal behavior in Maori to a single “warrior gene” illustrates how genetic science can be used to reinforce negative stereotypes about, and racial prejudice toward, a minority ethnic group. In this case, an unproven scientific hypothesis was transformed into an objective scientific account that located Maori deviance in biology. Maori were said to carry a warrior gene, which explained higher incidences of violence, gambling, drug addiction, alcoholism, smoking, risk taking, and criminal behavior. In the public imagination an entire ethnic group was then marked out as potentially deviant due to this genetic difference. Discourse analysis draws attention to the political work of genetic explanations for human behavior. The presentation considers the warrior gene as introducing a new biology as destiny argument which simultaneously reinforces old prejudices, diverts attention from the social shaping of human behavior, and suggests that the New Zealand government need not intervene to address Maori health inequalities.
Qualitative Evaluation of the Nurse–Muslim Patient Relationship
Fernando Jesus Plaza Del Pino
University of Almeria
Soriano Ayala Encarnacion
University of Almeria
We present a qualitative study carried out in two hospitals in the south of Spain, in which we have dealt with the nurses point of view about their relationship with their Muslim patients and the circumstances that determine the success and/or failure of this intercultural encounter. The research method used is the grounded theory, using in-depth interviews as a strategy for data collection (N = 32). The data have been examined analyzing the contents and identifying emergent categories.
Among those aspects that we have identified that favor the establishment of effective nurse-Muslim patient helpful relationship we would point out for special mention are an awareness of the existing cultural differences, the will to learn more about the other culture, and the willingness to use of this knowledge to improve the care provided. Among the aspects that hamper the relationship, we would point out the prejudices and stereotypes that predetermine nurses' opinions of their Muslim patients, that stigmatize them, and that, in taking their own culture as a reference, value as negative all those customs and traditions that differ from the autochthonous ones.
In Spain the care of foreign patients has taken the professionals by surprise, without any specific training to prepare them for it. As a conclusion and based on our findings, we propose outlines that should define a training program aimed at bettering and adapting the care of Muslim patients to make it culturally sensitive and improve coexistence, respect for their culture, and quality in health care.
Autoethnographic Process: When the Researcher Is a Clinician
Barbara Plovie
University of Washington Bothell
Autoethnography is an accepted form of qualitative research. Illness narrative is one of the most common autoethnographic genres, and the lived experience of cancer is a common illness narrative. Researchers are challenged to demonstrate internal validity and reliability. Prospective data collection and analysis is one means to do so. To achieve both external and internal validity, the researcher must demonstrate transparency, which results in personal vulnerability. Only on unique occasions is the researcher also an expert clinician within the illness experience. I was diagnosed with invasive breast cancer while practicing as a woman's health care nurse practitioner. How is the autoethnographic process affected by the researcher as clinician?
I composed a patchwork of prose and poetry while undergoing two courses of chemotherapy and simultaneously maintained a personal journal. To demonstrate external and internal validity, I quoted my personal journal according to the timeline of each piece, and by doing so demonstrated my vulnerability. I subsequently reflected on each piece within 2 months of completing chemotherapy. To demonstrate personal transformation, I analyzed each patchwork piece according to type of narrative (testimony, emancipatory discourse, or destabilization narrative). The patchwork was overall an emancipatory discourse, whereas the reflections were destabilization discourse. I concluded that my personal transformation occurred within the autoethnographic reflective process. The question remains whether my vulnerability and transformation were heightened by the fact that I was a researcher and clinician, the prospective nature of my process, or both.
The Past Erased, or How Difficult It Is to Discard History: A Sociological Approach to the Phenomena of Alzheimer's Disease.
Andrea Radvanszky
Kalaidos University of Applied Science, Switzerland
Disease management is a social phenomenon in cases of Alzheimer dementia. Care of dementia patients is considered to be a great burden on caregivers. However, the specific interaction order at work in Alzheimer dementia is hardly illuminated by sociological theory concepts. In accordance with symbolic interactionism theory, we present the situational action systems of dementia patients and caregivers. To what extent does the burden of life-wordly contexts of action of those concerned relate to gender roles, role shiftings, identity crises, standards of normality, power strategies, and guilt and shame conflicts? In dealing with the profound disruption of the relationship structure, organ pathological diagnosis has a pivotal function. It prevents a meaningful biographical reconstruction of a generalized anomic condition of the individual. Responsibility is shifted to the caregiver, thereby putting him/her under enormous pressure and adding to feelings of guilt.
A new conceptual notion of care is presented to overcome the asymmetry in the relationship between the “healthy” and “unhealthy.” This approach focuses on complex exchange processes of the individuals involved.
Thirty semistructured narrative interviews with caregivers of Alzheimer's patients constitute the data basis. These were conducted as part of the “work & care” project of the Swiss National Science Foundation. The analysis was carried out using a combination of objective hermeneutics and grounded theory methods.
How the idiosyncratic reality of dementia patients in its characteristic can be better understood has yet to be researched. We suggest visual anthropology as a method for focusing on this other state of reality. In this respect, however, questions arise concerning research ethics.
Health-Seeking Behavior of the Hill Tribal Population in Bangladesh
Syed Rahman
BC Cancer Agency
Charles Normand
University of Dublin
In this paper the authors discuss various elements underlying health-seeking behavior among several tribal groups lives in hilly areas in Bangladesh. They attempt to provide a comprehensive portrait of obstacles and challenges faced in accessing and using health care provision in the tribal areas by tracing responses from different treatment sources that are available in the tribal areas. The reasons behind provider choice were also investigated, and issues concerning adolescent and maternal health as well as health behavior and knowledge are highlighted. Data for this study were collected using participatory tools and techniques, including focus group discussions and interviews involving 162 men, women, adolescent boys, and girls belonging to nine different tribal communities from six districts. Four main findings emerged from the study, suggesting that tribal communities might differ from the predominant Bengali population in their health needs and priorities.
Traditional healers are still very popular among tribal groups in Bangladesh.
Perceptions of quality and manner of treatment and communication override costs when it comes to provider preference.
Gender and age play a role in household decisions concerning health matter and treatment seeking.
There are distinct differences among the tribes concerning their health knowledge, awareness, and treatment-seeking behavior.
These findings challenge the present service delivery system, which has largely been based on needs and priorities formulated by the plain land population.
Celebrities and Spiritual Gurus: Redemptive Narratives of End-Stage Renal Disease, Transplantation, and Recovery
Rose Richards
Stellenbosch University
The individual's perspective of end-stage renal disease (ESRD), transplantation, and recovery has not been examined in much detail. When people write about their experience of ESRD and its treatments, they tend to adapt their stories to fit conventional narrative forms, such as the redemptive narrative.
Redemptive narratives attempt to derive meaning from an experience that has damaged an identity. They achieve this by determining a reason for the suffering and deriving some good from it. Doing this can also be a way of coping with liminality. However, liminality might not go away after recovery. ESRD can be only treated by dialysis or transplant, and both treatments require life-long health care.
In this presentation the author considers how two recent redemptive kidney transplant stories are constructed. Neither has been analyzed, although both are available in the public domain. The first narrative is a story of kidney transplantation leading to spiritual awakening. The second is a celebrity's tale of changing body image in a world of beautiful people. Despite their differences, both transplantees became seriously ill as adults. Afterward both of their lives are reconstructed through narrative to derive meaning from the experience and to come to terms with ongoing liminality.
Although the restorative properties of redemptive narratives have been considered, the impact of such a narrative on coping with ongoing liminality has not been examined. With these narratives, it seems to prevent an exploration of what the ongoing liminality means and thereby deny the resolution that it seeks.
Community Based Participatory Research Involving an International Collaborative Partnership and Cross-Sectoral Team: Determining Capacity
Solina Richter
University of Alberta
Kathy Kovacs Burns
University of Alberta
An international collaborative partnership and cross-sectoral research team were established between South Africa and Canada to facilitate the development of a joint health services and policy research framework and accompanying knowledge transfer strategies related to the health and social issues of low-income and homeless people.
A workshop was organized in South Africa as a creative method to involve a critical mass of Canadian and South African participants including researchers, health and social service providers, policy decision makers, and individuals from low-income and homeless communities. Having the right discipline and sector mix for the partnership and team is critical for the implementation of the community-based participatory research (CBPR) approach and to the development of a practical health research framework concerning homelessness.
Expert research and experiential presentations along with open discussions were arranged, focusing on some crucial common issues concerning homelessness and the CBPR process. Discussions included describing the best approaches to develop true CBPR, to support multisectoral cooperation, ensuring engagement of community members, and setting up co-learning processes that focus on system development and local and global capacity building. One of the positive outcomes was the agreement to continue work on identified priorities needed to develop a guiding framework for sustainable research and knowledge transfer. One major determined weakness or gap was the existing capacity of the partnership and cross-sectoral team to be actively and meaningfully involved in either health research with vulnerable populations such as low income or homeless, or knowledge transfer. Capacity comes before research!
Reflexively Layering Analysis in an Interpretive and Visual Ethnography
Jill Riley
Cardiff University
In a reflexive, interpretive, and visual ethnography of a British guild of weavers, spinners, and dyers, the nature of textile-making, its contexts, and meanings were explored using constructivist grounded theory as a methodological approach. The study was informed by symbolic interactionist, phenomenological, and hermeneutic perspectives situating the researcher as an insider. Data were gathered during fieldwork through participant observation, in-depth interviews, photography, documentary sources, material culture, and the ongoing generation of reflexive memos. Analysis required sensitivity to the diverse nature of the data in that the different forms—textual, visual, and material—offered different yet complementary perspectives on textile-making.
This paper concentrates on the development of a reflexive layered approach to analysis. Drawing on Alvesson and Skõldberg's (2000) levels of interpretation, analysis incorporated four interconnecting layers, beginning with preliminary interpretations of the underlying meanings inherent in the data. Second, through a more integrated level of interpretation as fieldwork progressed, categories and themes were developed, establishing directions, patterns, and relationships in the data. Analysis also took into account the different layers of meaning embedded in the visual and material data together with narratives and personal histories inherent in the interview data. Third, because events unfold over time and are grounded in traditional sociocultural practices, their temporal and historical significances were important for contextual understanding (Denzin 2001, Clarke 2005). Finally, through raising the analysis to a metalevel, the significance of gender, politics, technology, and cross-cultural relationships were considered to interpret the meaning of textile-making as a socioculturally constructed occupation.
Exploring the Experiences of Patients with a Long-Term Condition and the Value of Case Management: A Qualitative Study
Elizabeth Ann Saxon
University of Wolverhampton
Susan Lillyman
Birmingham City University
The community matron was established in 2005 in the United Kingdom to care for patients with long-term conditions and reduce unplanned emergency hospital admissions. A qualitative study was used to gain an insight into the lived experiences of this patient group and the value of case management. Eleven semistructured interviews were carried out by the research team and data was then coded and themed to establish meaning following emersion of the data.
Emerging themes identified that patients had complex conditions; they went on to explain a typical day for them and the value of the community matron. They also voiced how this new group of staff acted as a bridge between secondary and primary care and how they helped them stay independent. Trust and confidence in the service was highlighted as well as the role of health promotion.
Further research in this area could include staff perception of the service and the cost-effectiveness of such a program of care. It is important to acknowledge the hidden benefits of a service in light of service evaluation and changes in health care. Sometimes it is easy to overlook the patients' view, and they deserve to have a voice in the debate; therefore, it is intended that this paper will add to this every important issue.
What Helps or Hinders People with HIV or AIDS to Make Decisions about Advance Directives and Guardianship?
Craig R. Sellers
University of Rochester
A minority (about 25%) of people with HIV/AIDS have completed advance directives (ADs) for their future health care wishes. Even fewer have made guardianship arrangements for their dependent (minor) children. ADs include living wills and health care proxies. Guardianship is a legal mechanism for assigning care for minor children in the absence of their parents. These plans are important to document because most adults would want their wishes to be carried out in the future even if they are unable to articulate them at the time.
In this qualitative study, people with HIV/AIDS were sampled theoretically from among community-dwelling adults in western New York State (USA). Verbatim transcriptions of audiotape-recorded in-depth interviews were analyzed using a constructivist grounded theory approach (after Charmaz, 2006).
Four overarching conditions were found that affected an individual's ability to make plans for the future: spiritual beliefs, interpersonal relationships and experiences with family/friends and health care providers, active/inactive substance use, and future time orientation. Each condition included several dimensions. Unless all or nearly all these conditions favored the ability to make plans, individuals were unlikely to be able to plan for their future health care or care of their children.
Clinicians routinely work with people with HIV/AIDS, yet the topic of planning for the future is difficult to discuss and is frequently avoided. Participants in this study were eager to talk to their clinicians, and suggestions for improving clinical practice as a result of these research findings are provided.
Cardiac Rehabilitation: Home and Belonging in Participant Narratives
Lisa Seto
University of Toronto
Jan Angus
University of Toronto
Jen Lapum
Ryerson University
Marnie Kramer-Kile
University of Toronto
Craig Dale
University of Toronto
Beth Abramson
St. Michael's Hospital
Alexander Clark
University of Alberta
Paul Oh
Toronto Rehabilitation Institute
Jennifer Price
Women's College Hospital
Susan Marzolini
Toronto Rehabilitation Institute
The home features prominently as the context of cardiac rehabilitation (CR) practices. This can be crucial to adherence as the home can hold multiple meanings for individuals, such as a place of origin, privacy, security, and belonging. In this ethnography, analysis drew on postcolonial theory to examine how CR participants with diabetes incorporate recommended lifestyle changes into their daily routines. Postcolonial theory is concerned with meanings of home and belonging, and with the representation of knowledge. Interviews and participant journals were completed with 16 men and 11 women, and 14 identified as immigrants to Canada. As home is a place where bodily practices are developed and maintained, many participant narratives were contextualized within the domestic sphere. However, “home” was further expanded within these accounts to include weekend cottages, workplaces, and other locations where participants spent significant time. These were all settings where tacit, practical knowledge was deeply embedded but also called forth practices that were not compatible with CR prescriptions. Several participants described accounts of “unhomely” experiences in settings where they felt uncomfortable or out of place. Many immigrant participants spoke about “back home” and the subjugated knowledges lost in immigration. Often discussion about a prior home exhibited a sense of belonging and nostalgia for a place more conducive to a healthy lifestyle. Analysis of these disjunctures highlights the creative work of redefining everyday settings and practices during CR. The findings demonstrate the multiple sites and forms of knowledge that CR participants must combine to envision meaningful lifestyle changes.
The Central Problem Experienced by Mothers Who Use Illicit Drugs
Jennifer Sharp
Curtin University of Technology, Perth, Western Australia
Anne Bartu
Curtin University of Technology, Perth, Western Australia
Illicit drug use is a major public health problem in Australia with illicit-drug-using women being one of the most marginalized minority groups in our society. With a paucity of literature related to the psychosocial phenomenon of the experience of illicit-drug-using mothers the problems faced by these women were not previously understood. To address this neglect, a grounded theory study in the Glaserian tradition was undertaken.
The central problem, relevant to all study participants, was the threat of loss. The threat of loss emanated from (a) judgment and disapproval by self and others; (b) being abused, controlled, overwhelmed, and dependent; (c) damaging myself and damaging my baby; (d) losing my baby or having my baby taken off me; (e) having a sense of not belonging; and (f) not trusting others and not being trusted. These problems resulted in loss of respect; loss of freedom; loss of health; loss of child; loss of identity; and loss of trust. Each loss experience had distinct characteristics but each was interconnected to other loss experiences where a loss in one area influenced or had a cascade effect to other loss experiences.
By providing a detailed interpretation of the scope, complexity, and interrelationships among different loss experiences, a better understanding of the lives of illicit-drug-using mothers has been achieved. This interpretation has provided a platform on which to articulate the basic psychosocial process these mothers used to manage the multiple challenges they faced.
The Inadequacy of Direction to Guide Novice Grounded Theorists
Jennifer Sharp
Curtin University of Technology, Perth, Western Australia
Anne Bartu
Curtin University of Technology, Perth, Western Australia
Many human experiences defy measurement, and to understand social phenomena, one needs to interpret the meanings humans assign to events and situations. Qualitative research allows researchers to explore participants' experiences from within their social context and interpret, conceptualize, and develop theory on human behavior, values, culture, and relationships. Grounded theory (GT) was first discovered by Glaser and Strauss in the 1960s. The disciplinary roots of GT were in social psychology and sociology, with theory development and symbolic interactionism being central to the method's purpose. Later the method was implemented by others with differing interpretations and apparent divergence from the original processes articulated by Glaser and Strauss. Today, the major authors on grounded theory have marginally different opinions on certain aspects of the method, which can cloud the clarity for neophyte grounded theorists.
For the novice, implementation of the method is not clear, and it is often not until the final stages of the research process that one understands what the literature was attempting to articulate, then it begins to make sense. This presentation describes implementing GT in the Glaserian tradition in a study of illicit-drug-using mothers in Perth, Western Australia, and provides a comprehensive conceptualisation of the recursive procedural process that happened over a prolonged period of time. The discussion covers the process from candidacy, through the development of the theory, and production of the report. It highlights the hazards and pitfalls and provides some suggestions of how to avoid similar traps.
Limiting Loss through a Process of Safeguarding
Jennifer Sharp
Curtin University of Technology, Perth, Western Australia
Anne Bartu
Curtin University of Technology
This grounded theory study provides a better understanding of the experiences of Western Australian mothers who use illicit drugs. Findings revealed a pervasive central problem of the threat of loss. In an attempt to overcome the threat of loss, the basic psychosocial process employed by mothers who use illicit drugs was: limiting loss through a process of safeguarding. The mothers engaged in this core process through three subprocesses: safeguarding during pregnancy, safeguarding as mother, and safeguarding self and “all that is mine.” The process was characterized by oscillation between reactive strategies of struggling and proactive strategies of taking back control that temporarily managed, modified, or negated immediate crises and persistent challenges.
Despite the extreme challenges these mothers faced, the goals, motivations, and aspirations demonstrated in this study paralleled those of mainstream mothers. They worked hard attempting to achieve “good mother” status with limited support and multiple intrusions on their lives. They demonstrated a capacity for strength and resilience but were repeatedly exposed to threats that undermined their capacity to achieve their goals.
The knowledge gained from this study advances previous interpretations of mothers who use illicit drugs as highly stigmatized, disadvantaged, and marginalized. Although they remain vulnerable, stigmatized, and marginalized, new interpretations of resilience, motivation, strength, and “good mother” have emerged.
“But We Can't Go Back”: The Effect of Raising Expectations Through Organizational Leadership Development: Consequences of Failure to Follow Through
Jude Spiers
University of Alberta
Greta Cummings
University of Alberta
How Lee
University of Alberta
Paula Lagenhoff
Cross Cancer Institute
Janice Sharlow
Deloitte Touche Inc.
Background: In 2004, a provincial cancer agency developed and implemented a leadership development initiative (LDI) to enhance organizational leadership; 259 leaders were invited to participate. This program was suspended due to provincial health care restructuring. The purpose of this paper is to explore participants' perceptions and attitudes toward investment in a time-limited initiative.
Methods: A mixed-method design explored whether LDI implementation influenced job satisfaction, emotional health, and leadership practices of LDI participants, and work life culture. Qualitative focused ethnography (18 focus groups and 13 individual interviews) explored perceptions of the experience and purpose of the LDI.
Results: The LDI was regarded as a critical strategy for helping leaders grow and cope with change and to help in changing organizational leadership work life to a more collaborative and inclusive model. Quantitative findings suggest levels of cynicism and emotional exhaustion had significantly increased. Qualitative inquiry explored the notion of an organizational history of “flavor of the month” development initiatives and growing skepticism, burnout, and disengagement of organizational employees. “Aggressively optimistic” participants argued for the inherent value of the initiative but “hedged their bets” by “enjoying” the experience but not being committed to it until there was significant evidence that the program would be institutionalized in the agency.
Research implications: It is difficult to quantitatively detect change in leadership behavior or workplace culture as a result of leadership development programs. In this case study, qualitative work was critical to interpreting the meaning of somewhat negative and distressing quantitative indicators of worsening work life.
Exploring the Experience of Breastfeeding through the Lactation Management Model
Rebecca Stanley
Vancouver Island University
Karyn-Grace Clarke
Vancouver Island University
The benefits of breastfeeding have been well documented in the literature, leading to the current recommendations for exclusive breastfeeding to 6 months with continued breastfeeding up to 2 years and beyond. However, in Canada the majority of infants do not receive breast milk for the recommended length of time. Understanding the experiences of breastfeeding women is crucial to understanding the low rates of breastfeeding, which persist despite considerable promotion of “breast is best.”
Our study explores the breastfeeding experiences of 10 women from the third trimester of pregnancy until weaning in an emergent longitudinal case study approach. This study is unique as documentation of breastfeeding experiences beyond 6 months is not evident in the literature. The study framework follows the lactation management model, which provides women with a high level of professional support from an International Board Certified Lactation Consultant (IBCLC).
The antenatal portion of our study focused on the breastfeeding perceptions and expectations of the women and their partners and factors that influenced those beliefs. Fear of the breastfeeding experience and discomfort with breastfeeding in public were prominent findings. Factors that influenced breastfeeding beliefs included self-determination, body image, sexuality, health care providers, information sources, family, partner, lifestyle, and employment.
The second portion of our study will analyze the breastfeeding experience from birth to 12 months. Findings from our study will contribute to our understanding of the multidimensional nature of breastfeeding and will have implications regarding how health care services are structured to effectively support breastfeeding women.
Expectations of Return to Work for Injured Workers with Subacute Back Pain: A Grounded Theory Research Study
Alison Stewart
University of British Columbia
Emily Polak
University of British Columbia
Richard Young
University of British Columbia
This current qualitative grounded theory research study is focused on unpacking the dynamic, complex, and multifaceted construct of expectations of return to work from the subjective perspective of the injured worker. This presentation will provide some background on the current research literature about subacute low back pain as well as the role of workers' expectations in returning to work. The role of expectations is believed to have more influence on recovery than objective findings in disability (Schultz et al., 2007).
We will touch on the stance of the researchers in relation to our topic and the reasoning behind our choice of qualitative grounded theory method to conduct this investigation into the construct of expectations.
In this presentation we will present a grounded theory based on themes that have emerged from this exploratory qualitative investigation into the construction of expectations of return to work for injured workers' with nonspecific subacute low back pain.
By examining where expectations come from, we hope to better understand the different factors that relate to the formation of expectations, and the implications for psychosocial interventions. Using a biopsychosocial approach, we intend to build on current understanding of injured workers' subjective perspectives in relation to return to work. It is hoped that the findings of this study will contribute to tailoring effective interventions for injured workers who are off work due to nonspecific subacute low back pain. An enhanced understanding of the construct of expectations will fill a gap in current research (Pransky et al.,2005; Schultz et al., 2007).
Perceptions of Gastrostomy Feeding in People with Developmental Disabilities: A Comparison of Parent/Substitute Decision Makers and Health Care providers
Beverley Temple
University of Manitoba
Many of the studies currently available regarding the use of gastrostomy feeding in people with developmental disabilities (DD) have focused on the surgical and growth outcomes. This presentation will describe the findings of a study conducted through a residence for people with DD in Manitoba. Interviews were conducted with both parents/substitute decision makers (SDM) and health care providers to consider the question, What are the differences and similarities of parent/SDM and health care providers' perspectives of the use of gastrostomy tubes for feeding for people with DD?
This cross-sectional descriptive qualitative study used interviews (focus group and individual). Recruitment of participants used postings, mail-outs, and snowball techniques to recruit people with a variety of perspectives about the topic. All interviews were taped and transcribed. Thematic data analysis was completed using NVivo data analysis software to facilitate identification of common themes and characteristics of the themes arising from the interviews. The discussion is focused on interpreting the differences in perspectives and implications for possible changes in practice. Gastrostomy feeding is a disconcerting topic for parents and as health care providers gain a better understanding of parental perspectives, discussions with parents during this important decision-making time will be less confrontational.
A Therapeutic Psychopoetics: Metaphors in Narratives of Cancer and Aging
Ulrich Teucher
University of Saskatchewan
Rita Hamoline
University of Saskatchewan
Chad Hammond
University of Saskatchewan
Jay Cowsill
University of Saskatchewan
Devon Andersen
University of Saskatchewan
Wendy Duggleby
University of Saskatchewan
Roanne Thomas-MacLean
University of Saskatchewan
Although cancer can strike at any time, it is primarily an illness of the aging, yet hardly anything is known about the difficulties with which older cancer patients struggle as they try to make meaning of their experiences. Obviously, cancer is an experience that is enormously difficult to put into language: How should the suffering, uncertainty, and fear of dying be stated? Metaphors help to address these difficulties and indeed, cancer patients' narratives abound with metaphor. Therefore, it is important to examine how these images are used in the search for meaning.
Building on a typology of more than 300 metaphors of cancer and its treatment that I have gathered, I have developed a triple methodology, a “therapeutic psychopoetics,” capturing a variety of aspects in life with cancer. A quantitative analysis helps to identify various general dimensions of metaphor usage and serves as a background for a qualitative, hermeneutic poetics of subjective metaphor use in cancer narratives. My past work experience as an oncology nurse serves to help me evaluate the differential therapeutics of these metaphors: The same metaphor might be beneficial to one patient but destructive to another. We have employed this therapeutic psychopoetics for the proposed oral presentation, analyzing published and unpublished cancer narratives written by aging cancer patients (e.g., Broyard 1992; French, 1998; Lerner 1990; Matthews 2007; Price 1994; Rieff, 2008; Terzani, 2007, 2008). The observations can enable health professionals to know what to listen for in older patients' narratives so that cancer care can be improved.
The Role of Men in Maternal and Newborn Health
Rita Thapa
MIRA
Joanna Morrison
University College London
Anthony Costello
Centre for International Health and Development
Maternal and neonatal mortality rates are highest in developing countries, where most women give birth at home without trained health workers. Intervening at the community level is important when considering how to meet Millennium Development Goals 4 and 5. In rural Nepal, women of reproductive age have less power within households, and men are often the key decision makers in this context. Despite this, few attempts have been made to involve men in community-based efforts to reduce maternal and neonatal mortality. We describe the role of men in caring for women and newborns in rural Makwanpur District, Nepal, and explore the factors that facilitate or hinder men's involvement in care. Qualitative data were collected using focus group discussions, semistructured interviews, and key informant interviews with purposively sampled stakeholders. Data were collected from married men, married women, birth attendants, and priests. Data were tape-recorded, transcribed, translated into English, and analyzed using NVivo software. We found that that although men were concerned about the health of their female family members during pregnancy, childbirth, and the postpartum period, many factors prevent them from taking a more active role. Social pressure and social taboos, family structure, sex of the child, and lack of knowledge about how to care for neonates make it difficult for men to participate in the care of newborns particularly. These findings will help policy makers and program implementers to design interventions to motivate men and the community to improve maternal and neonatal health.
The Illusion of Reassurance in Health Care
Gerard Tobin
University of New Hampshire
Purpose: To explore the lived experience of recipients of a cancer diagnosis through focusing on the narratives regarding how the diagnosis was given and the power of words used by health care professionals when dealing with them.
Background: It is estimated that 1.4 million new cases of cancer will be diagnosed in 2009 (ACS). How that diagnosis is given to the person is vitally important for their psychological, physical, and spiritual well-being. To be given a cancer diagnose is a traumatic experience, the psychological impact of which cannot be underestimated.
Methods: The study was guided by hermeneutic phenomenology. Snowball sampling was used to invite people who received a cancer diagnosis to participate in the study. The focus of this presentation will be on the narrative of 10 recipients and the meanings which they attributed to their story. Unstructured in-depth interviews were used to collect the data. The goal of analysis was to provide descriptions that capture and communicate the meaning of the lived experience.
Results: Three themes emerged that encapsulated the experience of recipients, recognizing the trajectory from the prediagnostic stage to the post labeling of a cancer diagnosis and its meaning for the person so diagnosed.
Conclusions and implications: Truth and openness were seen as critical to enabling the person to cope with their diagnosis. The need to have one's suspicions acknowledged and not dismissed and an overwhelming cry for recognition as a person were paramount
Qualitative Bereavement Research: Are Principles Sacrificed by Process to Please Research Ethics Review Boards?
Gerard Tobin
University of New Hampshire
Joan Lalor
Trinity College Dublin, Ireland
Agnes Higgins
Trinity College Dublin, Ireland
Qualitative health researchers frequently immerse themselves in the research field while undertaking research studies of sensitive topics. Frequently relationships develop between the interviewer and interviewee that are unpredictable when the project is planned. Although in recent times recognition has been given to the myriad of boundary issues that can emerge in qualitative research, little attention has been afforded to the influence of ethical review boards on the process. The personal interaction that occurs during one-to-one interviews is undoubtedly critical in the process of data collection, yet this core method of data collection is frequently highlighted by research ethics committees as a potential source of harm to potential participants.
In this paper presents the experience of three researchers undertaking bereavement research in Ireland. There is a tendency for bereaved persons to be conceptualized as vulnerable and in need of protection during the process. Committee feedback frequently raises concern that participants might be traumatized by the interview process rather than benefit from the process.
Examples of the feedback received from committees and participants' responses to the experience of being interviewed are offered as illustrations to advance arguments and strategies that may be utilized by researchers seeking ethical approval but remain beneficial to bereavement research. Qualitative researchers are urged to consider the impact of a process approach to ethical review on the experience of participants taking part in bereavement research and the quality of future studies that ignore the personal interaction so fundamental to the process.
Routinizing the Stigmatizing Process when Living with Psoriasis
Margaretha Uttjek
Dermatology and Venereology Clinic, University Hospital
A study with a sociological approach of the individual's everyday life with psoriasis was performed in northern Sweden. Eighteen persons with psoriasis from a county in northern Sweden participated in qualitative interviews.
An obvious finding was that to cope with consequences of the disease, that is the visibility and stigmatizing process, commonly used strategies were routinization of treatment as well as adjustment to the stigmatizing process, and acceptance. The stigmatizing process was worst in the younger ages and the first time after onset of psoriasis. These strategies were developed with age, and mostly they had an empowering effect. By using routinizing, they helped themselves to develop a good enough personal quality of life. However, most of them saw nothing positive about having psoriasis. The conclusion is that by using routinization of treatment and stigmatizing process the participants maintained or regained their self-esteem and empowered themselves.
Becoming an Evidence-Based Practitioner: A Three-Level Empowerment Process
Brigitte Vachon
Université de Sherbrooke
Marie-José Durand
CAPRIT
Jeannette LeBlanc
Occupational therapists are encouraged to use an evidence-based practice model to inform their clinical decisions with best current evidence. The aim of this study was to empower occupational therapists who had recently taken a formal CE program in the field of work rehabilitation to develop their ability to use an evidence-based practice model in their work rehabilitation practice.
A collaborative research methodology was used to explore and support the participants in the adoption of this practice change. Eight occupational therapists were recruited to participate to a reflective practice group that was convened for 12 meetings and held during a 15-month period. The data collected were analyzed using the grounded theory method. The results of this study revealed that participants progressively learned to improve their utilization of an evidence-based practice model by adopting a three-level empowerment process: Deliberateness was used at the self level; client-centeredness was used at the clientprofessional interaction level, and system-mindedness at the system level. Evidence-based practice took place when a change occurred at either the professional-client interaction level or the system level. The results from this study contributed to an improve understanding of the complexity of evidence-based practice change and supported the need to combine an individual and systemic approach to empower professionals in becoming evidence-based practitioners.
Listening to First Nations and Inuit Youth in Canada: A Qualitative Investigation for the Development of Adolescent Alcohol Abuse Early Interventions
H. A. Van Wilgenburg
Dalhousie University
Nancy Comeau
Dalhousie University
Pamela Collins
Dalhousie University
Sherry Stewart
Dalhousie University
Earlier, we developed a personally- meaningful set of interventions for preventing alcohol misuse in high personality risk adolescents. We are currently applying this method with First Nations and Inuit teens. In a quantitative study, we investigated associations between personality factors and drinking motives as applied to First Nations and Inuit teens' alcohol use. Finding supported differential pathways of sensation seeking (SS) to enhancement motives, anxiety sensitivity (AS) to conformity motives, and hopelessness (H) to coping motives, all risky drinking motives.
In a qualitative investigation, 64 youth from three provinces at high personality risk for alcohol abuse (i.e., SS, AS, or H) were interviewed about their motives and contexts for drinking. Results substantially extended the quantitative study findings. For example, AS teens reported appreciating alcohol because drinking helped them feel less anxiety about fitting in with others in social situations. We then developed personality-matched, motive-specific early interventions to meet First Nations and Inuit at-risk adolescents' needs, with stories and images drawn by First Nations and Inuit teen artists that were based on our earlier study findings. The cognitive-behavioral techniques to be used have been previously demonstrated effective with adults and teens from the mainstream culture. We plan to test the efficacy of these interventions in First Nations and Inuit youth.
Moving beyond a Secondary Analysis
Kathleen Watts
Keele University
Jane Richardson
Keele University
Bie Nio Ong
Keele University
Within this presentation I will introduce a methodology that is being piloted as a way in which to combine metasynthesis techniques with a qualitative secondary analysis. This approach is being developed to examine a number of data sets that have been collected by the Arthritis Research Campaign National Primary Care Centre at Keele University, United Kingdom, that look into the experiences of living with a range of chronic pain conditions.
The concept of combining the two techniques will be discussed as a way in which contextual information can be incorporated into the secondary analysis while also allowing for a more thorough reanalysis than a metasynthesis on its own can achieve. In approaching the data in this way, a more robust methodology can be created that will generate findings with enhanced validity.
It is proposed that through using this methodology and acknowledging it as a metatechnique, a midrange theory can be produced. The wider aim of my research is to reanalyze the multiple datasets to develop a theory that is applicable to chronic pain in general.
Qualitative Research Online: Using E-mail Focus Groups
Steven Whitcombe
Cardiff University
Jill Riley
Cardiff University
This paper focuses on the use of e-mail focus groups as part of a mixed-method project investigating occupational therapy workforce development in England. Following an online survey, two e-mail focus groups were used to gather qualitative data. One explored therapists' perceptions of their practice and the second concentrated on student supervision. The focus groups were designed to run asynchronously over 5 working days to minimize work disruption, enabling therapists from a wide geographical area to participate flexibly.
Closed groups were set up via the university's e-mail system with an administrator to filter incoming and outgoing mail. Groups were facilitated by a research team member. Because of the virtual nature of the group, respondents were asked to provide a personal pen picture as an initial introduction. Separate questions focused the discussion each day, prompts and supplementary questions elicited clarification. Daily digests were posted for comment and verification and a summary of the key points from the discussion were provided at the end of the week.
E-mail focus groups had advantages in that respondents had time to think before responding. Transcripts were temporally ordered, easing data processing and analysis. The immediacy of the data meant that findings can be discussed by the research team on a daily basis. The asynchronous nature of the process and absence of nonverbal cues, however, meant that there was a lack of spontaneous interaction and respondents could “go cold” on a question. Facilitators needed to be continually responsive and without coordination the process could become unmanageable.
Intercultural Caring in Maternity Care from a Patient Perspective: A Metaethnography
Anita Wikberg
Åbo Akademi University, Finland
Katie Eriksson
Åbo Akademi University, Finland
Terese Bondas
University of Borås, Sweden
There are many qualitative transcultural nursing, maternity care, and caring studies, and therefore metastudies are warranted to advance evidence-based care and disciplinary knowledge. The aim of this study, which is part of a doctoral dissertation, is to explore and describe intercultural caring in maternity care research from a patient perspective.
The theoretical perspective is Eriksson's caritative theory and Wikberg and Eriksson's model for intercultural caring. In total, 40 studies are synthesized using Noblit and Hare's metaethnography method. The following opposite metaphors were found: caring versus noncaring, language and communication problems versus information and choice, access to medical and technological care versus incompetence, acculturation: preserving original culture versus adapting to new culture, professional caring relationship versus relatives and community involvement, caring is important for well-being and health versus conflicts cause interrupted care, and vulnerable women with painful memories versus racism. “Alice in Wonderland” emerged as an overarching metaphor to describe intercultural caring in maternity care from a patient perspective. Furthermore, intercultural caring is seen in different dimensions of uniqueness, context, culture, and universality; there are specific cultural and maternity care features in intercultural caring; there is an inner caring consisting of respect, presence, and listening as well as external factors such as economy, organization, power, and legal status of the patient that have an impact on caring.
The presentation will focus on the refutational accounts because this type of metaethnography has not been located. The use of theory to increase understanding in a metaethnography will also be discussed.
“I Just Want to Be a Paramedic”: Experiences of Students on a Preregistration Foundation Degree in Paramedic Science
Julia Williams
University of Hertfordshire
In the United Kingdom there are several options for people who want to register as a paramedic. There are 2-year, 3-year, and 4-year higher education pathways that all lead to registration as a first-level paramedic. However, there is no research that looks at differences between the various programs in terms of outcomes relating to practitioners' knowledge, skills, and competence. As a starting point, this exploratory study focuses on students' experiences of undertaking a 3-year foundation degree in paramedic science. A purposive sample of students participated in individual reflexive interviews that were recorded, transcribed, and subjected to rigorous processes of thematic analysis. Participants reported feelings of “belonging,” which they attributed to being accepted by senior crew-mates who viewed them as “workers” rather than students. Although the participants had no personal experience of 2-year programs, they believed that these were not long enough to gain adequate “on-the-road” clinical experience; interestingly, participants emphasized length of time in clinical settings rather than the quality of the exposure. All participants supported higher education routes to professional registration, identifying that increased levels of knowledge and enhanced skill acquisition are essential if paramedics are to maintain credibility as one of the allied health professions. To build on the findings of this study, future research should include investigation, not only of students' experiences on different programs but also of whether newly registered practitioners differ in their contribution to patients' care depending on their choice of educational route to registration as a paramedic.
Power Dynamics in Qualitative Health Research: Do They Really Matter?
Julia Williams
University of Hertfordshire
When using qualitative methods researchers must consider the impact on the relationship between researcher and participants particularly in respect of power dynamics and locus of control. These can be especially important when health care professionals engage in research, irrespective of whether the researcher is directly involved in provision of the participants' health care.
This presentation focuses on some of the issues encountered during research when participants knew that the researcher had professional qualifications and expertise in areas outside the specific remit of the study. Examples of this include being known to be a registered nurse when interviewing other staff and patients, being part of the students' teaching faculty while researching their experiences on pre-registration programs, and being identified as a health care professional with a knowledge of the social welfare system when working with street homeless people. To illustrate how power dynamics between researcher and researched can provide interesting challenges to data collection and subsequent analysis and interpretation, examples will be drawn from studies which used a variety of methods including observation and prolonged engagement, focus groups, and individual interviews. The discussion will address some of the everyday issues that arose and incorporate examination of the decisions made as the research progressed. Consideration will be given to measures taken to minimize potential bias within the studies, the researcher's experience of the insider/outsider phenomenon, and the construction and impact of the power relations between participants and researcher.
Coresearching the (Extra) Ordinary Experiences and Practices of Rural Family Therapists
Annette Woodhouse
Monash University
Although family therapy practice and theory has a rich and diverse representation in the literature, less has been written or is known about those family therapists who work in rural regions. Given this and the inherent issues of working rurally such as, the social disadvantage, isolation, limited access to services, education, supervision, and the long-standing drought it would seem relevant to work with rural family therapists themselves to understand their experiences and realities of working rurally in the Australian context.
This research project is situated within an interpretive theoretical paradigm influenced by social constructionist and feminist research .A participatory action research strategy shapes the overall project, including the data generation and analysis. This research methodology allows for collaborative coresearch with rural family therapists to explore a multitude of factors in relation to practice that are not always visible while focusing on therapists' competencies.
This fully collaborative insider research has raised significant issues of rurality, power and the need for relational ethics in working with rural professional colleagues. This presentation reviews the complexity of these issues informed by the development of an approved ethical framework during this research project. This presentation contributes to the sparse literature on rural family therapists while providing a potential ethical model for collaborative co-research with rural participants.
Abstracts, Poster Sessions: Listed alphabetically by first author
Pregnant Women's Process of Decision Making to Stay or Leave a Violent Intimate Partner Relationship
Kathryn Banks
University of Alberta
Although research has been conducted for more than 20 years on the consequences of abuse during pregnancy, little is known about the process of decision making regarding the tension between seeking safety and creating a two-parent family. The aim is to develop an in-depth understanding of pregnant women's decision-making related to staying in or leaving a violent intimate relationship. A constructivist grounded theory research design will support substantive theory development about pregnant women's decision-making about whether to stay in or leave a violent intimate partner relationship. This is based on the symbolic interactionist assumption that individual choices and actions arise from situated meanings and understandings of experience.
Feminist standpoint theory will guide the research in examining the position of women within their experiences, the diversity as well as shared patterns of women's experiences and the inequities that shape women's choices and actions. Data will be generated through individual interviews with women who are 18 years of age and older who have experienced intimate partner violence during a current or previous pregnancy. Women will be asked to reflect on their experiences of making decisions about living with or leaving a violent intimate partner relationship during pregnancy. Data will be analyzed concurrently with data generation using constant comparative techniques to identify themes, and emerging theoretical relationships. The analysis will be guided by a critical feminist questioning of underlying values and social conditions that affect women's experiences. Study findings will inform policy and program decisions to promote women's and children's health and safety.
Understanding the Online Learning Experience as a Phenomenon of Interest
Helen Biblehimer
Mansfield University, Pennsylvania
During the design of three online graduate courses, three separate dedicated discussion boards were created to facilitate the formation of learning communities. The first was a traditional discussion board that posited questions for discussion about a topic. A second was dedicated to Helping Each Other, and its purpose was to empower students to answer others questions, and a third, “By the Water Cooler,” was created and was intended to simulate the interaction between students before and after class in a brick-and-mortar classroom. After the researcher had taught these classes, and read the entries on the Helping Each Other and By the Water Cooler for 3 years, it became apparent that there seemed to be themes emerging from the communication between students on two of the three discussion boards and that this written dialogue could be used as a data source for a phenomenological research study.
The purpose of this ongoing phenomenological study is to understand the phenomena of online learning through the dialog placed on course discussion boards. A hermeneutic phenomenology approach, using Ricoeur's perspective, is being used to help describe the online learning experience of graduate students. This ongoing study demonstrates an innovative strategy for data collection. Preliminary emerging themes and the implications for improvement of online course design and teaching will be presented in order to promote a better understanding of the phenomena, thus influencing course design.
Caring for Older Adults: Making Meaning of a Complex Practice
Sherry Dahlke
University of British Columbia
Nursing practice with older adults is influenced by multiple complex factors, ranging from shifting population demographics and health care reform to personal knowledge and values about aging. Because nurses hold a pivotal role in care delivery, understanding the complexities of nursing practice with older adults could provide an opportunity to plan care improvements for an aging population. Therefore, the purpose of this study is to explore how nurses make meaning of their practice with older adults and the factors influencing this process.
I propose to examine this question using grounded theory (GT) methods directed by a symbolic interactionism (SI) perspective. Drawing on SI will allow me to explore how nurses make meaning of the care they provide to older adults. SI will also enhance the rigor of GT methods through the addition of reflexivity and relationality, to ensure that as researcher I consider my engagement in meaning making with participants. The study will be conducted in an acute care environment; interviews and participant observations of nurses' interactions with older patients and the health care team will be analyzed using GT methods of concurrent data collection and data analysis, and constant comparison. Theoretical sampling will direct further participant sampling as the research process unfolds. The product of this study will be a GT explaining how nurses make meaning of their practice with older adults and the multiple factors influencing this process. This theory will ultimately provide a basis for understanding how to improve care for this growing population. how nurses make meaning of their practice with older adults and the multiple factors influencing this process. This theory will ultimately provide a basis for understanding how to improve care for this growing population.
Deaf Children's Parents and Siblings' Opinions on the Use of Brazilian Sign Language
Maria de Fátima Françozo
State University of Campinas
Regina Akamine
State University of Campinas
Gisele Lourenço
State University of Campinas
This research was conducted to find out about deaf children's parents' and siblings' opinions on the use of sign language with the deaf child, given that rejecting to learn and use such a language is frequent in Brazil. Qualitative procedure was employed, using interviews with open-ended questions as the tool to collect data. Ten parents and 10 siblings were chosen as the participants of the research. The data were assembled into analytical categories and then described.
The participants said they did not know anything about sign language until the deaf child was enrolled in the rehabilitation agency, but some of the parents subsequently mentioned that they had at least seen the manual alphabet. The parents remembered they had a negative reaction when told that they should learn sign language to use with their child on an everyday basis. Some parents first refused to learn, worried about the possibility of the child never talking once she started to sign. Others thought it would be too difficult to acquire the language. Only a few of them indicated they accepted it as a challenge. As far as the siblings are concerned, there were no negative feelings about learning the new language, but the access to sign language classes was difficult due to time and distance. Most of them had their mothers as their sign language instructor. The difficulties in accepting sign language are very much related to the lack of information about deafness as well as to prejudice against it.
Strabismus and Subjective Quality of Life
Marion Habersack
Medical University of Graz
Petra Petz
Free Researcher
Strabismus is a significant problem with considerable psychosocial effects on health. In cases of strabismus, in Austria coverage of costs is only given within the procedure of treating the medical relevant diagnose; no coverage of costs is given for “cosmetic” or subjective handicaps due to strabismus. However, patients experience dysfunctionality, abnormality, and social exclusion in all aspects of life. Strabismus affects one's social and economic status.
The study design was based on extensive history and narrative interviews. The findings of narrative interviews were consistent with those of patient history and showed that the physical dysfunctionality is not the main criterion for not feeling healthy and that the consideration of social determinants and gender categories are critical for proper diagnosis and treatment. We recommend that medical professionals view the strabismus affliction in different ways through modified models of illness. These models are of utmost importance for qualitative health research. The model of P.-E. Schnabel corresponds with the experiences of the participants in our study. Schnabel's main focus is the transition from the state of health to illness and vice versa. There are patients who feel handicapped (subjective dimension) but who are not diagnosed by the medical professionals as strabismus is usually an aesthetic concern; however, others perceive them as abnormal. Those who do not feel handicapped do not consult medical professionals and are thus never diagnosed, but they are nonetheless seen as being abnormal.
Tying the Knot: A Bow Tie Model for Chronic Illness and Transformational Learning Theory for the Adult Learner as Patient
Richard Hovey
University of Calgary
For patients living with chronic illness, the relationship between their experience in the health care system and their progression through complex and evolving learning needs is critical for learning to live with both the biomedical/pharmacological treatment and the social/emotional aspects toward living well but differently than before their diagnosis. Transformational learning theory and practice affords such an efficacious way forward. Through the use of a bow tie model, the meaning of living with a chronic illness (osteoporosis), derived from hermeneutic research data of 12 participants, was used to consider relevant adult education theories and practices to meet these learners' complex needs. A bow tie model proved to be an effective reflective guide to assist the health educator in the knowledge translation and transfer process. The research demonstrated that people with a chronic illness diagnosis find their way toward meaningful reengagement with their life and that this process can be facilitated and/or enhanced through the consideration of adult learning theory and practice. The bow tie model provided a successful conceptualization means to tie reflective research-into-educational practice for transformative adult learning humanistic scholarship.
Retiring Early to Provide Care: The Decision-Making Process and Perceptions of Choice
Áine Humble
Mount Saint Vincent University
Janice Keefe
Mount Saint Vincent University
Some caregivers retire earlier than planned due to caregiving demands, which has important health implications (e.g., loss of health plans, lowered retirement savings, and unexpected restructuring of retirement expectations). Little is known about how caregivers decide to retire, though: what factors are taken into account and how much control individuals feel they have in the decision. How choice plays out in individuals' decisions is important to understand, given that it is a major determinant of retirement health outcomes (Shultz, Morton, & Weckerle, 1998). As the second part of a mixed-methods study, 44 Nova Scotians (two-thirds were women, more than half were from rural areas) were interviewed using semistructured interviews. Questions focused on employment histories, caregiving, the decision to retire, retirement planning, and retirement experiences. MAXQDA software assisted with the analysis. Techniques included open, focused, theoretical, and descriptive coding; memo writing, and searches for code co-occurrences.
For most caregivers, deciding to retire was driven by a sense of morality about caregiving; individuals felt morally obligated to provide care (e.g., through a promise made to someone). Strains over employment and family responsibilities were key, but concerns about their own well-being (e.g., psychological, financial) were relatively unimportant. Those who perceived full choice in their decision, compared to those who felt they had less or no choice, were more likely to also be financially prepared for retirement. Regardless of perception of choice, however, most individuals wished to return to work, and many were disappointed, disenchanted, or angry with their retirement experiences to date.
Living in Long-Term Residential Care: A Critical Ethnography of Person-Centered Care
Elizabeth Kelson
University of British Columbia
Recent media reports and personal accounts of poor living and working conditions in care facilities has intensified Canadians' concerns over the quality of long-term residential care (LTRC). Given that up to 90% of persons in care in Canada have moderate to severe dementia (Herrmann & Gauthier, 2008) and that resources are increasingly scarce (Leibing, 2006), the need to address institutional care has never been more pressing (Reid et al., 2007). Traditional (biomedical) care has been criticized for its inability to address the psychosocial context of care. As an alternative, person-centered care (PCC) models, which foreground resident biography, have steadily grown in popularity. Despite this, issues of high staff turnover, low job satisfaction, and the marginalization and stigmatization of the “nursing home” persist. Care facilities continue to be sites of social and physical segregation (Reed-Danahay, 2001), operating as “heterotopias of deviation” (Foucault, 1967) where residents and staff coexist in a culture that challenges personhood and citizenship (Kitwood, 1997; Vesperi, 1995). A research gap exists in understandings of how PCC is enacted and how these models actually mitigate impediments to LTRC. The purpose of this ethnographic study is to critically examine PCC in LTRC by (a) describing a PCC culture of care; (b) examining how PCC influences and constructs the experiences of residents, families, and staff; and (c) understanding current conditions to work toward transformation. Data generation methods include participant observation, photo-elicitation, interviews (with residents, families, and staff), focus groups, and reviews of provincial and institutional policies.
Indigenous and Rural Understandings of “Inclusion” for Organizational and Community Physical Activity Promotion: Narratives from Health Promotion Practitioners and Social Workers in Rural Alberta
N. Ernest Khalema
University of Calgary
Christina Loitz
University of Alberta
Nancy Spencer-Cavaliere
University of Alberta
The analysis presented in this poster highlights the perceptions of what “inclusion” means in the context of physical activity promotion by a qualitative sample of Indigenous social workers and rural health promotion practitioners in Alberta. The data were analyzed as part of a multisector knowledge mobilization health promotion project commissioned by the Alberta Centre for Active Living (ACAL) entitled Physical Activity for All: Understanding Inclusion. The study aimed at understanding how the concept of inclusion is articulated at the programming, policy, and practice level in health promoting organizations (HPOs). Literature reviews of the ecological model for physical activity promotion (Sallis & Owen, 1999) emphasize the need for a broad perspective that not only includes individual factors, but also contextual factors (cultural, economic, social, and environmental) of physical activity promotion. Although Indigenous social workers and rural health promotion practitioners acknowledge the importance of individual characteristics (i.e., intrinsic motivation), they caution that HPOs tend to overlook sociocultural and environmental determinants of physical activity promotion at both the organizational and community levels. Thus, the impact effectiveness of physical activity promotion programs targeting vulnerable and underserved groups depend on culturally inclusive and con-textually sensitive physical activity promotion models. The preliminary analysis of the data therefore suggest that for inclusion to be institutionalized within HPOs, existing physical activity promotion models must emphasize a more comprehensive approach that acknowledges the significance of broader contextual determinants of physical activity related activities such socioeconomic status (SES), racialization processes, locality, and the political/policy climate.
Health Care Seeking Behavior of Newly Diagnosed HIV-Infected People from a Rural and Urban Community in South Africa
Annamarie Kruger
North-West University
Minrie Greeff
North-West University
In the PURE-South Africa study, 1,999 volunteers who regarded themselves as healthy enrolled after giving signed consent. Although participants saw themselves as healthy, the contrary was true for some participants when they reported during the baseline survey in 2005. Of these participants, 332 were diagnosed with HIV. These participants with newly identified health problems were immediately referred to the local health clinics or hospitals with a referral letter from the principal researcher. The aim of the research was to explore the health care seeking behavior of the people newly diagnosed with HIV after having been referred to a health care facility a year earlier.
A survey and an exploratory and descriptive qualitative research design were followed. Convenient sampling was conducted. Data was collected by means of a short survey list followed by an in depth interview. Each researcher wrote extensive demographic, descriptive, and reflective field notes during and after each interview. For the quantitative data in the survey list, frequency and cross-tabulations were performed using the SPSS 15 statistical package. The qualitative data were analyzed using the open coding technique of content analysis.
Only 27.7% of participants newly diagnosed with HIV, in fact, visited a health care center and sought medical care. Three main aspects influencing health care behavior of the participants became clear during the interviews: (a) various forms of stigmatization, (b) aspects around the illness itself, and (c) factors influencing access to health care services.
Using an Ecological Approach to Understanding the Barriers and Facilitators to Physical Activity Promotion among Seniors in Rural and Urban Contexts
Christina Loitz
University of Alberta
N. Ernest Khalema
University of Calgary
Nancy Spencer-Cavaliere
University of Alberta
Physical activity is recognized as a method of prevention and treatment of a wide range of physical and psychological disorders (Dishman et al., 2004). According to the 2009 Alberta Survey on Physical Activity (Loitz et al, 2009), commissioned by the Alberta Centre for Active Living (ACAL), 63% of adults over 65 years are considered inactive. As a result, ACAL explored barriers and facilitators to physical activity in a project entitled: Physical Activity for All: Understanding Inclusion. This poster presents the preliminary findings of perceived barriers to active transport, leisure time physical activity, and household physical activity among a qualitative sample of older adults (N = 21) in three different communities (urban, semi-urban, and rural). The barriers and facilitators to physical activity were conceptualized according to Sallis et al.'s (1997) ecological model that highlights interactions between intrapersonal, interpersonal, community, environmental and organizational levels of influence for physical activity promotion. A series of focus groups were conducted, transcribed verbatim, and analyzed systematically to identify recurrent themes.
According to the participants' narratives, the ecological model was applicable. Participants did not consider active transport a plausible type of physically active in rural areas or smaller cities due to environmental barriers. Household physical activity was primarily impeded and facilitated by individual level factors. Community connectivity and inclusive practices were highlighted as having a positive impact on physical activity participation. The data highlight the salience of the ecological model to assist in planning and strategizing tailored interventions for older adults while taking into consideration the size of the community.
(Ad)ministering love: Providing Family Foster Care to Infants with Prenatal Substance Exposure
Lenora Marcellus
University of Victoria
Infants who have experienced prenatal substance exposure are frequently cared for within the environment of out-of-home care, or foster care; foster families are the primary caregivers within this system and therefore provide the environment and relationships key to supporting healthy development of infants already vulnerable due to multiple health and social challenges.
This qualitative research study identified the process of becoming a foster family and providing family foster care giving within the context of caring for infants with prenatal drug and alcohol exposure. A constructivist grounded theory approach was used to study foster families (including mothers, fathers, birth and adoptive children) who specialized in caring for infants within a Canadian provincial child welfare system. The basic social process of (ad)ministering love was identified. This presentation will describe the three phases of this process and the core concepts within each phase.
The theoretical framework explains and accounts for well-functioning family foster homes that care for infants with prenatal substance exposure and serves as a basis for improved practice, policy development, education and training, research and evaluation. Information from this study will be useful for those interested in strengthening the system of foster care for the infant population, including health and social service providers who support infants and foster families, policy makers, particularly within the child welfare system, and foster families themselves.
Framing Obesity as a Complex System
Carrie Matteson
Simon Fraser University
Amanda Palmer
Simon Fraser University
Luvdeep Malhi
Simon Fraser University
Holly Buhler
Simon Fraser University
Diane Finegood
Simon Fraser University
The rising rate of obesity is a complex problem, arising from the interactions of multiple systems that are composed of many interrelated variables, peoples, and groups. This complexity suggests that it is useful to view the obesity epidemic through a complex systems lens in order to understand the interrelations between the numerous variables involved. In 1999 Donella Meadows suggested 12 places to intervene in a complex system. In this study we adapt Meadows' framework to analyze where in the obesity system stakeholders believe interventions need to be focused. The modified framework consists of five levels: paradigms, goals, whole system structure, feedback, and structural elements.
Qualitative data sets containing actions recommended to combat obesity and chronic disease were analyzed. Data were coded and sorted using NVivo 8 and Excel 2007. Multiple researchers standardized sorting into the framework through an iterative process. The methodology and challenges to developing the modified framework will be discussed.
There was consistently high researcher agreement in sorting data into the modified framework, implying that we were able to effectively standardize sorting. In all the data sets analyzed, actions that targeted specific elements were recommended more frequently than actions that would affect the whole system structure and relatively few suggestions were targeted at creating or interfering from feedback loops. This framework could be used in the future to compare recommended and currently implemented actions in obesity prevention to identify and understand barriers to implementation.
Using Qualitative Methods to Identify and Develop Conceptual Models and Promising Practices for Nursing Staffing and Scheduling
Hilary Maxwell
Children's Hospital of Eastern Ontario
Katherine Moreau
Children's Hospital of Eastern Ontario
Christopher Sorfleet
Bruyère Continuing Care
This project demonstrates how qualitative research methods can be used to identify and develop conceptual models and promising practices for nursing staffing and scheduling. The purpose of the project is to detail the nursing staffing and scheduling models and promising practices that are being used at four health care settings; namely, a pediatric hospital, a continuing care health center, a pediatric rehabilitation hospital, and a community-based hospital. The systematic development, identification, and optimization of the conceptual models and promising nursing staffing and scheduling practices assist these organizations in addressing health human resource issues such as absenteeism and overtime. To date, focus groups, key-informant interviews, and document reviews have been conducted at each site. Individuals from a variety of positions within each organization (e.g., nurses, human resource specialists, managers, operation directors, information technologists) have participated in focus groups and key-informant interviews to provide a breadth of information for the project. Results are presented in the form of log frames that identify the objectives, resources, activities, outputs, and outcomes for each institution's staffing and scheduling model. This presentation highlights these results but places emphasis on the unique and innovative processes used to obtain them.
Disordered Eating and Silent Knowledge: What the Voices of Adolescent Girls Tell Us about Primary Practice
Colleen McMillan
McMaster University
Understanding the complexity of disordered eating starts with transcending disciplinary practice barriers and historically opposing epistemological paradigms. Within a span of 2 years at-risk adolescent girls can progress from disordered eating to an eating disorder. This research aimed to understand on a deeper level predisposing cultural factors that placed these girls initially at risk and if primary family practice can be a juncture to intervene in an innovative and preventative way. Could this lived experience be transferred over to a more effective template for physicians to identify at-risk girls?
Using a model that values the patient-physician relationship for recruitment, 16 at-risk girls aged 11 to 14 were identified to participate. Prolonged focus group involvement over 4 months resulted in collecting a multiplicity of voices that spoke to the importance of connection and dependence as resiliency factors. Recognizing that voice is not always verbal, data collection methods included artwork, blogging, photovoice, and visual mapping exercises. These voices formed the language of “body talk” that is not collected by clinical assessment questions asked by health providers. Analysis through a constructivist grounded theory approach was strengthened through multidisciplinary inter rater reliability involving medicine, nursing, dietary and social work. Member check was continuous through out the research period to attain integrity and trustworthiness.
Using the language of body talk reframes how knowledge is defined and exchanged between consumer and health care provider. Incorporating lived knowledge into traditional assessment questions offers a innovative practice template in addressing problematic relationships with food.
Cherry Ames: Maven or Monster
Marilyn Meder
Kutztown University
Where do we learn about our mission and purpose in life? How do we explore various options and mentally imagine a professional life? As I was a child from a less affluent, nonprofessional background, reading shaped and formed my heart's desire to be a nurse. The Cherry Ames series shaped the image of nursing for what are middle-aged nurses today. We had future nurse clubs and reading groups that explored many aspects of the compassion, character, and critical thinking that successful role enactment.
At one point, these texts were viewed as antiquated examples of the subservient nurse. The series went out of print and out of sight for many years. However, the Cherry Ames series is resurfacing for exploration by children as well as by the nursing profession. This study describes and analyzes 15 books of the series, describes 6 interviews with novice and experienced nurses, explores visual media regarding the series, and presents themes that arose from the data. Assertiveness, adaptation, collaboration, compassion, caring for, care-taking, conflict management, cross-generational communication, critical thinking, cultural diversity, independence, social justice, and caring for varied and vulnerable populations arose from the data collected. These key themes are then discussed within a focus group of 5 nurses for response to the impact of the resurfacing of Cherry Ames within our profession. Suggestions for future texts aimed at the promotion of nursing are offered.
“Planned Spontaneity” for Pleasure and Bonding: A Qualitative Investigation into the Individual, Social, and Environmental Determinants of Recreational Poly-Substance Use
Warren Michelow
University of British Columbia
Jane Buxton
University of British Columbia
Trevor Skutezky
University of British Columbia
Much research to date with users of substances other than tobacco or alcohol involves quantity/frequency methods, structured interviews, or use of predefined scales. It is typically situated at the extreme end of harmful use among marginalized populations, or is concentrated on adolescents or youth. Many people who use substances are adults whose use is not characterized by dependence or addiction. Poly-substance use is the norm, can be considered instrumental or functional, and is aimed at achieving psychosocial goals. Among this large population, there is little research that extends beyond the single-drug-focused quantitative studies.
This innovative study took a grounded theory approach to investigate individual, social, and environmental determinants and patterns of recreational poly-substance use among adults. Semistructured interviews explored the most recent episode of poly-substance use. Constant comparison was used to identify theoretical saturation. Fourteen interviews approximately 45 minutes long were completed, 7 each with men and women. Participants were aged from 19 to 35 years; the majority were employed or enrolled in college or university.
Results indicated that participants typically followed a well-articulated, often preplanned strategy when getting high. Substance choice and dosing strategies were primarily driven by the contingent availability of a variety of interchangeable substances and instrumentally matched to the setting of use. Key social determinants were maximizing opportunities for social inclusion and bonding. We recommend that research and prevention efforts are cognizant of the sophisticated strategies used, social and environmental determinants and functional goals to better understand recreational poly-substance use.
Picturing Family-Centered Care
Katherine Moreau
University of Ottawa
Canadian pediatric health care settings are under increasing pressure to understand and uphold the philosophy of family-centered care. The health and rehabilitation literature explicates the premises, principles, and elements of the philosophy of family-centered care but often fails to detail the history and development of it within the Canadian context. By understanding the history and development of family-centered care, Canadian pediatric health practitioners are better able to understand, uphold, and implement it. However, the history, development and initial implementation of this philosophy is mostly written from an American perspective. This American perspective might parallel the Canadian experience, but as the Canadian political agenda and health care system are very different from the American, there are several discrepancies.
As an initial step in the development of a detailed Canadian history of family-centered care, randomly selected historical photographs from the years 1910 to 1979 have been analyzed at multiple levels using a modified version of Erwin Panofsky's iconographical approach. Overall, the analysis of these photographs provides valuable insight into the history of the development and implementation of the philosophy of family-centered care in Canadian pediatric health care settings. However, it also illustrates the need for additional qualitative research (e.g., document analyses, interviews) to fully understand the development and implementation of family-centered care in Canada.
The Role of the General Practitioner in the Lives of Australian Gay Men with Depression
Christy Newman
University of New South Wales
Susan Kippax
University of New South Wales
Limin Mao
University of New South Wales
Deborah Saltman
Brighton and Sussex Medical School
Michael Kidd
Flinders University
The health concerns of gay-identified men have been well documented, including a higher risk of HIV and a greater vulnerability to depression, due in no small part to marginalization and discrimination. This is certainly true of Australian gay men. However, Australian studies also indicate that many gay men are proactive health consumers supported by an open-minded general practice workforce, at least in the central areas of major cities. This is at odds with the international (mostly American) literature that suggests that gay men avoid disclosing sexuality and/or HIV status in health care settings because of fear or evidence of homophobia.
In the light of these various claims about gay men's health, this paper will explore two themes from semistructured interviews with 40 gay men with depression, focusing on discursive representations of the general practitioner (GP). Participants were recruited from general practices providing clinical services to high numbers of gay men in inner city Sydney and Adelaide. The first theme represents the roles GPs adopt in managing depression. The second represents the roles GPs play in gay men's lives more broadly, ranging from a central and trusted figure (e.g., “a doctor who's up with the lingo”) to one held at an emotional distance (e.g., “I wouldn't want to worry him”). In both themes, depression is seen to complicate the doctor-patient relationship, contributing to sometimes productive but also sometimes harmful tensions in these gay-friendly medical practice settings, in which sexuality and HIV are constituted as everyday and non-stigmatized aspects of the clinical encounter.
How Nurses Understand the Pain That Their Patients Experience: Phenomenological Description in Acute Nursing Setting
Yumi Nishimura
Osaka University
Hiroki Maeda
Tokai University
When patients complain of pain, nurses attempt to assess its degree and cause to help them. Because this pain is another person's experience, however, debates have raged over the difficulty and method of understanding it. This study aims to explore a practice used to understand patients' pain from a phenomenological perspective. Specifically, we conducted fieldwork multiple times in an acute ward, individually interviewed nurses, and then transcribed and analyzed these transcripts. We made every effort to conduct the investigation ethically.
This study focuses on incidents that occurred on the site with regard to the nurses' understanding of a lung cancer patient's pain caused by bone metastasis, which the patient reported as aversive and annoying. The patient's complaint of pain changed continuously despite the periodic administration of narcotic medications, and that made the nurses feel uncomfortable. Moreover, when nurses found a discrepancy between the degree of pain that a patient reported and the expression of pain they saw on the patient's face, they left the pain unassessed, as something others could not understand. Meanwhile, the nurses took preventive measures to avoid hindering patients' everyday activities and to minimize possible hazards due to pain, in advance of their assessment. Through these practices, the nurses considered and assessed their patients' pain.
“Peer but Not Peer”: Women's Experiences of Infant Feeding Peer Counseling in a High HIV Prevalence Area
Barni Nor
Department of Women's and Children's Health
Yanga Zembe
Health Systems Research Unit, Medical Research Council
Karen Daniels
Health Systems Research Unit, Medical Research Council
Tanya Doherty
Health Systems Research Unit, Medical Research Council
Debra Jacksson
School of Public Health, University of Western Cape
Beth Maina Ahlberg
Skaraborg Institute for Research and Development
Eva-Charlotte Ekstrom
Uppsala University
Postpartum transmission of HIV during breastfeeding remains an unsolved public health problem in resource-poor settings, where refraining from breastfeeding is neither feasible nor safe. This paper explores how women perceived and experienced infant feeding peer counseling within a cluster randomized controlled trial in three socio-demographically diverse areas in South Africa. Twenty seven HIV-infected and uninfected women were purposively sampled for this study in an attempt to understand different dimensions and perspectives of infant feeding peer counseling within a high HIV prevalence context.
The study used emergent qualitative design with multiple data generating methods, including individual interviews and participant observations with women, review of peer counseling visit records, and informal interviews with peer counselors. Our findings raise questions on the concept of “peer.” Although some women feared the peer counselor visits and questioned their intentions, others, especially HIV-infected women, valued peer counseling for the emotional support provided. Being HIV infected with limited or no network of support appeared stressful for most women. The effects of data collection on the delivery and uptake of peer counseling is discussed. Our findings underline the contextual barriers facing peer counselors and show that these challenges could have important implications for the effectiveness of infant feeding counseling in areas with a high HIV prevalence. Addressing these barriers is an important step in improving infant survival, growth, and development.
Striving for Success: Education and Career Aspiration Experiences in the Lives of Young Aboriginal Women from Metro Vancouver
Natasha Panina-Beard
Trinity Western University
Faith Auton-Cuff
The education and career aspiration experiences of young Aboriginal women from the Metro Vancouver area were explored. These experiences were complex and interconnected with other life processes influencing women's education and career experiences. Hermeneutic phenomenological inquiry was employed to derive the essence of the young Aboriginal women's lived experiences with education and career. This methodology allowed for a culture-respecting approach to engage 7 women to share their knowledge through stories.
The following eight equally important themes emerged from the interviews:
Identity development,
Family and community,
Mainstream and traditional ways of learning,
Social experiences,
Generational transmission of trauma,
The educational settings,
The meaning of education
The role of spirituality.
Issues such as curriculum, approach to teaching, family and community situation, access to education, experiences with racism, and availability of career counseling were present in the women's stories and influenced their decision-making regarding educational and career choices. Excerpts from the interviews were used to support the interpretation of the meanings and enhance the reader's understanding of the young Aboriginal women's experiences. This study deepened understanding of the phenomenon of interest, provided implications for counseling, and supported the need for change in the educational system.
The methodology employed was not originally developed to conduct research with Indigenous populations, and a non-Aboriginal researcher conducted the study. Further research in the area of Aboriginal education and career guidance will provide a deeper understanding regarding the needs and experiences of Aboriginal people in education in order to better support them as they strive for academic success.
Divergent Narratives among Parents of Chronically Ill Children
Vinitha Ravindran
University of Alberta
Lynne Ray
University of Alberta
Our study was motivated by the experiences of pediatric home care nurses working with families of children with high care needs. Clinically, they questioned whether families were set up to succeed as best as possible when taking an ill child home. We employed a narrative approach informed by the works of Polkinghorne (1988), Bruner (1990), and Clandinin (2000) to our interpretation of interviews with parents from 11 families with children who required significant clinical management at home. We interviewed 11 mothers and 8 fathers up to five times over a period of 18 months. For each family we asked, What is their family story as it relates to the care of their child? and What influences the construction of their story line? We created summary narratives that addressed each family's story line, their theories of why this happened to their child and family, the cultural fictions shaping their story, family roles, the tone of their story, and their relationship with professionals.
Among the composite stories two key narratives were dominant. In child-focused narratives, parents accepted their child's condition and associated care and got on with their life. They believed health professionals generally had their best interests in mind but were facing their own constraints. In parent-focused narratives, the parents emphasized their ongoing fight for their child's rights, demonstrated a pervasive negative mindset, and were suspicious of health care professionals. Our findings suggest that early negative events have a lasting effect on parent-professional relationships and that promoting trust early is critical.
What Has Influenced People's Health and Well-Being over the last 100 Years in Halton?
Gaynor Reid
University of Liverpool
Evelyn Kinsella
Paul Cooke
Doreen Shotton
Lyn Williams
The presentation will introduce an oral history study taking place in an industrial town in the northwest of England. The population of the borough is estimated at 118,400 residents and is one of the 88 most deprived areas in England. The borough has been identified as having a higher than national average level of poor health; the area has traditionally been dominated by the chemical industry. The chemical industry has now declined in importance, but there is evidence to suggest that its legacy is perceived to be ongoing (Burgess et al., 2003).
The aims of the study are to provide an analysis of the factors that residents perceive to be influencing health and well being in the borough, to take a new approach by involving local people throughout the research process from idea conception through to dissemination in order to develop research capacity within the local community, and to evaluate the scope and limitation of the approach from several key perspectives.
The study followed a participatory approach of user involvement and recruited 10 participants using purposive and snowball sampling techniques. Fifteen semistructured interviews were conducted, exploring the issues of health and well-being. The research team comprised of members from local community activist groups, and volunteers. The team were supported by an academic researcher who provided training as each stage of the research process required. The presentation will discuss the findings and the team's experience of this unique collaboration.
Crossing Over: The Discursive Space of Dialysis
Rose Richards
Stellenbosch University
Narrative structures and informs one's perception of the world, and illness narratives demonstrate this particularly clearly. Not much narrative work or personal writing has been done about the experience of dialysis, and many qualitative studies of dialysis are of aging populations, where dialysis becomes a discursive space in which issues are debated and sides are chosen, but whose experiential nature remains elusive. My own experience of dialysis, when I was 21 and 22, lasted 11 months, and I decided to write about it autoethnographically.
As a recursive method of research and one that in some senses is never complete, autoethnography seems to mirror the nature of dialysis itself. My experience of dialysis was one of contrasts and contradictions. I vacillated between fear and relief, illness and health, certainty and uncertainty. Although dialysis saved my life, it kept me in a liminal space. I came to recognize a conflict in my writing between how I experienced dialysis as a patient and how I remembered it as an academic, while dialoging with other academic texts, so I returned to my personal and academic narratives and reconsidered them. I realized in so doing that I had to retell the story and in some ways tell it for the first time. This presentation captures some of the aspects of that journey and attempts to present in truncated form what my present discursive space of dialysis is. I hope that this will enlarge the field for qualitative research of dialysis, especially regarding younger dialysis populations.
Autoethnography: Nursing while Black. A 14-Year Review of Role Conflict in Nursing
Ora Robinson
California State University, San Bernardino
The purpose of this study is to explore and describe the experiences of a Black nurse who experienced role conflict in their academic educator role as a function of their race and its impact on psychological well-being and cardiovascular health. The nurse will look at existing data in the form of a disposition to identify the areas of role conflict. Prior research among professional Black working women identified areas of role conflict as a result of de-legitimization of the professional role, being held to a higher standard, coined “scrutinization of the professional role,” and encounters with resistance and insubordination from their other nurses, coined “horizontal abuse.” The methodology will be grounded in qualitative methods such as phenomenology to explore and understand the lived experience of a Black nurse experiencing role conflict in their professional role as a nurse. The theoretical framework is grounded in role theory and role conflict. Role conflict defined for this study is any condition in which individuals, while holding a position, perceive they are confronted with incompatible role expectations. Role conflict occurred when intrapersonal views were in conflict with how the role should be played based on societal norms. Black women juggle multiple roles: their inherited role related to race, “ascribed role”; their role based on educational achievement, “achieved role”; and ‘age-related roles.” This novel approach will use autoethnography and phenomenology to review existing data from within the framework of self-reflection by the nurse involved in case.
Nursing Student Perceived Experiences with Racism in Nursing and Its Impact on Cardiovascular Changes, Psychological Well-Being, and Learning Outcomes
Ora Robinson
California State University
Background: There has been emerging research reports of racism in nursing as a result of nurses being eyewitnesses to racism while in their nursing role. White nurses reported experiencing reverse racism when working with colleagues from a different racial, ethnic, or cultural group (Blendon, Buhr, and Cassidy, et al., 2007).
Purpose: The study is to investigate nursing students' perceived experiences with racism in nursing through direct experiences, observed acts of racism, and demonstrating acts of racism toward others and its impact on their cardiovascular status, psychological well-being, and learning outcomes.
Theoretical framework: According to Hardy and Conway (1978) roles are evaluated by societal norms and intrapersonal views are in conflict on how the role should be played based on social norms.
Methods: Qualitative methods will be used in the form of storytelling and quantitative methods in the form of surveys.
Findings: Initial findings show a reluctance of Black minority students to participate in the study for fear of retaliation and reported cardiovascular and psychological changes at the thought of participation.
Future implications: Findings may help begin the conversation with minority nurse colleagues to understand the issues and resultant health consequence of overt and covert acts of racism.
Interpretive Description: An Innovative Approach to Understanding the Complexity of Rural Rehabilitation Practice
Robin Roots
University of British Columbia
Linda Li
Arthritis Research Centre of Canada/University of British Columbia
Research questions that seek to understand clinical phenomena are not easily answered using traditional qualitative methods. Initially derived in the field of nursing, interpretive description offers a novel analytic framework for applied research. Through identifying the shared realities of individuals' experiences, the constructed and contextual nature of the clinical phenomena is integrated with the collective knowledge of the discipline. Interpretive description is well suited to illustrate the unique nature of providing rehabilitation services in rural communities where the dialect of theoretical knowledge and the challenge of rural practice, including geography, limited resources, the diversity of patient conditions and complexity of patient needs, must be considered.
The aim of this ongoing study is to construct an understanding of rural rehabilitation practice from the perspectives of physical therapists (PTs) and occupational therapists (OTs) in rural and remote regions of British Columbia. We will conduct in-depth face-to-face interviews with a purposive sample of 20 OTs or PTs. Interpretive description will be used as a framework to explore the following important questions: What skills and knowledge do rehabilitation professionals recognize as unique to rural practice? How do they perceive their roles in primary care? What barriers do they encounter? What strategies do they use to address these challenges? Fundamental to interpretive description is the extension of inquiry and interpretation to inform clinical understanding and guide practice. We envision that the findings will be useful for the development of a rural educational framework that guides the academic preparation of OTs and PTs entering rural practice.
The Lived Experience of Liver and Kidney Transplant Recipients
Kristy Sands
Geisinger Health System
Tracey Kopenhaver
Geisinger Health System
Approximately 5,000 patients undergo liver or kidney transplants each year. Most commonly, the transplanted organ is obtained from a deceased donor. Although the medical care following the transplant is increasingly refined with improved outcomes, less is understood about the patient's experience of receiving a liver or kidney transplant from a deceased donor.
The purpose of this study was to examine the holistic experience of receiving a liver or kidney transplant from a deceased donor. By understanding the transplant experience from the recipient's point of view, nurses will be better able to anticipate patient needs and develop individualized plans of care for each recipient.
The sample consisted of adult liver and kidney transplant recipients transplanted with deceased donor organs within the Geisinger Health System after January 1, 2006. Geisinger Health System is a level-one trauma center located in rural Pennsylvania. A phenomenological approach was utilized to examine the lived experience of the transplant recipients. The holistic experience was described through personal interviews with transplant recipients conducted by the researchers. The data collected were analyzed using Colaizzi's framework. Common themes related to receiving a kidney or liver transplant will be presented.
The implications for nursing are greater understanding of the holistic experience of receiving an organ transplant, increased awareness of recipient needs, and improved plans of care for recipients.
Working through “Risk” in Everyday Nursing Work
M. Bianca Seaton
University of Toronto
Over the past few decades, the phenomenon of “risk” has become an increasingly pressing problem for social scientists. Many scholars are in tacit agreement that we live in a climate of heightened awareness, publicity, and perception of risk and that the ensuing practices of risk assessment and management have become an unavoidable aspect of present-day social and organizational life. This may be especially true for hospital-based nurses, who are themselves viewed to be “at risk” for certain health and safety hazards as a result of their everyday work caring for patients but are also expected to constantly assess and manage health and safety risks to the patients under their care, thereby protecting their employing hospitals from the risk of litigation.
We have limited knowledge of what nurses do with “risk”; that is to say, how they make sense of the concept, how they make use of it in understanding and managing their everyday work lives, and how it may influence their routine activities caring for patients. Drawing on insights from a study in progress at St. Michael's Hospital in Toronto, Ontario, and findings from an applied ethnographic study of nurses in Hamilton, Ontario, this presentation discusses contradictions in the ways that the nurse study participants “work through” risk in their everyday professional lives physically, socially, and psychologically, and the way that their risk perceptions, conceptualizations, and behaviors are typically understood by outsiders. This disjoint has important implications for future occupational health and safety policy and practice in hospitals.
Taking Time Intentionally for the Self: Mindful Weight Loss
Kathleen Spadaro
University of Pittsburgh
Rebekah Hamilton
University of Illinois at Chicago
John Jakicic
University of Pittsburgh
Susan Cohen
University of Pittsburgh
This study explored the experiences of adults following participation in a randomized controlled trial of a 24-week Standard Behavioral Weight Loss Program plus Mindfulness Meditation (SBWP+MM). Qualitative research methods based on Thorne's interpretative description were used to understand and interpret individual and the larger group experiences with mindfulness meditation as an addition to dietary restrictions, increased exercise prescription, self-monitoring, and other standard behavioral weight loss strategies. Twelve participants from the SBWP+MM intervention arm (N = 22) were recruited into the qualitative arm of the study. Purposeful sampling included 1 male, 1 African American, the youngest in age and three of the older participants (age range = 21.40–55.60), and 7 participants who represent the range of the weight loss, attendance, and diary completion range.
The overarching theme from the interview analysis was expanding mindfulness in personal life. Specific subthemes described the theme of expanding mindfulness in personal life and were related to the MM component. The actions connected to mindfulness appeared to assist participants in their weight loss. The themes were taking time for self, paying attention, listening to self, conscious choice (these four with intentionality), openness/tolerance, self-responsibility, positive outcomes, and lifestyle changes. This study suggests that MM combined with a SBWP might enhance the success of overweight/obese adults. Factors identified in this study need to be examined further using prospective designs, a longer study time frame, a larger sample size, and greater variability in the sample.
Patients' Experience of Changes in Health Complaints Five Years after Removal of Dental Amalgam
Therese Thornton Sjursen
University of Bergen
Lars Björkman
University of Bergen, Norway
Per-Einar Binder
University of Bergen, Norway
Vigdis May Helland
Dental Biomaterials Adverse Reaction Unit, Norway
Knut Dalen
University of Bergen, Norway
Background: Patients with suspected adverse reactions to dental amalgam sometimes request removal of their amalgam fillings, even when no causal relationship can be found between dental amalgam and their complaints. This project is part of a study on changes in health complaints after removal of all amalgam fillings in a group of patients with suspected adverse reactions to dental amalgam. Participants were required to undergo a dental and medical baseline examination, removal of all amalgam fillings, and four follow-ups.
Aims: The aim of this part of the project is to investigate how participants have experienced changes in health complaints, or the lack thereof, after removal of dental amalgam and how these experiences have influenced and have been influenced by their everyday life.
Methods: After the final follow-up 5 years after completed removal of dental amalgam, 12 participants were asked to participate in a semistructured interview about experiences of possible changes in health complaints. The interviews were videotaped, and the software program QSR-NVivo 8 was used for transcription and analysis. A modified version of Giorgi's phenomenological method is used as framework for the research process.
Findings: At the time of submitting this abstract, all 12 participants have been interviewed, and we are now transcribing and analyzing the interview data. Preliminary themes that have been identified are elimination of worry, acceptance of complaints, and multifactorial understanding of health.
Implications: We believe these findings represent an important addition to previous research which has mainly focused on objective findings and measurements of reported health complaints.
An Exploration of the Nutritional Advice Given to Patients by Allied Health Professionals: Preliminary Findings
Julia Williams
University of Hertfordshire
Jane McClinchy
University of Hertfordshire
Lynne Gordon
University of Hertfordshire
Gail Fairey
University of Hertfordshire
Mindy Cairns
University of Hertfordshire
Long-term health conditions, either wholly or partly diet related, continue to increase in the United Kingdom. The focus of current health strategies has moved towards preventing ill health by empowering patients with long-term conditions to take more control of their care. All members of the multidisciplinary health care team are expected to work together in the provision of patient-centered care and to assist patients in improving their health (Darzi, 2008). Allied Health Professionals (AHPs) will be “key to health promotion [such as in]… advising on diet, exercise” (Keen, 2008). However, the views of AHPs regarding provision of this advice are not known. There is little research exploring whether AHPs, other than dieticians, have had training in aspects of nutrition and diet and the giving of such advice to patients, and whether they feel confident in this area of health education.
This study is a work-in-progress, and currently radiographers, paramedics, physiotherapists, and radiotherapists are participating in focus groups to explore whether they do actually engage in these activities with patients and whether they feel confident and equipped to do this effectively. This poster will identify preliminary findings from the focus groups. The researcher will engage the audience in discussion about which emergent issues could usefully be taken forward in a national survey across the UK to find out more about AHPs' opinions with regard to this potential role expansion, and what preparation and professional development needs to be provided for AHPs to achieve positive patient outcomes in this area of work.
Walk-Throughs to Assess Services: A Novel Qualitative Technique
Jennifer Wisdom
New York State Psychiatric Institute and Columbia University
Serene Olin
New York State Psychiatric Institute
Priscilla Shorter
New York State Psychiatric Institute
Geraldine Burton
New York State Psychiatric Institute
Kimberly Hoagwood
New York State Psychiatric Institute
Novel data collection methods are needed to improve the quality of health care services. Traditional qualitative interview and observational techniques do not capture complete data about service encounters. This paper describes a pilot standardized walk-through to assess the services of family advisors, who assist families of children with mental health problems in New York. To develop standards of care and fidelity measures for family advisors in New York, data are required about the process and content of services provided. Using techniques from business and management (walk-through) and medical training (standardized patients), we created a structured walk-through protocol to collect qualitative data and trained a family advisor to be a “standardized parent” and portray a specific set of parent concerns about a child with mental health problems.
The standardized parent simulated a parent seeking services and “walked through” initial and follow-up meetings with a family adviser to determine the process and content of services. The standardized parent collected data through observation, responses to a structured survey, and audiotapes of the encounters. Qualitative content analysis (a) provided a first-person narrative account of the service encounter and (b) identified factors of strength and areas for improvement in service provision and (c) provided a baseline of family advisor response to a specific parent-child scenario. With additional walk-throughs, findings can be used to establish standards of care and guide training to improve family advisor services in New York. The use of standardized walk-throughs can be a useful tool to gather data about service provision.
Abstracts, Symposia: Listed alphabetically by submitting author
“Here's a Picture of My Messy Pantry”: Photographs as a Window for Understanding Family Food Practices
Gwen Chapman
University of British Columbia
Many qualitative health researchers have begun to employ photography as a data collection and elicitation technique. Visual methods can complement other qualitative methods by providing an alternative window for understanding people's perspectives regarding health practices and experiences. However, because these methods are relatively new, there are many unexplored questions regarding how photographs can be used and analyzed in qualitative studies, and what they can add to findings. This symposium will draw from a cross-Canada multisite study that is investigating food habits of families from urban and rural communities. Data collection has included use of photographs in two ways: Participants have been asked to take photos of how food fits into their lives, and have also been asked to respond to a set of images provided by the researcher, discussing their responses. In this symposium we will present three papers that explore the challenges and insights that these methods have presented.
i What Can a Photo Tell Us? Photo Elicitation in a Qualitative Food Study
Sonya Sharma
University of British Columbia
Brenda Beagan
Dalhousie University
Gwen Chapman
University of British Columbia
Photo elicitation can enable participants' involvement in qualitative inquiry and be a stimulus for discussion about what is meaningful to them, evoking deeper elements of human consciousness than words, and thus “de-centering the text.” It can also be a limitation in that photographs only capture (re)presentations of the self. For this presentation we will focus on two case studies from a cross-Canada study on family food habits. Examination of the photos taken by two mothers from two different families from the same community shows notable differences and similarities in how they present the foods that are significant in their daily lives. For example both mothers took a photograph of carrots, one of fresh home-grown carrots, the other of attractively displayed carrots in the store. On the one hand, these photos confirm and illustrate the (re) presentations of the self that participants discussed in their interviews. On the other, they suggest deeply embedded perceptions of the self, for example in how the food is presented and what is left out of the photos (e.g., junk foods). This can indicate performances of the self through food of which participants are not aware, potentially de-centering the text and the descriptions they give of their photos. The researcher's interpretation of the photos alongside the participants' explanations produces multiple layers of understanding. Both parties bring rich, complex, and sometimes contradictory meanings to photo data, which can enhance qualitative health research by providing another lens through which to explore participants' worlds.
ii Photographic Constructions of Local Food Environments
Gwen Chapman
University of British Columbia
Brenda Beagan
Dalhousie University
Helen Vallianatos
University of Alberta
Brent Hammer
University of Alberta
Sonya Sharma
University of British Columbia
Population health approaches to promote healthy eating address the interaction of individual, interpersonal, and environmental determinants of eating behaviors. Consequently, nutrition researchers are increasingly interested in characterizing local food environments, including restaurants, fast food outlets, supermarkets, and other food outlets, and how these relate to individual nutrition indicators. Much of this research is approached from an objectivist stance, where researchers measure and map predetermined characteristics of the environment. Less attention has been paid to the ways that people living in a community construct their relationship with their food environment.
In our qualitative study of food practices of families from 10 urban and rural communities across Canada, one of the ways we are addressing this gap is by asking participants to take photographs of their local area, including places where they would or would not eat or shop. Examination of the images obtained reveals the heterogeneity in meanings people construct through their interactions with their physical environment, and the similarities and differences in how people from different communities portray their locale. Findings suggest that the relationship between food environments and the family is a process of mutual constitution and social construction, which may affect and have implications on the health and food practices of Canadians. Use of photo elicitation methods in this study illustrates how this method can complicate and augment other forms of qualitative data collection and analysis in health research.
iii “Some Guys Wouldn't Eat It, ‘Cause It Looks Like Leaves”: Gendered Food Patterns as Revealed through Photo Elicitation
Brenda Beagan
Dalhousie University
Gwen Chapman
University of British Columbia
Michelle Szabo
York University
Sonya Sharma
University of British Columbia
Food choices and eating patterns are guided by numerous factors, among them the relationship between symbolic meanings of food and social portrayals of identity. Most basically, some foods and ways of eating tend to be seen as more masculine whereas others are understood as more feminine, yet it is often an uncomfortable experience to admit to this perception of gendered food.
In our qualitative study with families in 10 communities across Canada, we used photo elicitation techniques to try to delve deeper into gender and food, beyond what participants might offer in an interview about their own beliefs. When shown 26 photographs of a wide range of foods, and asked to categorize them by gender, many participants started by insisting they could not do this. As one teen said, “I'm not sexist with my food.” Participants then went on to produce remarkably similar gender categories of foods, offering rationales that incorporated food quantity, quality, type, presentation, familiarity, and degree of “messiness.” In this presentation we focus on the denial of gendered foods expressed in the interviews, particularly exploring intersections of class and rural/urban location. Second, we explore the gendered categories participants produced, examining intersections with foods categorized as healthy/unhealthy as well as adult/child foods. Finally, we highlight the benefits and limitations of this form of photo elicitation for qualitative health research, particularly for illuminating desired self-presentation, while also tapping into the operation of stereotypes perceived as socially undesirable.
Using Social Theory to Guide Qualitative Health Research: Critical Realism and Heart Disease
Alexander Clark
University of Alberta
This symposium will provide a comprehensive and clear overview of how social metatheory (critical realism) can be harnessed to guide and strengthen qualitative health research. The session will consist of three linked papers that
outline the tenets and background of critical realism,
detail how these tenets have and can be expressed in qualitative studies and systematic reviews, and
provide a more detailed overview of funded exemplar studies using critical realism.
The first paper will present the tenets and background of critical realism. The second paper will outline how critical realism can be applied to understand issues related to gender. The third paper will examine how critical realism can be applied to understand health behaviors. The concluding discussion will focus on how participants might apply critical realism in their own research projects and how the approach can be presented to appeal to research funding bodies.
i The Background and Tenets of Critical Realism
Alexander Clark
University of Alberta
Jan Angus
University of Toronto
Critical realism originated in philosophy in the late 20th century but has been used increasingly to guide research in the human sciences. This paper aims to provide a clear and comprehensive overview of tenets of critical realism, to convey why the metatheory is useful for qualitative health research and how it can be applied. This paper first describes the background of critical realism in work of philosopher Roy Bhaskar. The tenets of the metatheory will then be outlined and explained; these include recognition of reality independent of human perceptions, a generative view of causation in open systems, and a focus on explanations and methodological eclecticism using a post-disciplinary approach. Overall, critical realism is proposed as being philosophically strong and useful for (a) understanding the complexities of health decisions and outcomes, (b) optimizing health service and practice, and (c) researching biopsychosocial pathways. The paper will conclude with a discussion of the implications of the tenets for critical realist-driven qualitative research into gender, culture, health equity, and health services.
ii Accounting for Masculinity: Diabetic men's Goals in Cardiac Rehabilitation
Craig Dale
University of Toronto
Jan Angus
University of Toronto
Alexander Clark
University of Alberta
Lisa Seto
University of Toronto
Marnie Kramer-Kile
University of Toronto
Jennifer Lapum
Ryerson University
Paul Oh
Toronto Rehabilitation Institute
Susan Marzolini
Toronto Rehabilitation Institute
Beth Abramson
St. Michael's Hospital
Jennifer Price
Women's College Hospital
Cardiac rehabilitation (CR) is offered to people with coronary heart disease (CHD) and aims to reduce behavioral risk factors (such as smoking and unhealthy diet) through education, support, and supervised exercise. Though lifetime risk of CHD is the same across sexes, CR has been developed to mostly meet the needs of men. Women have consistently been identified as being less likely to participate in CR, yet there is little discussion of gender as a significant social influence on men's goals and participation in CR. Men with diabetes form the largest subpopulation within CR, and they encounter multiple threats to male privilege associated with changes in physical, sexual and economic performance. Their goals and participation are not well understood. This analysis draws on interview data from an ethnographic study of 16 men recruited from two urban CR programs in Toronto, Canada. It addresses CR within a larger framework of masculinity to uncover disjunctures of experience that shape patterns of participation. Men described mechanistic goals of bodily performance aligned with sexual health (erectile dysfunction), work and sporting activities, all subfields where men continually renegotiate masculinity. The work of merging CR guidelines with available resources and personally meaningful goals resulted in situated expertise. Retired and economically advantaged men had greater success combining knowledges to create personally appropriate CR practices. Many sought ongoing support to blend CR activities and diabetes self care with their continuing efforts to maintain privilege within subfields of masculinity. Greater awareness of masculine threats might foster improved adherence in CR.
iii A Study Using Critical Realism: Understanding Why Some Low-Income People with Heart Disease Change Their Diet but Others Do Not
Amanda G Duncan
University of Alberta
Stephanie Heath
E. June Trevoy
Alexander Clark
University of Alberta
Health behaviors and “lifestyle change” are important factors in reducing risk from chronic conditions like coronary heart disease (CHD). People of low socioeconomic status (SES) are at much higher risk of developed CHD and, after diagnosis, are more likely to die sooner, have worse health, and benefit least from health services and treatments. This paper describes how critical realism was applied using the realist-explanatory framework in a qualitative study of people of lower SES with CHD. The study aim was to understand the factors influencing willingness and capacity to eat a healthy diet.
Semistructured interviews were conducted using critical realism as incorporated into the realist-explanatory framework. Data are presented from 28 participants with confirmed CHD (17 women and 11 men; mean age of 68.5 years, range 45–88 years). Data were collected via home-based semistructured interviews focusing on the knowledge, experiences, and perceived barriers and facilitators to health behavior change.
Findings: Living on low income affected CHD patients' ability to make changes to dietary behavior and placed within the larger context of the difficulties of health behavior change for vulnerable populations. Food choice was not simply a matter of knowledge or choice but was always constrained by limited resources.
Studying a Vulnerable Population: Three Lenses toward an Interpretation of the Lived Experiences of Families Who Have Lost a Child
Guenther Kruger
University of California, San Francisco
One of the strengths of qualitative approaches is the way in which the individual researcher as observer interprets and represents a view of the situation under investigation. In this symposium three separate studies that each focus on a similar population, parents who have lost children, demonstrate how multiple lenses can provide a broad range of results and findings. The narratives and first-person accounts for each approach have been analyzed in three very different ways, the results of which underscore multiple points of view, rich descriptions, and a range of reported experiences. Additionally, the varying analyses, including the use of NVivo software, extend our understanding of the problem at hand. The resulting constructions will allow participants to make their own connections and comparisons as they take note of the ways in which the presenters have approached the issues.
i The Making of SIDS and the Vulnerability of Its Living Victims
Karen Martin
Department of Sociology, University of Alberta
This paper is part of a larger project that uses a Foucauldian lens to explore and demonstrate how three disciplinary discourses—theology, medicine/science/bureaucracy and psychology—differently construct and govern sudden infant death and the bereaved parent over time. Beginning with a reexamination of interviews conducted for a ground theory study of parents bereaved by SIDS between 1964 and 1986, the new project shows that the naming and acceptance of SIDS as an official cause of death is influenced by the construction of this type of bereaved parent as psychologically vulnerable and sympathy-worthy. Once ignored and viewed with suspicion, the newly identified SIDS parent becomes an object of considerable research and therapeutic interest when subjected to psychology's gaze.
To demonstrate how this happens, I examine the text, agency, and circulation of “The Psychiatric Toll of Sudden Infant Death Syndrome,” an article that first appears in 1969 in a journal for general practitioners. In this paper I demonstrate the discursive power of this particular article and how its subsequent circulation contributes to the construction of the innocent and vulnerable SIDS parent, which, in turn, shames the state and its various agencies into getting SIDS accepted as an official cause of infant death and into increasing funding for research, support services, and education about SIDS and the problems and needs of its live victims. Among other things, this study illustrates the many insights that are gained when Foucault's “toolbox” is used to study the history, construction, and governing of emotions like grief.
ii Understanding the Lifeworld of Bereaved Families
Maria Gudmundsdottir
Family Health Care Nursing
This paper is part of a larger study exploring the experiences of bereaved families who lost young children to sudden and unexpected death. Interpretive phenomenology was used to develop an understanding of the impact of the loss on family meanings, concerns, and practices. Given the vulnerability of the population under study, it was challenging to gain access to the population. Multiple in-depth interviews were conducted with 7 families (N = 15) and care was taken to ensure the well-being of participating family members through follow-up telephone calls and built-in referral services. Family members were encouraged to reflect upon and describe aspects of their experiences. Concrete narratives of particular family situations were solicited to explore the complexity of each situation. Family members were interviewed both together and separately over a period of 2 to 11 months, 6 months to 3 years after the children's death. Findings revealed that families attempted to rebuild their lives following the loss. Family members were deeply suffering following the unexpected loss of their young child, and their efforts to rebuild their lives were neither smooth nor easy. Previously taken-for-granted family practices had been disrupted with the death and at times those prior practices became meaningless. Families attempted to replace meaningless practices by becoming pregnant, finding meaning in the loss, and creating rituals that allowed for continued connections with the dead child.
iii Parents' Experiences with the Aftermath of Sudden Infant Death Syndrome
Guenther Kruger
University of California, San Francisco
The sudden and unexplained death of an apparently healthy infant produces a profound and catastrophic sense of loss in parents. This presentation examines these outcomes using a constructivist grounded theory approach in conjunction with NVivo software. A discussion of the role of software in analysis will be included. The findings describe the grief process and the subtypes of memories these parents articulate, ranging from extremely traumatic to dissociative to pleasant. Issues of coping and resilience are examined as well as the unique social stressors that these parents encounter. Emerging issues, including the relationship of emotion and grief and the physiology of bereavement, will be described. By examining pertinent aspects of grief theory, emotional memory, and posttraumatic stress disorder (PTSD) along with empirical evidence from interviews with parents, a more specific understanding of the unique trajectory that these parents undergo emerges. Grief theory explains issues including meaning reconstruction and ways in which healing occurs, whereas PTSD and emotional memory add information on the extreme trauma and life-altering changes that parents described in the interviews. Thus, the SIDS experience is unusual, not the same as other forms of grief but also not as pathological as PTSD, as some parents do overcome the trauma on their own and do heal in time. The parents' narratives in this study help to introduce concepts that are emerging in the literature. These include aspects of complicated grief, physiological and anthropological dimensions of grief, and long-term effects relating to grief-related morbidity and mortality.
Re-stor(y)ing Life within Life-Threatening Illness
Laurene Sheilds
University of Victoria
A diagnosis of life-threatening illness creates substantial disruption in one's perceptions of self and life story. Increasing numbers of people with serious illness live in-between the promise of treatment and the threat of recurrence or progression of disease, yet this experience is not well understood. This liminal space provides an opening for re-stor(y)ing one's life within the context of an uncertain future. A better understanding of these liminal experiences is important for developing meaningful supports and resources to improve quality of life for survivors of cancer, end-stage renal disease and HIV/AIDS. This symposium will focus on findings from a CIHR funded narrative inquiry exploring how people living with life-threatening illness story and re-stor(y) their lives. The symposium will present (i) exploration of methodological tensions, (ii) examination of dialogical interview strategies, and (iii) analysis of participants' narratives of their liminal experiences of living with life-threatening illness.
i Methodological Tensions in a Narrative Inquiry Exploring Life-Threatening Illness
Anne Bruce
University of Victoria
Laurene Sheilds
University of Victoria
Anita Molzahn
University of Alberta
Kelli Stajduhar
University of Victoria
Kara Schick-Makaroff
University of Victoria
Linda Shea
University of Victoria
Accepting that experience happens narratively, stories provide a window into how people understand and make sense of their lives. A diagnosis of life-threatening illness creates substantial disruption in one's perceptions of self and life story. Stories about life and illness flow from cultural metanarratives and back into them, and in this way stories are inscribed and constituted through discursive processes. This first presentation in a three-part symposium will focus on the research design of a project using narrative inquiry to explore how people living with a diagnosis of cancer, end-stage renal disease, or HIV/AIDS story and re-stor(y) their lives. Within the presentation we will explore the notions of story-ing and re-stor(y)ing, discuss the importance of the question in relation to people living with life-threatening illness, and describe the correspondence of the research question to the selection of narrative inquiry as a methodology. Our current experience in using narrative methodology will provide a basis for exploring some of the attributes of narrative inquiry that are particularly rich. Three methodological tensions of narrative inquiry will be described: (a) listening for the (un)sayable in how people living with life-threatening illness story and re-stor(y), (b) attending to dialectics and liminal spaces within stor(y)ing, and (c) engaging in the multiplicity of storying/re-stor(y)ing, recognizing the fluidity of the storying process. Examples from the study will be used to portray how these aspects of narrative analysis are enacted.
ii Re-stor(y)ing: The Dialogical Why?
Kara Schick-Makaroff
University of Victoria
Linda Shea
University of Victoria
This presentation, the second of three in the symposium, will focus on narrative interviewing strategies as a means of inviting participants to story and re-stor(y) their unique lives within dominant cultural narratives. Interviewing as a process of dialogical engagement will be explored and discussed within the context of stories of participants living with cancer, end-stage renal disease, and HIV/AIDS. The “dialogical why” evolved as language to describe the process of engaging people who might be faced with unanswerable/existential questions in living with a life-threatening illness in (re)presenting their experience within this narrative inquiry. Through first-person accounts of interviewing processes, conceptualizations of dialogical interviewing will be explicated. The strengths and challenges of dialogical interviewing will be discussed including the emergent, unfolding nature of the interview process and the co-construction of multiple layers of re-stor(y)ing. Reflexivity as integral to the dialogical interview process will also be explored in relation to some of the questions faced by the research team in undertaking dialogical interviewing, such as, How do we begin the interview (and why did we not start with the dominant biomedical narrative)? How do we foster dialogical conversations? and How are we listening within dialogical interviews? Emerging understanding(s) of dialogical interviewing will be described in relation to the analysis process.
iii Re-presenting Narratives of Re-stor(y)ing within Life-Threatening Illness
Laurene Sheilds
University of Victoria
Anita Molzahn
University of Alberta
Anne Bruce
University of Victoria
Kelli Stajduhar
University of Victoria
Kara Schick-Makaroff
University of Victoria
This final presentation in the symposium will address the preliminary findings from this narrative inquiry exploring stories of people living with life-threatening illness. The findings from 34 participants living with cancer (10), endstage renal disease (14), and HIV/AIDS (10) who have participated to two consecutive interviews over the past 18 months are described. The intent of the first interview was to establish a relationship and explore participants' experiences of living with a life-threatening illness. In the second interview, held approximately 9 months later, participants brought representational objects (e.g., poem, music, wig, picture of family pet) to portray or symbolize their experiences of living with life-threatening illness and in this way to re-stor(y) their experience. The representational object created an avenue for participants to explore liminal experiences of living with life threatening illness. Findings from three domains of narrative analysis are considered: (a) engaging in a multiplicity of storying and re-stor(y)ing recognizing a fluidity in this process (e.g., complex interactions of metastories with individual experiences of illness, family, legal, and survival stories); (b) attending to dialectics and liminal spaces within stor(y)ing (e.g., planning for living while planning for dying); and (c) listening for the (un)sayable in how people story and re-stor(y) living with life-threatening illness (e.g. “I don't know what will happen next“, “I don't want to go there” “I don't know if I'll live for five years and if so, what then?”). Narratives of stor(y)ing and re-stor(y)ing are presented in this study.
Author Index
Abramson, Beth, 25, 48
Ahlberg, Beth Maina, 40
Akamine, Regina, 34
Al-Banay, Hana, 3
Amani-Yao, Regine, 20
Amin, Maryam, 3
Andersen, Devon, 28
Andruske, Cynthia Lee, 3
Angus, Jan, 4, 25, 47, 48
Auton-Cuff, Faith, 40
Balneaves, Lynda, 14
Banks, Kathryn, 33
Barbour, Rosaline, 4
Barnes, Donna B., 4
Bartu, Anne, 25, 26
Beagan, Brenda, 46, 47
Bell, Jessica, 8
Biblehimer, Helen, 33
Bidgood, Bruce, 5
Binder, Per-Einar, 44
Birbaum, Rachel, 5
Björkman, Lars, 44
Bondas, Terese, 20, 31
Borland, James, 5
Boston, Patricia, 6
Bottorff, Joan, 14
Brehm, Connie, 18
Bruce, Anne, 6, 50, 51
Buhler, Holly, 37
Bundon, Andrea, 6
Burton, Geraldine, 45
Buxton, Jane, 38
Cairns, Mindy, 45
Carey, Martha Ann, 18
Chabot, Catherine, 7
Chapman, Gwen, 46, 47
Chircop, Andrea, 7
Christensen, Jon, 8
Clark, Alexander, 25, 47, 48
Clarke, Karyn-Grace, 27
Clarke, Laura Hurd, 6
Cohen, Susan, 44
Coholic, Diana, 8
Collins, Pamela, 30
Comeau, Nancy, 30
Cooke, Cheryl, 8
Cooke, Paul, 41
Costello, Anthony, 28
Coughlin, Kevin, 11
Cowsill, Jay, 28
Cummings, Greta, 26
Dahlke, Sherry, 33
Dale, Craig, 25, 48
Dalen, Knut, 44
Daniels, Karen, 40
DeForge, Ryan, 9
Dickinson, Helen, 11
Djukic, Branka, 9
Doherty, Tanya, 40
Dole, Debora, 10
Driedger, S. Michelle, 13
Duggleby, Wendy, 28
Duncan, Amanda G., 48
Durand, Marie-José, 30
Edge, Dawn, 10
Ekstrom, Eva-Charlotte, 40
Encarnacion, Soriano Ayala, 21
Eriksson, Katie, 31
Evans, Marilyn, 11
Fagermoen, May Solveig, 16
Fairey, Gail, 45
Finegood, Diane, 37
Finestone, Hillel, 20
Finkelstein, Adi, 11
Françozo, Maria de Fátima, 34
Freeman, Tim, 11
Funk, Laura, 12
Galdas, Paul, 14
Geekie, Connie, 12
Ghazzawi, Andrea, 20
Given, Lisa, 13
Gordon, Lynne, 45
Grant, Aileen, 12
Grant, Jill, 7
Greeff, Minrie, 13, 17, 36
Gudmundsdottir, Maria, 49
Guenette, Francis, 17
Habersack, Marion, 34
Hall, Jodi, 9
Hamilton, Rebekah, 44
Hammer, Brent, 46
Hammond, Chad, 28
Hamoline, Rita, 28
Hartley, Sally, 19
Heath, Stephanie, 48
Helland, Vigdis May, 44
Higgins, Agnes, 29
Hoagwood, Kimberly, 45
Hovey, Richard, 34
Humble, Áine, 35
Jacksson, Debra, 40
Jakicic, John, 44
Jardine, Cindy, 13
Jenkins, Tania, 13
Jinks, Clare, 19
Johnson, Joy, 7
Kang, Bindy, 14
Kavanagh, Roisin, 15
Keefe, Janice, 35
Kelson, Elizabeth, 35
Kenney, Christine, 21
Khalema, N. Ernest, 35, 36
Kidd, Michael, 39
Kinsella, Evelyn, 41
Kippax, Susan, 39
Kniveton, Karen, 15
Kopenhaver, Tracey, 43
Kovacs Burns, Katharina, 15, 23
Kramer-Kile, Marnie, 25, 48
Kruger, Annamarie, 36
Kruger, Guenther, 48, 49
Lagenhoff, Paula, 26
Lai, Daniel W. L., 3
Lalor, Joan, 15, 16, 29
Lapum, Jennifer, 4, 25, 48
Larocque, Sylvie, 4
Lawler, Denise, 15, 16
LeBlanc, Jeannette, 30
Lee, How, 26
Leegaard, Marit, 16
Lemyre, Louise, 20
Letvak, Susan, 16
Li, Linda, 43
Lillyman, Susan, 24
Loitz, Christina, 35, 36
Lougheed, Sean, 8
Lourenço, Gisele, 34
Lyons, Renee, 7
Maarefvand, Masoomeh, 17
Maeda, Hiroki, 40
Malhi, Luvdeep, 37
Manandhar, Dharma, 19
Manuel, Patricia, 7
Manyedi, Eva, 17
Mao, Limin, 39
Marcellus, Lenora, 37
Marshall, E. Anne, 17
Martin, Karen, 49
Marzolini, Susan, 25, 48
Matteson, Carrie, 37
Maxwell, Hilary, 37
McClinchy, Jane, 45
McDonald, Carol, 18
McIntyre, Marjorie, 18
McMillan, Alison, 13
McMillan, Colleen, 38
Meder, Marilyn, 38
Merryfeather, Lyn, 18
Meyers, Eva, 18
Michel, Isabelle, 4
Michelow, Warren, 38
Miller, William, 6
Milne, Heather, 18
Molzahn, Anita, 50, 51
Morden, Andrew, 19
Moreau, Katherine, 37, 39
Morrison, Joanna, 19, 28
Newman, Christy, 39
Nishimura, Yumi, 40
Nor, Barni, 40
Normand, Charles, 22
O'Connor, Deborah, 3
Oh, Paul, 25, 48
Olausson, Sepideh, 20
Oliffe, John, 14
Olin, Serene, 45
Ong, Bie Nio, 19, 30
O'Sullivan, Tracey, 20
Palmer, Amanda, 37
Panina-Beard, Natasha, 40
Patterson, Sue, 21
Petrovskaya, Olga, 6
Petz, Petra, 34
Phibbs, Suzanne, 21
Pitter, Robert, 7
Plaza Del Pino, Fernando Jesus, 21
Plovie, Barbara, 22
Polak, Emily, 27
Price, Jennifer, 25, 48
Radvanszky, Andrea, 22
Rahman, Syed, 22
Ravindran, Vinitha, 41
Ray, Lynne, 41
Reade, Jennifer, 7
Rehman, Laurene, 7
Reid, Gaynor, 41
Richards, Rose, 23, 42
Richardson, Jane, 30
Richter, Solina, 15, 23
Riley, Jill, 23, 31
Robinson, Ora, 42
Robinson, Suzanne, 11
Roots, Robin, 43
Rukholm, Ellen, 4
Russell, Grant, 20
Saltman, Deborah, 39
Sands, Kristy, 43
Saxon, Elizabeth Ann, 24
Schick-Makaroff, Kara, 50, 51
Schreiber, Rita, 6
Seaton, M. Bianca, 43
Sellers, Craig R., 24
Seto, Lisa, 4, 25, 48
Shambley-Ebron, Donna, 10
Sharlow, Janice, 26
Sharma, Sonya, 46, 47
Sharp, Jennifer, 25, 26
Shea, Linda, 50
Sheilds, Laurene, 50, 51
Shorter, Priscilla, 45
Shotton, Doreen, 41
Shoveller, Jean, 7
Sjursen, Therese Thornton, 44
Skutezky, Trevor, 38
Soon, Judith, 7
Sorfleet, Christopher, 37
Spadaro, Kathleen, 44
Spencer-Cavaliere, Nancy, 35, 36
Spiers, Jude, 26
Stajduhar, Kelli, 50, 51
Stanley, Rebecca, 27
Stewart, Alison, 27
Stewart, Sherry, 30
Stewart, Suzanne, 17
Szabo, Michelle, 47
Temple, Beverley, 27
Teucher, Ulrich, 28
Thapa, Rita, 19, 28
Thomas, Audrey A., 4
Thomas-MacLean, Roanne, 28
Timmermans, Katherine, 4
Tobin, Gerard, 28, 29
Trevoy, E. June, 48
Udell, Wadiya, 8
Vachon, Brigitte, 30
Vallianatos, Helen, 46
Van Wilgenburg, H. A., 30
Watts, Kathleen, 30
Weadon, Claude, 8
Weaver, Tim, 21
Whitcombe, Steven, 31
Wikberg, Anita, 31
Williams, Julia, 31, 32, 45
Williams, Lyn, 41
Wisdom, Jennifer, 45
Woodhouse, Annette, 32
Young, Richard, 27
Zadeh, Abbas Deilami, 17
Zembe, Yanga, 40