Lifelines

Insights and inspirations: A qualitative exploration of community health workers' motivations in Myanmar and Bangladesh

Community Health Workers (CHWs) play significant roles in various settings, with their motivations and retention strategies widely studied. Yet, literature is sparse on CHWs from Myanmar, who are key to primary health care in marginalized and conflict-affected areas. This study explores the unique challenges these CHWs face, using firsthand accounts. Life story interviews, enhanced with a lifeline tool, were conducted with 34 CHWs from conflict-affected regions in Myanmar and in Rohingya camps in Bangladesh. Additionally, eight key informant interviews were held with leaders from organizations that work with CHWs. Data analysis was facilitated by NVivo 14 software and four layers of influence adapted from Urie Bronfenbrenner's ecological systems theory of human development. The findings reveal that, CHWs primarily joined organizations to acquire skills and knowledge. In Bangladesh, the focus was on job-related skills, whereas in Myanmar, healthcare skills were prioritized. Despite remuneration being inadequate, it remained crucial for retention, as did the sense of being valued by the community in Myanmar. Mental health support emerged as a potential need for CHWs. Funding deficits and fragmented support presented organizational challenges, thereby impacting both program implementation and retention of CHWs. To address these challenges, effective, sustainable CHW programs in conflict-affected regions require a shift towards long-term support for organizations and health systems. This includes focusing on CHWs' mental health and stakeholder engagement. Short-term, fragmented solutions may revert to pre-existing situations once removed. Sustainability planning is key to break the CHW turnover cycle and maximize investments in these contexts.

Trauma-Disclosure, Meaning-Making, and Help-Seeking in Mothers Experiencing Homelessness: Results From a Trauma-Focused, Clinical Ethnographic Narrative Intervention

Mothers experiencing homelessness are seldom asked about past trauma that may be causal to housing instability and poor health. There are also few validated trauma-focused interventions in family shelters. To address this gap, we tested the feasibility and acceptability of the trauma-focused clinical ethnographic narrative intervention (CENI-TF) in increasing mothers' trauma disclosure, appraisal of its meaning in their lives, and help-seeking behaviors. We also present the qualitative findings to contextualize the intervention. Findings are organized under three major domains and nine subthemes that capture participants' voices and experiences. The CENI-TF has the potential to promote help-seeking behaviors and interrupt recurring cycles of trauma and housing instability in this at-risk population.

"I feel like I'm living the authenticity of my being": gender identity developmental trajectories of trans youth in Portugal

Background

Research into the identity development of trans people has been emerging, but there is still a need for further study. While significant processes for identity construction take place during late adolescence and early adulthood, it is important to understand which milestones are associated with the trajectories of gender identity (GI) development.

Aims

The present study aimed at exploring the gender identity (GI) developmental trajectories of young Portuguese trans people and the processes associated with them.

Methods

Interviews were conducted with sixteen young people aged between 16 and 26, recruited through LGBTI+ formal associations and informal online groups, as well as through psychology and sexology consultations. The interviews were conducted face-to-face and online and were analyzed through thematic analysis, which aims to identify, analyze and report patterns in a qualitative data series.

Results

Six themes were identified and linked to developmental milestones. These were related to: (1) Discomfort in relation to the gender assigned at birth and its social roles; (2) Body discomfort; (3) Discovery of trans identities; (4) Disclosure of GI; (5) Perceived support; (6) Authentic living of GI. Linked to these themes, four sub-themes were identified as well.

Discussion

Based on the life course theory, moments of transition and turning points were identified, as well as social influences such as historical time and place. Thereby, this study contributed to a better understanding of trans youth's GI developmental trajectories in the Portuguese context, where the study on this topic is still emergent, also contributing to inform the path to be taken at the international level regarding socio-legal policies concerning trans youth.

"I was very sad, but not depressed": phenomenological differences between adjustment disorder and a major depressive episode

Introduction

Adjustment disorder (AD) is a diagnosis that must be differentiated from major depressive episode (MDE) because of the therapeutic implications. The aim of this study is to understand the experience of patients who in their lifetime have been diagnosed with AD as well as MDE to establish the characteristics of each disorder.

Methods

A descriptive phenomenological approach was used with in-depth interviews to four patients and the method proposed by Colaizzi to understand the experiences and reach the description of both disorders.

Results

Three women and one man, with advanced schooling were interviewed. The participants emphasized the existence of differences that were grouped in: the attribution made by the individual, the theme of cognitions, the variability in the course, the possibility of mood modulation, the syndrome severity, the presence of hopelessness and the perceived course.

Conclusion

Phenomenological differences were found in the subjective experience of MDE and AD. The MDE would be described as an intense state of generalized shutdown of the subject's own life, with little response to events, and the AD, as a dynamic reaction attributed to a stressful event, with high variability in the course of symptoms due to the dependence on such event, with the preserved hope that it will end.

"Being Able to Be Yourself": A Qualitative Exploration of How Queer Emerging Adults Experience a Sense of Belonging in Rural Australia

Rural Australians with diverse sexualities (queer) are at higher risk of poor mental health outcomes and suicidal ideation than their heterosexual and urban peers. This is particularly the case for young people aged 18-29 years experiencing a developmental period known as emerging adulthood marked by significant volatility and change. A sense of belonging is a fundamental human need and has been found to function as a protective factor against depression and suicidality in rural, queer, and emerging adult populations. However, studies have not explored how queer emerging adults experience belongingness in rural communities. This paper presents a qualitative, exploratory study of 11 rural queer emerging adult Australians and examines their experiences of belongingness utilizing a four-factor framework of belonging-assessing competencies, opportunities, motivations, and perceptions. The results indicate that negative perceptions of inclusion in rural areas inhibit a sense of belonging from being established, by influencing the individual's motivations to belong and the competencies they apply to belong. Lower levels of perceived social acceptance and queer visibility are two perceptions that repeatedly affect a sense of belonging. Interventions that address perceptions and competencies, and increase queer visibility in rural areas, could increase a sense of belonging for queer emerging adults in rural Australia.

Contemporary pathways to adolescent pregnancy in Indonesia: A qualitative investigation with adolescent girls in West Java and Central Sulawesi

In the last decade, reduction in adolescent fertility rates in Indonesia has slowed despite national programmes and policies focused on addressing child marriage. Indonesia currently has the highest number of births to adolescent girls aged 15-19 years in Southeast Asia. There is a need to develop a more nuanced understanding of the drivers of adolescent pregnancy in Indonesia to inform programmes and policies tailored to young people's needs and priorities. This study explored adolescent girls' pathways to pregnancy across two provinces (Central Sulawesi and West Java) in Indonesia. We conducted participatory timeline interviews with 79 girls aged 15-21 years from urban, peri-urban, and rural communities and inquired about their relationships and life experiences leading up to pregnancy. We conducted follow-up interviews with 19 selected participants to validate and clarify preliminary findings. We identified six pathways to adolescent pregnancy which were broadly differentiated by the timing of pregnancy relative to marriage. Three pregnancy pathways within marriage were further differentiated by the main motivation for marriage-financial reasons, protecting the girl and family's reputation, or to progress a romantic relationship. Three pregnancy pathways outside marriage were distinguished by the nature of the sexual relationship preceding pregnancy-consensual sex, unwanted or pressured sex, and forced sex. Drivers of adolescent pregnancy include the acceptability of child marriage and stigma surrounding premarital pregnancy, family and social expectations of pregnancy following marriage, harmful gender-based norms and violence, and lack of sexual and reproductive health information and access to services. Adolescents follow varied pathways to pregnancy in Indonesia. The idealisation and acceptance of child marriage is both a catalyst and outcome of adolescent pregnancy, which is occurring amid stigma surrounding premarital sex and pregnancy, harmful gender-based norms and violence, and barriers to contraceptive access and use. Our findings emphasise that there are many drivers of adolescent pregnancy and different pathways will require intervention approaches that address child marriage alongside other key contributors.

Participant-Generated Timelines: A Participatory Tool to Explore Young People With Chronic Pain and Parents' Narratives of Their Healthcare Experiences

Visual methods are becoming more evident in health research. Timeline drawings have been used as a participatory tool alongside interviews in life course research. In this article, we describe how a method involving timeline generation can explore patient experiences along a treatment continuum. Grounded in previously published evidence and using specific examples from two studies exploring the experiences of young people treated for chronic pain, we outline the key components of this method. Moreover, we highlight the flexibility of its application and the importance of using a person-centered approach in tailoring the application pragmatically to study population-specific needs and characteristics, while answering the research question. We also reflect on how the dynamic visual display of the timeline and participants' explanations add perspective and understanding to complex and multidimensional human experiences associated with healthcare treatment. Furthermore, we outline how this method can help capture changes in the meaning and sense-making of these experiences over time, all the while fostering empowerment in study participants. Finally, the key considerations of using the method are outlined. It is our aim that this article provides the details required to inspire others to consider this novel method as a means of capturing the healthcare experiences of young people with other chronic conditions, an important first step in fostering the changes required to improve the quality of healthcare services and research.

Surviving Child Abuse in People With Mental Illness: A Grounded Theory Approach

The aim of this qualitative study was to examine the process of surviving child abuse in people with a mental illness in order to develop an explanatory theory. The study utilized the grounded theory approach. Seventeen community-dwelling adults with a mental illness who had experienced child abuse were interviewed. For the in-depth interview, the lifeline interview method was used. Data were collected from July 14, 2019, to February 28, 2020. The constant comparative method was used for analysis, to identify similarities and differences between different statements, and similar phenomena or theories were compared and analyzed continuously. The central phenomena were "losing oneself" and "in a precarious state." Participants used "expressing," "standing on one's own feet," and "avoiding" as coping strategies. Observed outcomes were "making life work for them" and "living with others." The core category was "losing myself, embracing myself as someone in a precarious state, and being reborn as the master of my life." Positive religious coping, having a supportive network, and emotional or physical distance from difficult situations played a major role in surviving participants' experiences of child abuse and being victimized because of their mental illness. Our findings provide a theoretical basis for understanding people with mental illness who have survived child abuse, and suggest that opportunities for sharing their stories, facilitating self-reliance, and avoiding the causes of their difficulties all play a role in their healing process. Based on this study, it is expected that clinical experts and policy developers will be able to formulate evidence-based interventions and policies.

Efficacy of a Contextualized Measurement of Life Satisfaction: A Pilot Study on the Assessment of Progress in Eating Disorder Therapy

Eating disorders strongly affect psychological distress and its perception. However, most of the existing instruments for assessing life satisfaction rely on a point-estimation method that is biased due to the circumstantial conditions around the time of assessment. The main goal of this study was to apply a different kind of instrument-the Life Satisfaction Chart-that situates the current state of life satisfaction in the context of personal history and describes the life stages through a graph. The assessment was applied to a sample of 29 adolescent women (average age of 17.88) who were enrolled in a clinical program to treat their eating disorders. The results showed that their estimation of their current life satisfaction was almost identical to the estimation provided by a therapist for those who were in therapy phases 1, 2, and 3 (of four), while patients' point-estimation satisfaction showed statistically significant differences when compared with the situated estimations. In therapy phase 4, significant discrepancies were observed between the therapist's perception and the patients' perception, because the therapist focused only on eating disorder recovery, whilst the patients evaluated their lives under almost-normal conditions, taking into account further dimensions. The Life Satisfaction Chart is a new approach to life-satisfaction measurement that showed promising measurement and therapeutical properties.

"Knitting Together the Lines Broken Apart": Recovery Process to Integration among Japanese Survivors of Intimate Partner Violence

OBJECTIVE

This study used narrative interviewing and grounded theory analysis to discover the phases of trauma integration for Japanese women who had experienced intimate partner violence (IPV).

METHOD

We interviewed 23 Japanese women who had experienced IPV using the Clinical Ethnographic Narrative Interviews (CENI) from November 2017 to September 2018 in Tokyo, Japan. The data from 11 participants who had achieved trauma integration using the Trauma Recovery Rubric were analyzed using a modified grounded theory approach.

RESULTS

Six phases of the trauma integration journey after IPV were discovered: (1) Chaos, (2) Burning out, (3) Focusing, (4) Challenging, (5) Deepening insights, and (6) Re-building. The survivors described the processes of exploration of themselves and their reactions to their concurrent challenges. They focused on finding ways to protect, re-discover, and re-embrace themselves by healing from physical, psychological, and spiritual distresses. They also rebuilt relationships with others and acquired knowledge and skills to achieve a new life. Notably, the primary components of their recovery processes were changes in self-perception and self-interpretation of the trauma itself and its impacts on one's life and within oneself from multiple angles. In addition, traditional Japanese norms and gender roles, such as beliefs concerning the "ideal life of a woman" and fear of not behaving differently from others, profoundly influenced their recovery process.

CONCLUSION

This study highlights the importance of incorporating individuals' cultures and their phase, needs, and personal self-development timeframes when developing trauma integration interventions.

Everyday heroes: Graphical life stories and self-defining memories in COVID-19 medical volunteers

OBJECTIVE

This study aimed to explore the autobiographical foundations of specific narrative identities, which made it possible to choose medical volunteering in the time of the pandemic, resist highly hazardous conditions of working in COVID-19 "red zones," and emerge from this work with a sense of meaning and optimism.

METHOD

In this study, we focused on the graphical life stories, self-defining memories (SDMs), and self-defining future projections (SDFPs) of four individuals who worked at COVID-19 "red zone" hospitals as medical volunteers.

RESULTS

The analysis revealed that all participants incorporated their volunteering experiences as meaningful and satisfying into their general narrative identity. They scored high on standard scales assessing subjective well-being and reported autonomous regulation of volunteer motivation. We identified narrative trunk lines and metaphors across autobiographical data, which differentiated the participants into four types of general identities extensively manifesting in volunteering identity: faith-based, influence-based, help-based, and success-based. The participants' graphical life stories, SDMs, and SDFPs showed similar patterns consisting of adult-oriented childhood, focus on mid-life events, and a redemption sequence in narration.

CONCLUSION

These findings could be taken as touchstones to highlight the critical value of self-continuity and sense of purpose in active coping with global challenges.

Parental experiences with their child's eating disorder treatment journey

BACKGROUND

Parents are integral in the treatment of pediatric eating disorders. The current study was conducted to further understand the barriers and facilitators that parents experience in accessing specialized, tertiary level eating disorder treatment for children and adolescents. The goals of the study were to understand the processes leading to diagnosis and treatment, perceived barriers and facilitators to accessing care, and parents' experiences over the course of their child's eating disorder treatment.

METHODS

Ten parents whose children were admitted to a Canadian tertiary level specialized pediatric eating disorders program took part in an exit interview upon their child's completion of treatment in the program. In-depth semi-structured interviews were combined with a visual timeline. Interpretive induction was performed to generate high-level concepts that emerged from the interviews.

RESULTS

Five high-level concepts were identified: (1) delays in identifying eating disorder symptoms, (2) challenges in accessing eating disorder services, (3) the right treatment at the right time, (4) emotional impact on parents, and (5) parental expertise and involvement.

CONCLUSIONS

Several barriers were identified by parents that interfered with treatment, including system-related challenges when accessing specialized eating disorder treatment, concerns about a lack of appropriate mental health support for their child, and difficulties with transitioning between community and tertiary level care. Negative emotions, including guilt and self-blame, were common early in the treatment journey. Themes of parental involvement throughout treatment, and parents taking charge of their child's recovery, emerged across interviews. The results of this study suggest the importance of early identification of eating disorder symptoms, facilitating smoother transitions between levels of care (e.g., community services and hospital-based eating disorder care), and improving clinical decision-making to ensure children and adolescents with eating disorders receive the most appropriate treatment based on their clinical presentation.

Youth and parent perceptions on participating in specialized multidisciplinary pain rehabilitation options: A qualitative timeline effect analysis

Background: Little is known about how the specialized treatment journey is perceived by youth with pain-related disability and their parents. Aims: Describe and compare the treatment effects and outcomes as perceived by youth and their parents enrolled in intensive interdisciplinary pain treatment (IIPT) or multimodal treatment (MMT). Methods: Eleven IIPT youth and five parents and three MMT youth and five parents were recruited. All were asked to complete a treatment journey timeline, followed by separately conducted semistructured interviews. Transcribed interviews were analyzed using reflective thematic analysis. Results: The main themes spanned the treatment trajectory. All participants described similar initial struggles (Theme 1). Positive and negative treatment effects associated with acquisitions and disruptions (Theme 2), and outcomes post-discharge related to supports and realities (Theme 3) emerged. Knowledge, skills, and support acquisition during treatment and feeling empowered and confident to self-manage postdischarge were identified as IIPT benefits. However, the change effort and life disruptions required and the difficulty transitioning to real life postprogram were acknowledged as detrimental IIPT impacts. Continuing with life as usual and maintaining supports in daily contexts (e.g., school personnel, friends) were reported MMT benefits. However, the challenges of managing pain, treatment adherence within the competing demands of daily realities, and the lack of support to integrate strategies were emphasized as detrimental MMT impacts. Conclusions: Detailed impacts of two specialized multidisciplinary pain rehabilitation interventions on the lives of youth with pain-related disability and their parents are described. The treatments benefits and previously unexplored detrimental effects are unveiled.

Silently Screaming in the Dark: Gender-Based Dynamics of Distress in Japanese Migrants

Prior literature has shown the female Japanese population experiences higher susceptibility to mental health disorders. The causal influences of help-seeking for distressed women were investigated through analysis of 24 interviews of Japanese immigrant women in the Detroit Metropolitan Area. The Clinical Ethnographic Narrative Interview (CENI) was utilized as the interviewing technique, investigating Japanese culture as a determinant of personal wellness. This study was a grounded theory examination of the interactions among gender, social context, cultural displacement, and a causal model for Japanese women's distress experiences. The resulting theoretical model revealed the familial and social dynamics traditional to Japanese culture developed feelings of poor self-worth common amongst study participants. This negative perception of self was exacerbated by gendered challenges of expatriation and intense pressures within this region's Japanese migrant community. These findings show the need for increased contact with at-risk populations to understand their causal models and help-seeking behaviors and expectations.

Visualizing participant experiences in maternal and child nutrition studies using timeline mapping

Iron and folic acid (IFA) supplementation is one of the most cost-effective interventions to prevent and treat anemia during pregnancy. Despite having the highest global burden of anemia among pregnant women, rates of IFA uptake in pregnancy in India are still very low, particularly in the state of Uttar Pradesh. While there have been several studies that explored challenges around IFA consumption and adherence, there is a paucity of studies that have synthesized this information into a single visual tool that can help program implementers understand the challenges and identify potential areas of intervention.  Timeline maps were developed as a visual qualitative tool to explore the nuances of health behaviors among pregnant women with respect to antenatal care (ANC) services, including IFA consumption.  Timeline maps were used to visually document critical events pertaining to ANC services chronologically, including details on contact points with the health system and events specific to IFA distribution, consumption and counselling.  Six research assistants (RAs) were trained on how to use timeline maps and record participant narratives. The RAs later participated in a focus group discussion to gain insight about their experiences using the tool. RAs reported that the timeline maps were easy-to-use and facilitated in-depth conversations with participants. RAs shared that they were able to actively engage the participants in co-creating the maps. The visual nature of the tool prompted participants’ recall of key pregnancy events and reflexivity. Challenges reported with the tool/process included recollection of past events and potential misrepresentation of information. These highlight a need to restructure training processes. Our findings indicate that timeline maps have the potential to be used in a variety of other program contexts, and merit further exploration.

Visualizing participant experiences in maternal and child nutrition studies using timeline mapping

Iron and folic acid (IFA) supplementation is one of the most cost-effective interventions to prevent and treat anemia during pregnancy. Despite having the highest global burden of anemia among pregnant women, rates of IFA uptake in pregnancy in India are still very low, particularly in the state of Uttar Pradesh. While there have been several studies that explored challenges around IFA consumption and adherence, there is a paucity of studies that have synthesized this information into a single visual tool that can help program implementers understand the challenges and identify potential areas of intervention.  Timeline maps were developed as a visual qualitative tool to explore the nuances of health behaviors among pregnant women with respect to antenatal care (ANC) services, including IFA consumption.  Timeline maps were used to visually document critical events pertaining to ANC services chronologically, including details on contact points with the health system and events specific to IFA distribution, consumption and counselling.  Six research assistants (RAs) were trained on how to use timeline maps and record participant narratives. The RAs later participated in a focus group discussion to gain insight about their experiences using the tool. RAs reported that the timeline maps were easy-to-use and facilitated in-depth conversations with participants. RAs shared that they were able to actively engage the participants in co-creating the maps. The visual nature of the tool prompted participants' recall of key pregnancy events and reflexivity. Challenges reported with the tool/process included recollection of past events and potential misrepresentation of information. These highlight a need to restructure training processes. Our findings indicate that timeline maps have the potential to be used in a variety of other program contexts, and merit further exploration.

Invalidation Experiences Among Non-Binary Adolescents

Mental health disparities among transgender adolescents are well documented and have generally been attributed to minority stress. However, significantly less is known about the minority stress experiences of non-binary adolescents or those who do not identify as exclusively male or female. This study qualitatively explored the unique ways that non-binary adolescents experience minority stress and how it influences their mental health and well-being. Lifeline methodology and photo elicitation were used to interview 14 ethnically diverse non-binary adolescents between the ages of 16 and 20, residing in New York City (NYC) and the San Franscicso Bay Area (SFBA). We present participants' experiences using a novel construct of invalidation, defined as the refusal to accept one's identity as real or true. Our findings indicate that invalidation is conceptually distinct from the established minority stressor of "non-affirmation." Non-binary adolescents experienced myriad forms of invalidation within multiple social contexts, which contributed to negative affective and cognitive processes, including confusion, self-doubt, rumination, and internalized shame. For many participants, the cumulative stressors related to invalidation contributed to poor mental health outcomes. Data from this study suggest that identity invalidation is a unique form of minority stress that may especially affect non-binary individuals, with significant implications for their social and emotional well-being.

Socio-cultural change in conflict and post conflict settings: five decades of giving birth in Cambodia

Background

This paper explores the changing experience of giving birth in Cambodia over a 53-year period. During this time, Cambodian people experienced armed conflict, extreme privation, foreign invasion, and civil unrest.

Methods

An historical perspective was used to explore the changing place and nature of birth assistance given to Cambodian women between 1950 and 2013. Twenty-four life histories of poor and non-poor Cambodians aged 40–74 were gathered and analysed using a grounded thematic approach.

Results

In the early lives of the respondents, almost all births occurred at home and were assisted by Traditional Birth Attendants. In modern times, towards the end of their lives, the respondents’ grand-children and great grand-children are almost universally born in institutions in which skilled birth attendants are available. Respondents recognise that this is partly due to the availability of modern health care facilities but also describe the process by which attitudes to institutional and homebirth changed over time. Interviews can also chart the increasing awareness of the risks of homebirth, somewhat influenced by the success of health education messages transmitted by public health authorities.

Conclusions

The life histories provide insight into the factors driving the underlying cultural change: a modernising supply side; improving transport and communications infrastructure. In addition, a step-change occurred in the aftermath of the conflict with significant influence of extensive contact with the Vietnamese recognised.

Trial registration

None.

Minority Stress and Drinking: Connecting Race, Gender Identity and Sexual Orientation

We carried out a constructivist grounded theory-based qualitative exploration on the relations between intersectional minority stress and drinking among a community sample of 20 Latinx and African American sexual minority, gender expansive women. Our overarching goal was to illuminate the nuanced ways in which participants’ lived experiences; in relation to race and ethnicity, gender identity, and sexual orientation, intersected to create complex forms of minority stress rarely captured in the research literature. Semi-structured interviews and lifeline methodology were employed to assess participants’ major life stressors and drinking history; particularly, when and how drinking became a regular part of participants’ lives. Our findings indicated that drinking was primarily connected to same-sex romantic partnerships, cultural and familial ties to alcohol, social norms within queer spaces, familial rejection and loss of racial and ethnic community, and chronic stress. Recommendations for research, practice, advocacy, education, and training are discussed.

Finding the Strength to Heal: Understanding Recovery After Gender-Based Violence

Little research has focused on the trauma healing processes of gender-based violence (GBV) survivors, with most research focusing on adverse outcomes. The purpose of this study, therefore, was to explore the nature of GBV healing through survivor narratives. Our analysis revealed important barriers and facilitators of trauma healing. Social context was discovered to have a powerful influence over both barriers and facilitators. Analysis of the nature of healing revealed three main objectives: reconnecting with the self, others, and the world. This information can be utilized by clinicians to create safer, more empowering, healing spaces for survivors.

The Qualitative Interview in Psychology and the Study of Social Change: Sexual Identity Development, Minority Stress, and Health in the Generations Study

Interviewing is considered a key form of qualitative inquiry in psychology that yields rich data on lived experience and meaning making of life events. Interviews that contain multiple components informed by specific epistemologies have the potential to provide particularly nuanced perspectives on psychological experience. We offer a methodological model for a multi-component interview that draws upon both pragmatic and constructivist epistemologies to examine generational differences in the experience of identity development, stress, and health among contemporary sexual minorities in the United States. Grounded in theories of life course, narrative, and intersectionality, we designed and implemented a multi-component protocol that was administered among a diverse sample of three generations of sexual minority individuals. For each component, we describe the purpose and utility, underlying epistemology, foundational psychological approach, and procedure, and we provide illustrative data from interviewees. We discuss procedures undertaken to ensure methodological integrity in process of data collection, illustrating the implementation of recent guidelines for qualitative inquiry in psychology. We highlight the utility of this qualitative multi-component interview to examine the way in which sexual minorities of distinct generations have made meaning of significant social change over the past half-century.

The Experience and Meaning of Physical Activity in Assisted Living Facility Residents

Assisted living (AL) residents engage in very low levels of physical activity (PA), placing them at increased risk for mobility disability and frailty. But many residents in AL may not perceive the need to increase their PA. This study explored the experience, meaning, and perceptions of PA in 20 older adults in AL. The factors associated with PA were also examined. Qualitative data were collected using semistructured interviews and analyzed using phenomenological methodology. Six themes were identified: PA was experienced as planned exercise, activities of daily living, and social activities based on a schedule or routine; PA meant independence and confidence in the future; residents perceived themselves as being physically active; social comparisons influenced perception of PA; personal health influenced PA; motivations and preferences influenced PA. The findings highlight the importance of residents' personal perceptions of PA and effects of the social milieu in the congregate setting on PA.

"It's Not Much of a Life": The Benefits and Ethics of Using Life History Methods With People Who Inject Drugs in Qualitative Harm Reduction Research

A life history approach enables study of how risk or health protection is shaped by critical transitions and turning points in a life trajectory and in the context of social environment and time. We employed visual and narrative life history methods with people who inject drugs to explore how hepatitis C protection was enabled and maintained over the life course. We overview our methodological approach, with a focus on the ethics in practice of using life history timelines and life-grids with 37 participants. The life-grid evoked mixed emotions for participants: pleasure in receiving a personalized visual history and pain elicited by its contents. A minority managed this pain with additional heroin use. The methodological benefits of using life history methods and visual aids have been extensively reported. Crucial to consider are the ethical implications of this process, particularly for people who lack socially ascribed markers of a "successful life."

"Do You Want to Go Forward or Do You Want to Go Under?" Men's Mental Health in and Out of Prison

More than 11 million people are currently imprisoned worldwide, with the vast majority of incarcerated individuals being male. Hypermasculine environments in prison are often tied to men’s health risks, and gathering information about mental health is fundamental to improving prison as well as community services. The purpose of the current study was to describe the connections between masculinities and men’s mental health among prisoners transitioning into and out of a Canadian federal correctional facility. Two focus groups were conducted with a total of 18 men who had recently been released from a federal correctional facility. The focus group interviews were analyzed to inductively derive patterns pertaining to men’s mental health challenges and resiliencies “on the inside” and “on the outside.” Participant’s challenges in prison related to heightened stresses associated with being incarcerated and the negative impact on preexisting mental illness including imposed changes to treatment regimens. Men’s resiliencies included relinquishing aggression and connecting to learn from other men “on the inside.” Mental health challenges “on the outside” included a lack of work skills and finances which increased the barriers that many men experienced when trying to access community-based mental health services. Mental health resiliencies employed by participants “on the outside” included self-monitoring and management to reduce negative thoughts, avoiding substance use and attaining adequate exercise and sleep. The current study findings offer practice and policy guidance to advance the well-being of this vulnerable subgroup of men in as well as out of prison.

The Use of the Clinical Ethnographic Narrative Interview to Understand and Support Help Seeking After Gender-Based Violence

Gender-based violence (GBV), characterized by the abduction or rape of women and girls to humiliate, intimidate, and traumatize them and their communities, is a profoundly disturbing tactic in international conflict. Long after armed conflict has ended, survivors continue to experience physical injuries, psychological trauma, and social and cultural stigma. Guilt, shame, and continued interpersonal violence can become a normalized part of daily life, significantly challenging the road to healing and recovery. Research about self-disclosure and narrative after GBV has shown that help seeking rates are shockingly low, with estimates ranging from 4-27%. From a feminist and a humanistic perspective, studying trauma history and related help seeking is delicate work that must use interview processes that ensure the survivor can tell her story without revictimization, while also aiming to restore personal mastery, empowerment, and self-understanding. Based on theories about benefits and challenges of the narrative after GBV and trauma, we propose that the Clinical Ethnographic Narrative Interview (CENI) allows researchers and practitioners a safe container to examine the complex interplay between suffering, culture, and help seeking. Using this interview, the interviewer and the participant work as partners to define, compare, and contrast the socio-cultural barriers and facilitators of help seeking. This paper explains the narrative theory and the challenges and benefits of the narrative approach after trauma. Then we provide support for the use of the CENI for an understanding of the help seeking process and facilitating a health-promoting narrative interview for survivors. We then address implications for research, practice, and policy.

The Relationship Timeline: A Method for the Study of Shared Lived Experiences in Relational Contexts

Lifeline methods-graphic illustrations of the pathways of lived experience traveled by individuals from birth to anticipated death-have been useful in the study of lived experience. Existing lifeline methods and research focus on the individual experience; absent from this literature are the collective experiences of those in intimate relationships. In this paper, based on our research with 120 same-sex couples, we present a method to allow for the joint creation of relationship timelines, which serve as the basis for eliciting dyadic data in multiple forms: graphic representations of relationship development through couples' creation of a timeline of key events and periods; qualitative narratives of couples' shared experiences; and quantitative ratings of significant events and periods in their lives together. Lessons learned from the application of this Relationship Timeline Method are discussed, as are implications for future study of the shared lived experience.

Severe Childhood Autism: The Family Lived Experience

This research examined the experiences of families living with a child with severe autism. There is limited literature on the experiences of families when a child has severe autism as distinct from milder autism and includes the voices of multiple family members. Van Manen's phenomenological approach was used for data collection and analysis. This approach allowed for the use of innovative data sources, including unstructured individual and family interviews, observations, and family lifelines (a pictorial, temporal picture with comments of the families lives). This study included 29 interviews with 22 participants from 11 families. All data were creatively triangulated and interpreted. Six essential themes were identified. First, families experienced autism as mysterious and complex because it is an invisible and unpredictable condition with diagnostic challenges. Second, families described severe autism behaviors that often caused self-injury, harm to others and damaged homes. Third, profound communication deficits resulted in isolation between the family and child. Fourth, families discussed the unrelenting stress from lack of sleep, managing the child's developmental delays, coordinating and financing services, and concern for the child's future. Fifth, families described consequences of isolation from friends, school, the public, and health providers. Sixth, families portrayed their need for compassionate support and formed 'hybrid families' (nuclear, extended families and friends) to gain support. Study results can be utilized to educate nurses/other providers about the unique needs of families with children with severe autism and could influence health care policies to improve the care for families caring for children with severe autism.

Visual Methods in the Assessment of Diet Intake in Mexican American Women

Assessment of dietary intake is based largely on self-report or use of biomarkers. However, neither self-report nor biomarkers inform nurses of patterns in dietary intake in the context of gender, culture, and ethnicity. This article describes the relevance of visual methods focusing on the context of dietary intake in Mexican American women, illustrated by a formative study. A qualitative, descriptive, methodological design incorporating photo elicitation was used. The sample consisted of 7 Mexican American women, who took photographs of their food intake, food preparation, and context of food consumption, such as family gatherings, which were then described by the women. Data included participant photographs, the descriptions of why each image was obtained, and stories about the photographs. Visual methods were found to be a relevant and important addition to traditional dietary assessment methods, to enhance gender, cultural, and contextually relevant assessment of dietary intake in Mexican American women.

Floating on Air: Fulfillment and Self-in-Context for Distressed Japanese Women

This research was part of a larger mixed-methods study examining culture, distress, and help seeking. We surveyed 209 Japanese women living in the United States recruited from clinic and community-based sites, and carried out semi-structured ethnographic interviews with a highly distressed subsample of 25 Japanese. Analytic Ethnography revealed that women described themselves as a "self-in-context," negotiating situations using protective resources or experiencing risk exposure. Women experienced quality of life (QOL) when they were successful. However, a related goal of achievingIkigai(or purpose in life) was differentiated from QOL, and was defined as an ongoing process of searching for balance between achieving social and individual fulfillment. Our resulting hypothetical model suggested that symptom level would be related to risk and protective factors (tested for the full sample) and to specific risk and protective phenomenon (tested in the distressed subsample). Thettests in the full sample found that women who were above threshold for depressive symptoms (n= 26) had higher social stressor and lower social support means. Women who were above the threshold for physical symptoms (n= 99) had higher social stressor means. Analysis of the interviewed subsample found that low self-validation and excessive responsibilities were related to high physical symptoms. We conclude that perceived lack of balance between culturally defined, and potentially opposing, markers of success can create a stressful dilemma for first-generation immigrant Japanese women, requiring new skills to achieve balance. Perceptions of health, as well as illness, are part of complex culturally based interpretations that have implications for intervention for immigrant Japanese women living in the United States.

TOGETHER Project to Increase Understanding of the HIV Epidemic Among Sub-Saharan African Migrants: Protocol of Community-Based Participatory Mixed-Method Studies

Background

Sub-Saharan African Migrants (SAM) are the second largest group affected by HIV/AIDS in Belgium and the rest of Western Europe. Increasing evidence shows that, more than previously thought, SAM are acquiring HIV in their host countries. This calls for a renewed focus on primary prevention. Yet, knowledge on the magnitude of the HIV epidemic among SAM (HIV prevalence estimates and proportions of undiagnosed HIV infections) and underlying drivers are scarce and limit the development of such interventions.

Objective

By applying a community-based participatory and mixed-methods approach, the TOGETHER project aims to deepen our understanding of HIV transmission dynamics, as well as inform future primary prevention interventions for this target group.

Methods

The TOGETHER project consists of a cross-sectional study to assess HIV prevalence and risk factors among SAM visiting community settings in Antwerp city, Belgium, and links an anonymous electronic self-reported questionnaire to oral fluid samples. Three formative studies informed this method: (1) a social mapping of community settings using an adaptation of the PLACE method; (2) a multiple case study aiming to identify factors that increase risk and vulnerability for HIV infection by triangulating data from life history interviews, lifelines, and patient files; and (3) an acceptability and feasibility study of oral fluid sampling in community settings using participant observations.

Results

Results have been obtained from 4 interlinked studies and will be described in future research.

Conclusions

Combining empirically tested and innovative epidemiological and social science methods, this project provides the first HIV prevalence estimates for a representative sample of SAM residing in a West European city. By triangulating qualitative and quantitative insights, the project will generate an in-depth understanding of the factors that increase risk and vulnerability for HIV infection among SAM. Based on this knowledge, the project will identify priority subgroups within SAM communities and places for HIV prevention. Adopting a community-based participatory approach throughout the full research process should increase community ownership, investment, and mobilization for HIV prevention.

Qualitative evaluation of the Teenage Mothers Project in Uganda: a community-based empowerment intervention for unmarried teenage mothers

Background

A large proportion of unmarried teenage mothers in Uganda face physical, psychological, and social problems after pregnancy and childbirth, such as obstetric complications, lack of education, and stigmatisation in their communities. The Teenage Mothers Project (TMP) in Eastern Uganda empowers unmarried teenage mothers to cope with the consequences of early pregnancy and motherhood. Since 2000, 1036 unmarried teenage mothers, their parents, and community leaders participated in economic and social empowerment interventions. The present study explored the changes resulting from the TMP as well as factors that either enabled or inhibited these changes.

Methods

Semi-structured interviews (N = 23) were conducted with former teenage mothers , community leaders, and project implementers, and lifeline histories were obtained from former teenage mothers (N = 9). Quantitative monitoring data regarding demographic and social characteristics of teenage mother participants (N = 1036) were analysed.

Results

The findings suggest that, overall, the TMP seems to have contributed to the well-being of unmarried teenage mothers and to a supportive social environment. It appears that the project contributed to supportive community norms towards teenage mothers’ position and future opportunities, increased agency, improved coping with early motherhood and stigma, continued education, and increased income generation by teenage mothers. The study findings also suggest limited change in disapproving community norms regarding out-of-wedlock sex and pregnancy, late active enrolment of teenage mothers in the project (i.e., ten months after delivery of the child), and differences in the extent to which parents provided support.

Conclusions

It is concluded that strengths of the community-based TMP seem to be its socio-ecological approach, the participatory planning with community leaders and other stakeholders, counselling of parents and unmarried teenage mothers, and the emphasis on education and income generation. The project can improve by earlier active participation of unmarried pregnant adolescents and increased support for parents.

The Clinical Ethnographic Interview: a user-friendly guide to the cultural formulation of distress and help seeking

Transcultural nursing, psychiatry, and medical anthropology have theorized that practitioners and researchers need more flexible instruments to gather culturally relevant illness experience, meaning, and help seeking. The state of the science is sufficiently developed to allow standardized yet ethnographically sound protocols for assessment. However, vigorous calls for culturally adapted assessment models have yielded little real change in routine practice. This paper describes the conversion of the Diagnostic and Statistical Manual IV, Appendix I Outline for Cultural Formulation into a user-friendly Clinical Ethnographic Interview (CEI), and provides clinical examples of its use in a sample of highly distressed Japanese women.

A life history of a Korean adolescent girl who attempted suicide

The present study explores the life history of a South Korean adolescent girl who attempted suicide. The study focuses on how sociocultural values affected her suicide attempt and how she made meaning out of the experience. The results revealed that her life history was a process of seeking independence and autonomy, and freeing herself from social stigmatization. The study highlights the need for professionals to examine the sociocultural context of adolescents, along with a consideration of their developmental characteristics and family relationships in order to understand adolescent suicidal behaviors.

Women in young and mid-adulthood: theory advancement and retroduction

This research explicated developmental constructs in women at the Age 30 and Age 50 Transitions. Fifty-five women participated in field study conducted over 16 years. Data collection strategies included interviews, focus groups, a life history technique, participant observation, and electronic participation. Individual and cohort effects were observed using interpretative analysis techniques. Concepts from Erikson's theory of psychosocial development were used for theoretical retroduction. The psychosocial tasks of the Age 30 Transition are identity confusion and intimacy as well as generativity. The challenge of the Age 50 Transition is to continue the tasks of intimacy and generativity and add integrity.