Reframing motherhood through the culture-centered approach: articulations of agency among young Nepalese women

Participatory Action Research to Explore the Role of Structural Violence on Marginalized and Racialized Young Parents

Structural inequities influence young parents' access to health care, housing, transportation, social support, education, and income. The current study adds to the extant literature by providing data directly obtained in collaboration with young parents to understand how structural violence affects the health and well-being of their families, ultimately resulting in community-driven policy recommendations developed in collaboration with the state health department. We engaged a diverse sample of young people-considered as community researchers in the project-including Black, Latinx, and/or LGBTQ+ pregnant and parenting young parents in a participatory action research (PAR) project in the spring of 2022 to explore their health and material needs while living in Springfield, Massachusetts. Together with young parents, we used participatory arts-based methods to conduct community and identity building, define research questions and photo prompts, conduct data collection (photos), engage in group thematic analysis, and take action at the state policy level. We also conducted individual semi-structured life-history interviews with the young parents. Participatory community-led findings indicate an urgent need for systemic change to increase access to safe and affordable housing; living-wage jobs; safe, high-quality, and affordable child care; and to bolster social support and disabilities services for young parents and their families. This participatory study funded by a state health department demonstrates that participatory community-driven data can have the power to mobilize community members and policy makers for social change if prioritized at the state and local levels. Additional practice-based implications include prioritizing participatory mentorship programs intended to aid young parents in navigating the complex systems that are vital to their survival.

Determinants of women's agency in accessing and utilising reproductive healthcare services; a systematic review

Women's agency is vital to access and use reproductive healthcare services, particularly in contexts where patriarchal beliefs and cultural norms limit women's desire to act on their goals or affect their access to essential resources. However, less is known about what resources enable women to exercise agency to access these services. A comprehensive systematic review was conducted to summarise existing evidence on the determinants of women's agency in accessing and using reproductive healthcare services. Various determinants were identified, including individual characteristics; household structure; reproductive health-related determinants; social relations; and economic factors. These determinants of women's agency in accessing reproductive healthcare services were strongly associated with social norms and cultural beliefs. Several gaps in the literature included inconsistent definitions and measurement of women's agency; lack of considering cultural sensitivities and socially acceptable practices in the conceptualisation and measurement of women's agency; a narrow focus on services related predominantly to pregnancy and birth, with other aspects of services including sexual health and safe abortion being largely unreported. The literature focused on developing countries in Africa and Asia, leaving a significant gap in knowledge about women's agency to access services in other geographical areas or among immigrant or refugee populations living in developed countries.

How Individuals Use Metaphors to Negotiate Fertility Treatment Decision-Making with Their Romantic Partners

Fertility problems, or the inability to conceive or carry a pregnancy to term for a period of over 12 months while engaging in unprotected sex, affects 12% of women and 9% of men of childbearing age. To answer calls for more research about individuals' fertility decision-making (DM) with their partners, we conducted in-depth, semi-structured interviews with 53 individuals who have experienced fertility decision-making with a romantic partner at some point in their lives. Our findings indicate at least three primary ways individuals and their partners navigated their decision-making communication in their infertility "journeys:" (1) the Driver-Navigator, (2) Driver-Passenger, and (3) Driver-Backseat Driver approaches. All decision-making communication approaches were viewed by individuals as collaborative (i.e. shared), but varied in degrees of "togetherness" (high, moderate, low) in how they communicated with each other about treatment decisions. Implications include helping couples and their clinicians to be aware of their DM approach(es) and offering alternative DM approaches based on understanding how and why certain approaches may (not) be effective in addressing goals, needs, and identities.

Women in the Margins: A Culture-Centered Interrogation of Hunger and "Food Apartheid" in the United States

Guided by the culture-centered approach to health communication (CCA), this study explores how marginalized US women understand and negotiate meanings related to hunger and health. The analysis is based on in-depth interviews with 23 women experiencing deep structural vulnerability. Findings revealed three paradoxical meanings related to hunger: (a) the "abundance versus scarcity" paradox where even though women were consistently short of food, industrially processed food was amply available to them through charitable food venues, (b) the "good food" versus "bad food" paradox, which showed that while women sometimes consumed whatever food was available, taste, healthfulness, and desirability of food were equally important factors, and (c) the "not-eating versus overeating" paradox, which showed how women experienced anxieties around both hunger and obesity; women experienced physiological hunger pangs, but were also concerned about weight-gain and obesity because of the abundance of processed food in their foodscapes. Overall, despite their best attempts at being good health citizens, women were not able choose the foods they wanted to eat because of inadequate government benefits and a lack of "good food" options in food charity settings. These paradoxical meanings reflect contradictions inherent in the neoliberal model of health citizenship, where the focus is on individual behavior change, while the role of governments in facilitating healthy foodscapes is overlooked.

Women's Agentic Role in Enabling and Dismantling Menstrual Health Taboos in Northern India: A Culture-Centered Approach

Communication about menstrual health continues to be influenced by institutional and social practices which deem it to be unclean and impure. In a country such as India, several customs and traditions reinforce secrecy and shame about menstruation. As such, scholars advocate the need to generate knowledge that can open opportunities to converse on the topic of menstruation and understand issues related to bodily changes. Using a culture-centered approach, this study examined how college-going adult women from two cities in Northern India made sense of menstrual health. Data collection included 20 focus groups with 180 college-going women and interviews with 16 female family members. Participants discussed communication patterns surrounding menstrual health and how they uphold, challenge, and change social practices. Specifically, participants reflected on how they were communicated to about their menstrual health with underpinnings of secrecy and shame and how the influence of current opportunities for openness encourage them to anticipate positive change. Theoretical and practical implications for studying communication around menstruation in diverse cultural contexts are discussed.

Explorations of Health in Aotearoa New Zealand's Low-income Suburbia

Underpinned by the notion that community voices should be central to the development of localized communication infrastructures for health and well-being, this study applied Dutta's culture-centered approach to examine the meanings of health and the navigation of being healthy among 118 people residing in low-income suburban areas in Aotearoa New Zealand. The culture-centered approach is based on dialog between researchers and community members, and it centralizes local contexts by building theories from within the culture and co-creating dialogic spaces of listening, formed at the intersection of structure, culture, and agency. In this study, participants constructed health in relation to food, housing, and health care, underpinned by financial inaccessibility and a deep-rooted cultural conflict between the collectivist norms practiced by the community and the neoliberal individualized structure. The study illuminates how the pathologization of culture by structure constitutes poor health outcomes and how agentic expressions of culture negotiate local structures to regain health and well-being through acts of resistance.

Gendered social practices in reproductive health: A qualitative study exploring lived experiences of unwed single mothers in China

China's family planning policy has historically silenced the voices of women, especially unwed single mothers at the expense of their reproductive health and overall wellbeing. Further, reproductive decisions in China are closely intertwined with marriage decisions and intergenerational dynamics, highlighting the relevance of gender in women's reproductive health experiences. Chinese unwed single mothers are in particular penalized for violating the gendered social norms supported by the national reproductive policies. Drawing on previous work that calls on the need to explore gender system and its influence on health, this manuscript explores the ways in which gender norms are played out for the unwed single mothers within romantic and intergenerational relations, with impacts on their reproductive health and decision-making. The findings show that reproductive decisions are interwoven with the fulfilment of other gendered identities, such as daughter, daughter-in-law and wife. Although the decision to go through unwed motherhood is reflective of their agency, the tie between childbirth and marriage does not allow the women to entirely break free from the social system. The findings also highlight the importance of considering the role of gender system that is played out within social relations, which in turn impacts the health of the women.

Understanding self-construction of health among the slum dwellers of India: a culture-centred approach

Disembarking from a traditional approach of narrow hazardous environmental and structural conditions in understanding urban slums' health problems and moving towards a new notion of what constitutes health for slum dwellers will open a new avenue to recognise whether and how health is being prioritised in disadvantaged settings. Drawing on in-depth semi-structured interviews with a total of 67 men and 68 women from Kolkata slums and 62 men and 48 women from Bangalore slums, this study explored how knowledge, social realities, material and symbolic drivers of a place interweave in shaping slum-dwellers' patterned way of understanding health, and the ways health and illnesses are managed. The current study adds to the growing evidence that ordinary members of the urban slums can articulate critical linkages between their everyday sociocultural realities and health conditions, which can support the design and delivery of interventions to promote wellbeing. The concept of health is not confined to an abstract idea but manifested in slum-dwellers' sporadic practices of preventive and curative care as well as everyday living arrangements, where a complex arrangement of physical, psychological, financial, sociocultural and environmental dimensions condition their body and wellbeing.

Developing and testing measures of reproductive decision-making agency in Nepal

Conceptual ambiguity in how we define reproductive empowerment has left the field with inconclusive evidence of its relationship to key reproductive outcomes. Our study aimed to develop and test a measure of reproductive decision-making agency, which is a critical component of reproductive empowerment, in a sample of married women from two Nepalese districts. Initial measures were developed based on theory and previous literature. Next, we used cognitive interviewing techniques to explore local meanings of reproductive empowerment and decision making through eight focus group discussions and 24 in-depth interviews. This process resulted in four core questions used to assess decision making across three domains of reproductive behavior: when to have children, whether to use family planning, and which family planning method to use. We combined these questions to develop an overall assessment of decision-making agency. These measures were included in a quantitative survey conducted with 1000 women, split evenly between the two districts. The combined measure of overall reproductive decision-making agency was internally consistent across the three domains examined (Cronbach's alpha = 0.6416), performed well across a range of validity assessments, including those aimed at assessing construct and criterion validity, and was predictive of a range of reproductive outcomes, particularly those related to feelings of reproductive control. The results suggest that the measures developed here provide insight into the nuances of joint versus sole decision making beyond those provided by standard measures. With better measures of reproductive agency, we can better design interventions for men and women, to meet their reproductive needs.

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New measures of reproductive decision-making agency developed using data from Nepal.

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New measures are predictive of reproductive self-efficacy and feelings of control.

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Comparison with other measures suggest ambiguity of meaning of joint-decisions.

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Measures offer insights into empowerment beyond what standard measures show.

The Cultural Competence of Health Journalists: Obesity Coverage in Four Urban News Organizations

This study sought to identify indicators of cultural competence in 670 news stories covering obesity by four urban news organizations: two mainstream newspapers and two ethnic newspapers serving the African-American and Hispanic communities. Through semantic network analysis, the research found that the news organizations converged on five themes: unhealthy lifestyle, food access and education, healthy lifestyle, public policy, and research. Public policy solutions were favored by the mainstream newspapers, while self-efficacy was emphasized in the ethnic papers. In all four newspapers, indicators of cultural competence were mixed. Ethnic newspapers showed particular competence in certain areas, such as community-based sourcing, direct mention of groups at risk for obesity, and lack of medical jargon. Chi-square tests showed, however, that the African-American newspaper discussed obesity less than expected, while the metropolitan daily directly mentioned ethnic groups at risk for obesity less than expected.

Structural Violence in Health Care: Lived Experience of Street-Based Female Commercial Sex Workers in Kathmandu

Thirty-five in-depth, semi-structured interviews were conducted with female, street-based, commercial sex workers in Kathmandu, Nepal. The framework of structural violence guided this study in identifying the structural context that impacts the female sex workers' lives and may cause harm to their health. Structural violence in health care was revealed through thematic analysis as (a) discrimination, (b) forced choice, and (c) limitations to health information sources. Lived experiences highlight how the sex workers engaged with structural limitations in health care access, services, and utilization. Structural violence conveys a message about who is entitled to health care and what a society emphasizes and expects regarding acceptable health behavior. Examining the structural violence highlighted how the sex workers negotiated, understood, and engaged with structural limitations in health care access, services, and utilization.

Mothers "Google It Up:" Extending Communication Channel Behavior in Diffusion of Innovations Theory

This study employed qualitative methods, conducting 44 in-depth interviews with biological mothers of newborns to understand women's perceptions and use of new media, mass media, and interpersonal communication channels in relation to health issues. Findings contribute to theoretical and practical understandings of the role of communication channels in diffusion of innovations theory. In particular, this study provides a foundation for the use of qualitative research to advance applications of diffusion of innovations theory. Results suggest that participants resisted mass media portrayals of women's health. When faced with a health question, participants uniformly started with the Internet to "Google it up." Findings suggest new media comprise a new communication channel with new rules, serving the functions of both personal and impersonal influence. In particular, pregnancy and the postpartum period emerged as a time when campaign planners can access women in new ways online. As a result, campaign planners could benefit from introducing new ideas online and capitalizing on the strength of weak ties favored in new media. Results expand the innovativeness/needs paradox in diffusion of innovations theory by elaborating on the role of new media to reach underserved populations. These findings provide an opportunity to better understand patient information seeking through the lens of diffusion of innovations theory.

Dancing around infertility: the use of metaphors in a complex medical situation

People use metaphors to cognitively frame their experiences as well as to explain those experiences to others, especially in complex medical situations. However, previous research has not fully explored the extent to which metaphors may be helpful or harmful to achieving well-being. This investigation fills this gap by identifying and explaining metaphor use in the context of infertility. Guided by self-determination theory, in-depth interviews were conducted with 22 women and men who had experienced an inability to conceive a child. Analysis of participant narratives yielded 10 prominent metaphors that reflect how participants' need for competence, autonomy, and relatedness were (and were not) met during their infertility experience. Results indicate that cognitively framing the infertility experience using certain metaphors is more likely to enhance personal and relational well-being, while others may be more harmful. Suggestions for communication with doctors, partners, families, and friends are discussed.

Lived experiences of street-based female sex workers in Kathmandu: implications for health intervention strategies

The lived experiences of women sex workers illustrate that sex work is frequently a manifestation of limited access to education, resources and jobs due to violence, oppression and patriarchy. However, some Nepalese sex workers reconstitute sex work as a viable form of work that provides food and shelter for their families and allows fulfillment of their duties as mothers. Through a culture-centred approach to research, which emphasis the voices of the marginalised and their own articulations of how marginalised spaces are negotiated, this paper offers an entry point to locating sex workers as active participants in their day-to-day lives. Thirty-five in-depth, semi-structured interviews were conducted with street-based female sex workers. Thematic analysis revealed the following three themes: (1) surviving through sex work, (2) financial security in sex work and (3) surviving sex work stigma. These findings have implications for health promotion involving members of this population. Lived experiences illustrate the need to move away from traditional, top-down, linear behaviour-change health campaigns to reconstitute health interventions within a participatory bottom-up approach that includes the voices of participants and is situated within their own context and needs.

Childbirth traditions and cultural perceptions of safety in Nepal: critical spaces to ensure the survival of mothers and newborns in remote mountain villages

OBJECTIVE

to uncover local beliefs regarding pregnancy and birth in remote mountainous villages of Nepal in order to understand the factors which impact on women's experiences of pregnancy and childbirth and the related interplay of tradition, spiritual beliefs, risk and safety which impact on those experiences.

DESIGN

this study used a qualitative methodological approach with in-depth interviews framework within social constructionist and feminist critical theories.

SETTING

the setting comprised two remote Nepalese mountain villages where women have high rates of illiteracy, poverty, disadvantage, maternal and newborn mortality, and low life expectancy. Interviews were conducted between February and June, 2010.

PARTICIPANTS

twenty five pregnant/postnatal women, five husbands, five mothers-in-law, one father-in-law, five service providers and five community stakeholders from the local communities were involved.

FINDINGS

Nepalese women, their families and most of their community strongly value their childbirth traditions and associated spiritual beliefs and they profoundly shape women's views of safety and risk during pregnancy and childbirth, influencing how birth and new motherhood fit into daily life. These intense culturally-based views of childbirth safety and risk conflict starkly with the medical view of childbirth safety and risk.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

if maternity services are to improve maternal and neonatal survival rates in Nepal, maternity care providers must genuinely partner with local women inclusive of their cultural beliefs, and provide locally based primary maternity care. Women will then be more likely to attend maternity care services, and benefit from feeling culturally safe and culturally respected within their spiritual traditions of birth supported by the reduction of risk provided by informed and reverent medicalised care.