The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States.

Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.

Development of a Self-Rated Mixed Methods Skills Assessment: The National Institutes of Health Mixed Methods Research Training Program for the Health Sciences.

INTRODUCTION: Demand for training in mixed methods is high, with little research on faculty development or assessment in mixed methods. We describe the development of a self-rated mixed methods skills assessment and provide validity evidence. The instrument taps six research domains: "Research question," "Design/approach," "Sampling," "Data collection," "Analysis," and "Dissemination." Respondents are asked to rate their ability to define or explain concepts of mixed methods under each domain, their ability to apply the concepts to problems, and the extent to which they need to improve. METHODS: We administered the questionnaire to 145 faculty and students using an internet survey. We analyzed descriptive statistics and performance characteristics of the questionnaire using the Cronbach alpha to assess reliability and an analysis of variance that compared a mixed methods experience index with assessment scores to assess criterion relatedness. RESULTS: Internal consistency reliability was high for the total set of items (0.95) and adequate (≥0.71) for all but one subscale. Consistent with establishing criterion validity, respondents who had more professional experiences with mixed methods (eg, published a mixed methods article) rated themselves as more skilled, which was statistically significant across the research domains. DISCUSSION: This self-rated mixed methods assessment instrument may be a useful tool to assess skills in mixed methods for training programs. It can be applied widely at the graduate and faculty level. For the learner, assessment may lead to enhanced motivation to learn and training focused on self-identified needs. For faculty, the assessment may improve curriculum and course content planning.

Realities of environmental toxicity and their ramifications for community engagement.

Research on community responses to environmental toxicity has richly described the struggles of citizens to identify unrecognized toxins, collect their own environmental health facts, and use them to lobby authorities for recognition and remediation. Much of this literature is based on an empiricist premise: it is concerned with exploring differences in how laypeople and experts perceive what is presumed to be a singular toxic reality that preexists these varying perspectives. Here, we seek to reexamine this topic by shifting the focus from facts to facticity-that is, by exploring the many types of knowledge that communities develop about toxicity and how these knowledges articulate with the ideas of scientific and governmental authorities about what kinds of information are valid bases for policymaking. In making this shift, we are influenced by work in semiotic anthropology and science and technology studies (STS), which emphasizes that lived experience generates distinct realities rather than different perceptions of the same underlying state. Using this framework, we present an analysis of oral history interviews conducted in 2013-14 in the small American town of Ambler, Pennsylvania. Part of Ambler's legacy as a nineteenth- and twentieth-century center of asbestos manufacture is that it is home to two massive asbestos-containing waste sites, one of which was being remediated by the Environmental Protection Agency (EPA) at the time of this study. Our interviews demonstrate that even asbestos, a toxin with a well-established public narrative, is a fundamentally different object for different members of the Ambler community. For many of these individuals, the epistemology and practices of the EPA are incongruent with or tangential to their toxicity-related experiences and their consequent concerns for the future. As such, our findings suggest caution in framing the community engagement efforts of environmental health agencies primarily as facilitations of citizen science; this approach does not acknowledge the multiplicity of toxic realities.

Shared conceptualizations and divergent experiences of counseling among African American and white older adults.

Research findings suggest that older adults prefer counseling for depression treatment; however, few older adults use counseling services. In this article we present the results of our analysis of semistructured interviews with 102 older adults to explore conceptualizations of counseling and impediments to use among African American and White older adults. We found that older adults believe counseling is beneficial; however, use was hindered in multiple ways. Older adults were skeptical about establishing a caring relationship with a professional. African American older adults did not mention social relationships to facilitate depression care, whereas White older adults described using personal relationships to navigate counseling services. African American older men were least familiar with counseling. Our findings suggest that African American and White older adults share a strong cultural model of counseling as beneficial; however, significant impediments exist and affect older adults differentially based on ethnicity.

How women conceptualize urinary incontinence: a cultural model.

AIMS: Urinary incontinence (UI) is common among women in the United States and worldwide. Although the biomedical model for female UI has been thoroughly examined, the cultural model women living with UI ascribe to has been less well described. The purpose of this study was to elicit salient features of a cultural model for long-term (>5 years) female UI and, in so doing, increase understanding of the conceptualization of female UI from an emic (patient-derived) perspective. Cultural models theory provided the overall framework for the study. METHODS: Freelist (n = 25) and pilesort (n = 13) exercises were completed by community-dwelling women with long-term UI. In the freelist exercise, participants listed 81 unique terms in response to the request: Please list all the terms you think of when you hear the phrase urinary incontinence. The most salient terms included: wet, embarrassed, diapers/pads, leakage, old age, urinate, annoyance, inconvenience. We then used the most culturally salient items from the freelist in three pilesort tasks. RESULTS: Results of the pilesort exercises suggest that some aspects of the cultural model are shared, whereas others are highly heterogeneous. CONCLUSIONS: A small core of salient emic terms reflects a shared cultural understanding of female UI. The cultural model includes emotional and physical elements. These findings are important in reframing and reexamining our understanding of female UI. Next steps include testing the cultural model by including salient terms used by women living with long-term UI in focus groups and clinical encounters.

Bridging Psychiatric and Anthropological Approaches: The Case of "Nerves" in the United States.

Psychiatrists and anthropologists have taken distinct analytic approaches when confronted with differences between emic and etic models for distress: psychiatrists have translated folk models into diagnostic categories whereas anthropologists have emphasized culture-specific meanings of illness. The rift between psychiatric and anthropological research keeps "individual disease" and "culture" disconnected and thus hinders the study of interrelationships between mental health and culture. In this article we bridge psychiatric and anthropological approaches by using cultural models to explore the experience of nerves among 27 older primary care patients from Baltimore, Maryland. We suggest that cultural models of distress arise in response to personal experiences, and in turn, shape those experiences. Shifting research from a focus on comparing content of emic and etic concepts, to examining how these social realities and concepts are coconstructed, may resolve epistemological and ontological debates surrounding differences between emic and etic concepts, and improve understanding of the interrelationships between culture and health.

Older patients' views on the relationship between depression and heart disease.

BACKGROUND AND OBJECTIVES: Longitudinal studies have found evidence of associations between coronary heart disease and clinical depression. We sought to understand older patients' views regarding relationships between depression and heart disease to facilitate patient-provider communication about heart disease and depression and to lay the groundwork for designing interventions. METHODS: The design was a qualitative study using semi-structured interviews. In all, 33 primary care patients 65 years and over with dysphoria, anhedonia, hopelessness, worthlessness, or sleep disturbance who were taking at least one medication targeting cardiovascular risk factors were interviewed in the office of their primary care clinician. Participants were asked open-ended questions about depression and heart disease and their treatment. A multidisciplinary research team coded the transcripts and identified key themes. RESULTS: Participants gave clear descriptions of how heart disease can lead to depression and depression can lead to heart disease. Participants supported treating depression immediately in the context of heart disease and generally preferred integrated care. CONCLUSIONS: Depression treatment may be more acceptable if discussed in terms of overall cardiovascular risk. Our results support the integration of depression management with management for risk factors for cardiovascular disease.

How older adults combine medical and experiential notions of depression.

Past research has suggested that patients might not accept depression treatment in part because of differences between patient and doctor understandings of depression. In this article, we use a cultural models approach to explore how older adults incorporate clinical and experiential knowledge into their model of depression. We conducted semistructured interviews about depression with 19 patients aged 65 years and older who were identified by their physicians as depressed. We found that whereas older adults viewed as helpful the doctor's ability to identify symptoms and "put it all together" into a diagnosis, they felt that this viewpoint omitted important information about the etiology and feeling of depression grounded in embodied experience and social context. Our findings suggest that more emphasis on issues related to the etiology of depression, the effect of depression on social relationships, and emotions emanating from depression might lead to more acceptable depression treatments for older adults.