ABSTRACT

REPRODUCTIVE HEALTH CHOICES, DISPARITIES, AND SOCIAL CONTEXTS OF AFRICAN AMERICAN ADOLESCENT FEMALES WHO UTILIZE SCHOOL-BASED HEALTH CENTERS

Gina Gabrielle Robinson-Osder

African American adolescent females (AAAFs) continue to experience high rates of sexually transmitted infections, including chlamydia, gonorrhea, and HIV. African American and Hispanic adolescent females also continue to have higher birth rates compared to their White counterparts.

The risk markers of race and ethnicity correlate with fundamental determinants of health such as low socioeconomic status and limited access to health care. The prevalence of some risk factors can be addressed and even decreased through early prevention and lifestyle changes that are facilitated through services delivered at School-based Health Centers (SBHCs).

The purpose of this critical ethnography was to better understand the multifactorial contributors to AAAFs’ reproductive health disparities. Aims included critically analyzing reproductive health decisions, use of SBHCs, peer influences and contextual factors in AAAF’s lives. The study participants were 20 sexually active, self-identified AAAFs between 15-18 years old, from lower socioeconomic backgrounds as identified by their zip codes. Data collection included in-depth interviews and observations of social activities with participants. The data were iteratively coded for major themes and subcategories. Two major overarching themes regarding the sexual debut of these AAAFs were the intersection of reproductive health, sexual behaviors, and developmental vulnerability in AAAFs, and the social contexts contributing to AAAFs’ reproductive health disparities.

All of the AAAFs in this study reported being unprepared mentally, physically, and emotionally for their sexual debut. Developmental vulnerability was more apparent in the younger AAAFs. The young females, none of whom were on any form of birth control, lacked the cognitive development to negotiate their readiness to engage sexually with their older male partners, versus the older adolescents who had partners their own age, were on birth control, and better negotiated their sexual debut. Thirteen of the 20 AAAFs had mothers under the age of 18 years when they were born. Despite 17 of the 20 AAAFs being exposed to neighborhood violence, they were remarkably resilient.

All of the AAAFs in this study ultimately started on birth control methods provided through the SBHCs. The SBHCs provided access to confidential reproductive health care, health education, and counseling, and should be used to address vulnerabilities in younger AAAFs.

ABSTRACT

LIVING-RELATED LIVER DONOR'S PERCEPTIONS OF LIFE AFTER DONATION

Annette Sue Nasr RN, PhD(c)

Purpose: The purpose of this interpretive research study was to understand the perceptions of life experiences of individuals who participated in living-related liver donation (LRLD). The specific research question of this study was: What is the impact of LRLD on the physical, emotional, and familial lives of the donor post-donation?

Background: Pediatric patients suffering from end stage liver disease (ESLD) must depend on cadaveric liver donation or living liver donation in order to sustain life. According to the United Network of Organ Sharing (UNOS) approximately 85,000 candidates are listed for organ transplantation, 17,000 are listed for liver transplantation. Cadaveric liver donation cannot meet the demand presented by children with ESLD, therefore alternatives to cadaveric donation must be established. One alternative to cadaveric donation is living liver donation. Historically there have been over 2,000 living liver donors in the United States (UNOS, 2004), most often a parent of the child with ESLD.

Methods: This interpretive study used ethnographic methods to gather information from 13 living parental donors regarding their physical, emotional, and familial lives since their donation. Donors were recruited from two transplant centers on the western coast of the United States. Interviews were audio taped and transcribed. Data was analyzed in order to produce themes and revealed specific dimensions of these phenomena. This study was approved by the Internal Review Board at Stanford University as well as the Committee on Human Research at UCSF.

Results: The overarching theme that expressed the impact that LRLD had on the donor was that of transformation. Within this theme of transformation major categories included: a self-awareness process, a re-clarification of familial relationships especially with the child who received the donated organ, and a change in perspectives on community.

Implications: Information developed in this study can be used to prepare the donor during the pre-transplant phase as well as to develop interventions to facilitate the adjustment of donors post-transplant. This study will provide nurses and healthcare professionals working in the field of transplantation insights about the issues that LRLD face.

Background: Early Mobilization (EM) in Pediatric Intensive Care Units (PICU) is safe and feasible. However, there are many issues preventing the adoption of EM into clinical practice.

Aim: The first aim is to use in-depth interviews, including open-ended and semi-structured questions, explore nurses’ concerns for patient safety while performing EM and how nurses overcome those safety concerns and still choose to participate in EM. The focus of the interviews is on describing the dimensions of patient safety concerns and how nurses develop strategies to safely deliver EM to their patients. The second aim is to use in-depth interviews, to explore, describe and analyze nurses’ perceptions of barriers and facilitators to performing EM, and to identify strategies nurses perceive would assist them to overcome barriers and increase adoption of EM within the PICU.

Methods: This focused ethnographic study included 15 in-depth interviews with 10 PICU nurses. Data were analyzed using thematic analysis.

Results: This is a three article-based dissertation. The first article is a scoping review of the literature examining nurses’ and family caregivers’ perceptions of early mobility programs in the PICU. This article was instrumental in identifying the scope of the dissertation study after the gaps in the literature were identified. In the second article, nurses discussed their perceptions of barriers to EM care in the PICU, beyond patient safety. In the third article, nurses perceived three categories of barriers: nurse engagement and nursing and unit factors, resources and equipment issues, and interdisciplinary issues. Facilitators to EM include improved condition with mobility, rehabilitation team, and impact on unit culture. The overarching theme that integrated these categories was nurses’ commitment to EM because they recognize the benefit and see the positive outcomes. These barriers presented challenges and nurses felt frustrated by having to navigate through these barriers, but these frustrations created opportunities for nurses to brainstorm and strategize ideas to overcome these barriers.

Conclusions: This study demonstrates the importance of thoughtfully considering the burden evidence-based programs have on the nurses who carry out EM. EM activities fall primarily on nursing staff, and organizational structures and resources must be allocated to reliably deliver this essential care. By better understanding the barriers, leaders can analyze and develop strategies to better integrate EM into practice.

Abstract

Undocumented Mexican immigrant women in the United States are increasing in numbers, and the causes of the social and health inequalities that afflict this vulnerable group of women remain enigmatic. The Latino epidemiological paradox reflects a deceivingly positive overall scenario of wellness, despite the fact that foreign-born Mexican women have a higher prevalence of certain chronic diseases than their U.S.-born counterparts. Current health policies have been created to purposefully exclude undocumented individuals, thus further widening the existing inequities. The research literature focusing on this under-studied group of immigrants is sparse, with the studies being primarily epidemiological in nature, therefore inadequately designed to reveal the origins of the access problem.

The purpose of this study was to understand the phenomenon of the barriers to care experienced by Mexican immigrant women who are forced to exist: (a) without the legal authorization to remain in the United States, (b) having limited or no healthcare coverage, and (c) while suffering from chronic medical conditions. This interpretive phenomenological study examined the healthcare seeking experiences of 26 Mexican immigrant women, employing in-depth interviews and participant observations as sources of data.

The findings derived from the women's narratives centered around several inter-related themes: (a) the failure on the part of healthcare staff and providers to recognize the medical needs of the Mexican immigrant women as legitimate, (b) the situatedness of the women as the defining factor of the healthcare possibilities available to them, and (c) the women's strong need to survive, and the value placed on work as the motivation to stay healthy and to provide for themselves and their families. The immigrant women participants experienced multiple constraints in managing their illnesses, and suffered debilitating effects of their medical conditions. The women responded to the constraints by making accommodations in the way they managed their chronic illnesses, often foregoing needed medications due to expense (or by obtaining them in any way they could), not seeing physicians when it seemed necessary to do so, opting for less expensive self-help techniques, and passing falsified results to gain access to certain medical resources.

Adolescents and young adults (AYAs) with cancer are encouraged or expected to be involved in treatment decision making (TDM). There is limited research on whether and how they want to be involved in TDM. Treatment outcomes in the AYA group have improved minimally compared to their older and younger peers. They experience treatment non-adherence rates as high as 60% that can lead to increased risk of relapse. Open communication, positive family relationships and involvement of the AYA in treatment decisions and illness management could support treatment adherence. However, there is insufficient research exploring the AYA’s involvement in TDM.

Focused Ethnography within the sociologic tradition informed by symbolic interactionism was used to explore and describe AYAs’ experiences with cancer TDM.

Semi-structured Interviews and informal participant observation were used. Thirty-one interviews were conducted with sixteen AYAs between the ages of 15 and 20 years. Participants were asked to reflect on a major recent treatment decision making experience (e.g., clinical trial or surgery) and other treatment decisions made since. Analysis included field notes, analytic memos and coding of interview transcripts. The research was conducted at two pediatric institutions.

Three dimensions related to AYAs’ involvement in cancer TDM were identified: 1) becoming experienced with cancer, 2) import of the decision and 3) decision making roles. AYAs’ preferences for participation in decision making may vary over time and by type of decision. Parents play a particularly important supportive role. Categories related to their new way of being were also identified and centered around not being able to do what they used to do, changing interpersonal relationships and living with uncertainty. Participants described spending more time with family who provided strength, support and advocacy. They described various strategies for dealing with cancer, and how they decided which activities to participate in, or avoid. Future research is needed to focus on developing and implementing interventions to assist AYAs to develop decision making skills and be involved in decisions about their care, as well and enable AYAs to feel less isolated and facilitate their adjustment to their new “cancer normal.”

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