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.

'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.

Gratitude and longing: Meanings of health in aging for Puerto Rican adults in the mainland.

Puerto Rican adults in the United States mainland live with socioeconomic and health disparities. To understand their contextual experience of aging, we interviewed participants in the Boston Puerto Rican Health Study. Through a Thematic Analysis we identify themes and tensions: normalization and acceptance of aging; gratitude; the importance of aging within social networks; longing to return to Puerto Rico at older age. We address the tensions between 'acceptance' and fatalismo as a cultural belief, and a function of structural barriers. The experience of aging is discussed in the context of Puerto Rico's history and continued dependence on the United States.

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.

Organizational hierarchies in Bulgarian hospitals and perceptions of justice.

OBJECTIVES: Health care reform in Bulgaria has been ongoing for two decades. Since 1990, it has been transforming from a socialized system of medical care with free access, to one which is decentralized, includes private health care services, the general practitioner model and a National Health Insurance Fund. In this context, we are conducting an international EC Framework 7 project: 'Improving quality and safety in the hospital: The link between organizational culture, burnout, and quality of care'. We focus on health professionals' perceptions of organizational hierarchies in Bulgarian hospitals and how doctors and nurses connect these to organizational justice. METHODS: We conducted seven focus groups and four interviews, with a total of 42 participants (27 nurses, 15 physicians and medical residents) in three hospitals. Data were analysed through thematic analysis and discourse analysis with Atlas.ti. RESULTS: From the perspective of health professionals, health reform has intensified traditional hierarchies and inequalities and has created new ones in Bulgarian hospitals. These hierarchies are continuously (re)constructed through language and practices and also destabilized through resistance. The health professionals protest fact that these hierarchies are permeated with unfairness and silence voices. All health professions (nurses, doctors, residents) in our study experience being unjustly positioned and disempowered in various hierarchies. They connect these experiences to stress and anxiety. CONCLUSIONS: Participatory action research needs to address multiple dimensions of organizational relationships in Bulgarian hospitals, including hierarchical relationships and ways of promoting organizational justice. STATEMENT OF CONTRIBUTION: What is already known on this subject? Health care organizations are hierarchically organized. Organizational injustice can contribute to burnout in health professionals. There is a high level of stress and burnout for health professionals in Bulgaria. What does this study add? This study adds understanding of changing hierarchies in hospitals during health care reform in the post-socialist period. Illuminates how health professionals' discourse sustains and resists hierarchical relationships in Bulgarian hospitals. Adds understanding of health professionals' perspectives on implications of injustice for their well-being.

Perspectives of Puerto Rican Adults about Heart Health and a Potential Community Program.

BACKGROUND: Puerto Ricans are the second largest Hispanic group in the U.S. and older adults have significant health disparities. Educational programs that address heart disease risk for this population have rarely been developed and implemented. PURPOSE: To address this gap, the Heart Healthy Initiative for Puerto Rican adults is being developed. To develop it as a participatory program, the community members were asked about their perspectives. METHODS: Five focus groups with 28 participants, aged 45-60, were conducted, transcribed and analyzed using Thematic Analysis. In-depth analysis of meanings of health promoting behaviors, in the context of cultural beliefs and values was carried out. RESULTS: The following themes were identified: Health as balance and integration; Health as connection of self, connection with others; Cultural meanings of lifestyle choices; Stresses and struggles. Participants suggested that the program should have significant variety and a holistic perspective, be sensitive to different needs and motivations, stimulate mutual understanding and shared cultural meanings. DISCUSSION: The program needs to support lifestyle changes which maximally preserve traditions and to introduce multi-level changes. TRANSLATION TO HEALTH EDUCATION PRACTICE: The identified cultural meanings of diet, physical activity and relationships were taken into account to develop the educational curriculum.

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.

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.

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.

Making up for lost time: the experience of separation and reunification among immigrant families.

In the United States today, one-fifth of the nation's children are growing up in immigrant homes. In the process of migration, families undergo profound transformations that are often complicated by extended periods of separation between loved ones--not only from extended family members, but also from the nuclear family. Though many families are involved in these transnational formulations, there has heretofore been little sense of the prevalence of these forms of family separations, nor of the effects on family relations. Further, such research has generally been conducted with clinical populations using Western theoretical frameworks and perspectives of families, limiting its applicability to immigrant families. The data presented in this article are derived from a bicoastal; interdisciplinary study of 385 early adolescents originating from China, Central America, the Dominican Republic, Haiti, and Mexico. Findings from this study indicate that fully 85% of the participants had been separated from one or both parents for extended periods. While family separations are common to all country-of-origin groups, there are clear differences between groups in lengths of separations as well as people from whom the youth are separated. Descriptive statistics of country-of-origin prevalence, patterns, and outcomes are presented. Results of analyses of variance indicate that children who were separated from their parents were more likely to report depressive symptoms than children who had not been separated. Further, qualitative data from youth, parent, and teacher perspectives of the experience of separation and reunification provide evidence that the circumstances and contexts of the separations lead to a variety of outcomes. We conclude with a discussion of attenuating and complicating factors family therapists should consider in the assessment and treatment of immigrant families.