Women's Reproductive Health in Sociocultural Context.

PURPOSE: The special issue on Women's Reproductive Health in Cultural Context covers multiple dimensions of women's reproductive health and how it might be shaped by cultural meanings, social and gender inequities, and power differentials, employing a variety of methodological approaches. On the one hand, it aims to bring to the forefront the conversation about how women's health is uniquely experienced and constructed in local settings, and on the other hand, it aims to draw broader conclusions from a perspective of interconnectedness of women and the shared issues that they face. METHODS AND RESULTS: The special issue was initiated through a call for submissions and includes ten articles on the topic of women's reproductive health in cultural context. CONCLUSIONS: The articles provide many insights into how the context in which they live can disadvantage women and endanger their health, as well as offer perspectives on women's resistance to disempowering and stigmatizing discourses and practices. It aims to be of interest to scholars in behavioral medicine, psychology, and other social sciences.

Burnout and health behaviors in health professionals from seven European countries.

OBJECTIVES: Within an underlying health-impairing process, work stressors exhaust employees' mental and physical resources and lead to exhaustion/burnout and to health problems, with health-impairing behaviors being one of the potential mechanisms, linking burnout to ill health. The study aims to explore the associations between burnout and fast food consumption, exercise, alcohol consumption and painkiller use in a multinational sample of 2623 doctors, nurses and residents from Greece, Portugal, Bulgaria, Romania, Turkey, Croatia and Macedonia, adopting a cross-national approach. METHODS: Data are part of the international cross-sectional quantitative ORCAB survey. The measures included the Maslach Burnout Inventory and the Health Behaviors Questionnaire. RESULTS: Burnout was significantly positively associated with higher fast food consumption, infrequent exercise, higher alcohol consumption and more frequent painkiller use in the full sample, and these associations remained significant after the inclusion of individual differences factors and country of residence. Cross-national comparisons showed significant differences in burnout and health behaviors, and some differences in the statistical significance and magnitude (but not the direction) of the associations between them. Health professionals from Turkey, Greece and Bulgaria reported the most unfavorable experiences. CONCLUSIONS: Burnout and risk health behaviors among health professionals are important both in the context of health professionals' health and well-being and as factors contributing to medical errors and inadequate patient safety. Organizational interventions should incorporate early identification of such behaviors together with programs promoting health and aimed at the reduction of burnout and work-related stress.

'The problem here is that they want to solve everything with pills': medication use and identity among Mainland Puerto Ricans.

Taking medications are complex symbolic acts, infused with diverse meanings regarding body and identity. This article focuses on the meanings of medications for older Puerto Ricans living on the United States mainland, a population experiencing stark health disparities. We aim to gain an understanding of the way multiple cultural and personal meanings of medications are related to and integrated in identity, and to understand how they are situated within Puerto Rican culture, history and circumstance on the US mainland. Data is drawn from thirty qualitative interviews, transcribed and translated, with older Puerto Ricans living on mainland United States. Thematic Analysis indicated four prevalent themes: embodiment of medication use; medications redefining self through the fabric of daily life; healthcare experience defined through medication; and medicine dividing the island and the mainland. While identity is impacted by experience of chronic illness, the experience of medication prescription and consumption is further related to the construction of the sense of self in distinct ways. For these individuals, medication use captures the dilemma of immigration. While cultural belonging and well-being remains on the island of Puerto Rico, the mainland hosts both easier access to and excess reliance on medication.

Puerto Rican Victimization and Crime on the Mainland: The Role of Acculturation.

This study addresses criminal victimization and contact with police among older Puerto Ricans living in Northeastern United States. Framing their experiences within the context of immigration, we assess the role that acculturation and perceived stress play on Puerto Rican crime and victimization. Data from the Boston Puerto Rican Health Study (BPRHS; N = 1,504) were analyzed using multiple logistic regressions. The experience of criminal victimization by Puerto Ricans is associated with higher educational attainment, increased perceived stress, and also with psychological acculturation. Contact with police is associated with linguistic, but not psychological, acculturation. Our findings give strength to the argument that exposure to crime and the criminal justice system increases with acculturation and that this argument is relevant to Puerto Ricans. Thus, the association between acculturation, criminal victimization, and police contact depends on the conceptualization of acculturation used. The relationship between stress, acculturation, and crime among Latinos is complex and warrants further assessment.

Managing uncertainty: healthcare professionals' meanings regarding the HPV vaccine.

BACKGROUND: New preventive technologies such as vaccines offer insight into psychological, social, and cultural landscapes. Providers have a key role in parents' decisions for vaccinating their children. Yet, perspectives from providers regarding the human papillomavirus (HPV) vaccine, or vaccination in general, are rarely sought PURPOSE: Our objective in this paper is to understand how the HPV vaccine is perceived by health care providers and the multiple contextual meanings it elicits. METHODS: We conducted interviews with 20 health care professionals in Bulgaria about their attitudes and practices related to HPV vaccination and their recommendations for policies. The verbatim-transcribed interviews were analyzed through narrative analysis, with a special focus on language. RESULTS: We illustrate providers' contradictory and contextualized constructions of the vaccine and the narrative strategies they use to manage any uncertainty it elicits. These include being advocates and missionaries for preventive health, confirming their trust in the medical profession and professional organizations, challenging patients' concerns with rational explanations, normalizing the risk of medical innovations, and avoiding the sexual nature of HPV transmission. CONCLUSIONS: The introduction of a vaccine to prevent HPV infection, and by implication, possibly cervical and other cancers, created hope, and at the same time, intensified confusion and uncertainty. Providers have been frustrated for years with the rising mortality from cervical cancer in Bulgaria, and their perceived powerlessness in affecting this. HPV vaccination, on the other hand, seems relatively simple and "taming uncertainty" positions them as instrumental in limiting (or even eliminating) morbidity and mortality in future generations.

Young women's constructions of the HPV vaccine: a cross-cultural, qualitative study in Scotland, Spain, Serbia and Bulgaria.

BACKGROUND: Following international trends, the HPV (human papilloma virus) vaccine was introduced in Europe for protection against infection from common strands of the HPV virus which can lead to cervical cancer. Young women aged 18-26 years are at greatest risk of infection by the HPV virus yet have been neglected in research, policy, and practice. PURPOSE: To explore young women's constructions of the HPV vaccine in four European countries with different implementation policies ranging from national school-based programmes, regarded as the gold standard, to regional on-demand and private provision. METHOD: Qualitative methods comprising 11 focus group discussions with 54 young women aged 18-26, in Scotland (n = 10), Spain (n = 25), Serbia (n = 9) and Bulgaria (n = 10). A discursive analysis was conducted, following an initial thematic analysis. RESULTS: Two competing discursive constructions were considered: the 'responsible young woman' discourse was constructed as someone with individual rights to health, choice and discretion along with responsibilities to protect health and make rational decisions. In 'the HPV vaccine: a discourse of exclusion', access to the vaccine, wider health promotion and knowledge was controlled by others which had the potential to undermine the young woman's health. We consider how young women managed this tension through recourse to being health vigilant. CONCLUSION: Qualitative, cross-cultural research highlighted common concerns amongst young European women towards being responsible citizens in the face of their health and highlighted socio-cultural constraints to knowledge and resources. We highlight cross-cultural implications particularly between Western and Eastern European contexts.

Determinants of self-rated health and the role of acculturation: implications for health inequalities.

OBJECTIVES: Self-rated health (SRH) is an important indicator of overall health, predicting morbidity and mortality. This paper investigates what individuals incorporate into their self-assessments of health and how acculturation plays a part in this assessment. The relationship of acculturation to SRH and whether it moderates the association between indicators of health and SRH is also examined. DESIGN: The paper is based on data from adults in the Boston Puerto Rican Health Study, living in the greater Boston area (n=1357) mean age 57.2 (SD = 7.6). We used multiple regression analysis and testing for moderation effects. RESULTS: The strongest predictors of poor SRH were the number of existing medical conditions, functional problems, allostatic load and depressive symptoms. Poor SRH was also associated with being female, fewer years of education, heavy alcohol use, smoking, poverty, and low emotional support. More acculturated Puerto Rican adults rated their health more positively, which corresponded to better indicators of physical and psychological health. Additionally, acculturation moderated the association between some indicators of morbidity (functional status and depressive symptoms) and SRH.Self-assessments of overall health integrate diverse indicators, including psychological symptoms, functional status and objective health indicators such as chronic conditions and allostatic load. However, adults' assessments of overall health differed by acculturation, which moderated the association between health indicators and SRH. The data suggest that when in poor health, those less acculturated may understate the severity of their health problems when rating their overall health, thus SRH might thus conceal disparities. Using SRH can have implications for assessing health disparities in this population.

Stories of Life during the First Wave of the COVID-19 Pandemic in Italy: A Qualitative Study.

The COVID-19 pandemic has imposed on people the need to find meaning in many unprecedented ways. The aim of this qualitative study was to explore how the general Italian population dealt with government restrictions and to understand personal experiences connected with the first wave of the pandemic in light of the personal construct theory (PCT) framework. One hundred and sixteen people (over 18 years old) completed an online survey between May and June 2020. Two independent researchers ran inductive thematic content analysis on data using a specifically developed international codebook. Five major themes were identified in the participants' narrations: difficulties, emotions, coping with lockdown measures, going back to normal, and change. The results, interpreted within the PCT transitions, showed that the pandemic represented a threat to participants' life plans, beliefs, and certainties. Some coped with it mainly by waiting for the pandemic to end and remaining firm in their beliefs and certainties, whereas others coped by trying to find alternative ways of giving sense to this experience and reconstructing personal meanings, claiming a change in their life and in society. Differentiating personal experiences of the COVID-19 pandemic is fundamental for designing personalised strategies to promote well-being.

Structural racism and reflections from Latinx heavy drinkers: Impact on mental health and alcohol use.

BACKGROUND: Discrimination and social inequity increase risk for alcohol use disorders among Latinxs. An alcohol intervention trial that led to significant reductions in alcohol-related consequences also produced significant reductions in mental health symptoms for Latinx heavy drinkers. In the current qualitative study, we explore this trial's mental health effect by examining participants' perspectives on the social context of immigration, i.e., structural barriers, and associations among the immigrant experience, stigma, depressive/anxiety symptomatology, and alcohol consumption. METHODS: Study participants were eligible if they completed the clinical trial, exhibited levels of depressive and anxiety symptoms that exceeded the range for clinical depression (≥18, CES-D) and anxiety (≥12, BAI) at baseline, and demonstrated significant declines in depression and anxiety symptoms 12 months following their completion of the trial. The study coded 24 participant transcripts using ATLAS.ti and thematic analysis. RESULTS: Participants reported their responses to structural barriers (e.g., a lack of educational supports, difficulties accessing safety net programs). Reported experiences of exclusion and discrimination were associated with depressive and anxiety symptoms. Stigmatization processes included feeling isolated and contributed to poor mental health. Participants reported drinking to cope with low mood. CONCLUSIONS: Structural barriers are exclusionary because they limit full participation and communicate who does/does not belong along race/ethnic lines, i.e., structural racism. Feeling stigmatized for being different was associated with feelings of anxiety and depression among our immigrant participants. Future interventions must focus on stressors associated with the constraints of being an immigrant. Understanding how structural barriers and structural racism impact health behavior can enrich the design and impact of interventions for socially disadvantaged Latinx individuals.

Reflexivity and humility evoke a transformable methodology in a post disaster context.

OBJECTIVE: The process of reflexivity is used to critically examine the experience of conducting qualitative research with functionally diverse older adults in a post disaster context. METHODS: The design of the study began with an interpretative phenomenological framework, using in-depth interviews. Fifteen individuals with functional and access needs living in Puerto Rico were interviewed regarding their experiences after Hurricane María of 2017. FINDINGS: In the field, it was necessary to expand the initial design, and adjust to participants' preferences and needs, as well as situational characteristics, without compromising ethical standards of practice. The methodology transformed because of the need for flexibility requiring humility from the researchers. A more relational form of inquiry was warranted, which acknowledged the intersubjectivity of human experience. This entailed adapting to community involvement, building rapport with community leaders functioning as gatekeepers, and integrating family or friends in interviews. DISCUSSION: The reflexive approach allowed for a better understanding of the researcher's positionalities and how they influence the ability or inability to develop trust (e.g. insider/ outsider status, Puerto Rican/ US, with functional and access needs/ without functional and access needs). CONCLUSIONS: Given the shift toward relational inquiry and due to the challenges faced while carrying out the study, we suggest that post-disaster qualitative research would benefit from further including principles of indigenous decolonizing methodologies, which can be incorporated into studies using interpretative phenomenological analysis.

"What I thought was so important isn't really that important": international perspectives on making meaning during the first wave of the COVID-19 pandemic.

BACKGROUND: The global COVID-19 pandemic has had a significant impact on the physical and mental health of people everywhere. The aim of the study is to understand how people living in 15 countries around the globe experience an unexpected crisis which threatens their health and that of loved ones, and how they make meaning of this disruption in their narratives. METHODS: Data were collected through an anonymous online survey during May-September 2020, which was during or just after the first wave of the COVID-19 pandemic, depending on the country. The questionnaire included demographic and three open-ended questions as prompts for stories about experiences during the initial months of the pandemic. The text was analyzed through inductive thematic content analysis and quantified for full sample description, demographic and subsequently international comparisons. RESULTS: The final qualitative dataset included stories from n = 1685 respondents. The sample was 73.6% women and 26.4% men. The mean age of participants was 39.55 years (SD = 14.71). The identified four groups of overarching themes were: The presence and absence of others; Rediscovering oneself; The meaning of daily life; Rethinking societal and environmental values. We discuss the prevalence of each theme for the sample as a whole and differences by demographic groups. The most prevalent theme referred to disruptions in interpersonal contacts, made meaningful by the increased appreciation of the value of relationships, present in (45.6%) of stories. It was more prevalent in the stories of women compared to men (χ² = 24.88, p = .001). CONCLUSIONS: The paper provides a detailed overview of the methodology, the main themes identified inductively in the stories and differences according to select demographic variables. We identify several major ways of making meaning of the pandemic. The pandemic has impacted many aspects of people's lives which give it meaning, no matter where they live.

Perceived discrimination, psychological distress and health.

Racism and discrimination can have significant implications for health, through complex biopsychosocial interactions. Latino groups, and particularly Puerto Ricans, are an understudied population in the United States in terms of the prevalence of discrimination and its relevance to health. Participants in our study were 45- to 75-year-old (N = 1122) Puerto Ricans. The measures were perceived discrimination, depressive symptomatology (CES-D), perceived stress (PSS), self-rated health, medical conditions, blood pressure, smoking and drinking behaviours, demographics. Our findings show that 36.9 per cent of participants had at some time experienced discrimination, with men, those with more years of education, currently employed and with higher incomes being more likely to report it. Experiences of discrimination were associated with increased levels of depressive symptoms and perceived stress. When controlling for covariates, perceived discrimination was predictive of the number of medical conditions, of ever having smoked and having been a drinker, and having higher values of diastolic pressure. Depressive symptoms are a mediator of the effect of perceived discrimination on medical conditions, confirmed by the Sobel test: z = 3.57, p < 0.001. Mediating roles of perceived stress, smoking and drinking behaviours were not confirmed. Increased depressive symptoms might be the main pathway through which perceived discrimination is associated with a greater number of medical diagnoses.

Discourse, Dissonance, and Dualities: How Drug Shortages Are Understood and Communicated Among Health Care Professionals.

Persistent drug shortages introduce challenges to clinicians and health care systems. We describe an exploratory qualitative study of key informants' perspectives, discourse, and experiences in confronting drug shortages. Semi-structured interviews were conducted with pharmacy directors and bedside clinicians at urban academic medical centers and surrounding community hospitals. Focused coding, reflexive review, and thematic analyses informed by constructionist grounded theory were employed. For some participants, the unpredictability of drug shortages created a siege mentality. Recognition of potentially related patient safety deficits also led to moral distress. Participants were often unprepared to make explicit allocation decisions nor openly discuss drug substitutions with patients. Despite these struggles; participants displayed resilience, and inter-professional teamwork, which eclipsed role constraints and medical hierarchical authority. Varied perspectives and responses are described.

"Taking responsibility for my health": Health system barriers and women's attitudes toward cervical cancer screening in Romania and Bulgaria.

The study used mixed-methods to illustrate the complexity of the interplay between the contexts in Bulgaria and Romania and women's attitudes and behaviors related to screening. A secondary analysis of quantitative data from Romanian (n = 1053) and Bulgarian (n = 1099) women and qualitative interviews (n = 30 Romanian, n = 35 Bulgarian) was performed. Low rates of screening attendance were found in both countries. Regression analysis illustrates that attitudes and social norms significantly predicted intentions and screening behavior in both countries. Thematic analysis revealed that systemic barriers and cultural meanings were relevant to women's decisions to attend screening or avoid contact with the health-care system.

Social support, life events, and psychological distress among the Puerto Rican population in the Boston area of the United States.

OBJECTIVES: The aim of this article is to investigate the role of social network support in ameliorating the psychological impact of life stressors that are prevalent for the older Puerto Rican population. METHOD: Social support was measured through the Norbeck Social Support Questionnaire, and psychological distress through the Center for Epidemiological Studies Depression Scale and the Perceived Stress Scale. We describe the life stressors (Norbeck Life Events) faced by Puerto Ricans and their implications for psychological distress. We present associations between depression, perceived stress, social support, and socio-demographic indicators. The role of social network support-emotional and instrumental-in buffering the effect of negative events is examined. Attention is given to the interacting effect of gender and the type of support. RESULTS: The analysis shows that dimensions of social support, particularly emotional support, are generally protective of psychological health. However, when delineating the moderating effects of gender, social support is beneficial for men, but manifestly less so for women. Emotional, tangible support and duration of social contacts show a moderate effect on the impact of life stressors on psychological distress which, however, is in a direction opposite to that proposed by the buffering hypothesis. DISCUSSION: Social ties are generally protective, but may also be contributing, particularly for women, to increased psychological distress in the face of stressful life events.

Compendium of the Health and Wellness Coaching Literature.

Health and wellness coaching (HWC) for lifestyle behavior change is emerging as a practice, role, and profession, in diverse health care, employee wellness, and community settings. Health care professionals apply HWC as a behavior change methodology for the prevention and treatment of diabetes, hypertension, hyperlipidemia, heart disease, cancer, and other chronic disorders. The purpose of this systematic review was to provide a comprehensive and organized compendium of HWC literature. To date, extant HWC literature remains scattered with no meaningful summary accessible. Lack of comprehensive summary stems from lack of consensus on HWC definition and standards. We applied a recently proposed, standardized definition of HWC to determine compendium inclusion criteria for peer-reviewed, data-based literature from relevant search engines (ie, PubMed, PsychInfo, and CINAHL). A systematic review process was executed and ultimately yielded 219 articles meeting HWC inclusion criteria. Of these, 150 were data-based and the remainder were expert opinion or review-style articles. A summary of results generally reveals HWC as a promising intervention for chronic diseases though further research is needed in most categories. The resulting HWC compendium organizes and describes the quantity and quality of available literature for the use and benefit of HWC practitioners and researchers.

Providers' constructions of the role of women in cervical cancer screening in Bulgaria and Romania.

The social and institutional context of health-care reform in Eastern Europe has important implications for cervical cancer screening and prevention. The incidence and mortality from cervical cancer in Bulgaria and Romania have risen, which is in sharp contrast to the steady decline in most other countries in Europe during the last 2 decades. To analyze these dynamics we conducted a multi-component study of health systems and psychosocial aspects of cervical cancer screening in Bulgaria and Romania. Following the disappearance of organized preventive programs, the initiative for cervical cancer screening has shifted to providers and clients and depends on the way they perceive their responsibility and interpret their own and each other's roles in prevention. We focus on how providers construct women and their role in prevention of cervical cancer through their accounts. The analysis identified several discourses and themes in providers' constructions of women's responsibility for prevention of disease. These include responsible women as 'intelligent' and 'cultured'; non-attenders as 'irresponsible' and 'negligent'; women as needing monitoring and sanctioning; and women as 'victims' of health-care reform. We discuss the implications for health-care reform and health promotion.

"I Do It With Love": Engagement in Caring for People With Dementia.

For caregivers, the impacts of caring for their loved ones with dementia at home are complex. The purpose of this study was to gain understanding of the meaning and experience of engagement for caregivers of individuals with dementia living in the community. Participants are from a culturally diverse population of low-income caregivers and care recipients in the northeastern United States. We conducted in-depth semi-structured interviews with caregivers (n = 17) who were caring for parents, friends, or other relatives with dementia. We used interpretative phenomenological analysis and identified the superordinate themes of connectedness, meaningfulness, acceptance, and vigilance. We conclude that caregiver engagement is a multidimensional phenomenon, with some dimensions being contextual and specific to caregiving. It is a relational concept, referring to a committed, vigilant, and meaningful relationship of caregivers and care recipients as active collaborators. The different aspects of engagement can complement each other, or they can be in contradiction.

The Views of Young Women on HPV Vaccine Communication in Four European Countries.

The Human Papilloma Virus (HPV) is the most common sexually transmitted infection (STI) and can cause cervical cancer. Two vaccines are available to protect against the most common strands of the virus. Vaccination programs differ across Europe but most neglect young adults, who are the group with the highest risk of contracting STIs. Our aim was to explore the views of young women from four European countries­Scotland, Spain, Serbia, and Bulgaria - about the HPV vaccine communication strategy. These countries are characterized by different cervical cancer prevalence and vaccine implementation policies. We conducted focus group discussions with young women (aged 18-26) with various vaccination histories in a purposive sample. We subjected the data to thematic analysis with the purpose of identifying themes related to communication about the HPV vaccine. We recorded the information sources mentioned by participants. Participants discussed numerous sources of vaccine-related information. They approached information critically rather than naively and questioned the sources' trustworthiness and motives. Participants desired transparent information about the risks of the virus and the risks and benefits of the vaccine. These risks and benefits were individualized in view of personal and external factors. Particular aspects of the vaccine and the way information was communicated resulted in feelings of uncertainty. There were notable cross-cultural differences in experiences with HPV vaccine communication. Our results suggest that transparent risk communication about the HPV vaccine is valued by young women. In addition, both individual and culturally-dependent factors influenced experiences with, and preference for information.