Despite the prevalence of hematological malignancies during early adulthood, very little is known about the hematopoietic cell transplantation experience among adolescents and young adults, and even less is known about their transition from the completion of therapy to long-term survivorship. Therefore, this dissertation research explored the experiences of critical transitions in early survivorship, such as discharge to the home setting, involvement of an informal caregiver at home, the trajectory towards self-care, and reentry to work and school, among a sample of adolescents and young adults after hematopoietic cell transplantation.

Grounded theory, influenced by Constructivism, guided all aspects of the study design. In-depth interviews, using a semi-structured interview guide, were conducted with 18 adolescents and young adults, who had received autologous or allogeneic hematopoietic cell transplantation for primary hematologic malignancy at age 15-29 years and were 6-60 months post-treatment. Interview transcripts were systematically analyzed to identify emergent categories and generate theory.

Findings from this study highlight participants’ experiences across three critical transitions in early survivorship. The first two transitions are sequential and have psychosocial, emotional, and behavioral components, while the third is not sequential and is more focused on an unfolding perspective. The transitions are: 1) a shift from hospitalization to the home and high reliance on informal caregivers; 2) attempts to resume previously normal activities, such as work and school; and 3) an emotional and existential shift involving a reconceptualization of the perception of the future. Participants described the context in which these transitions occurred, specific challenges they faced, and adaptive strategies they developed.

While the findings cannot be generalized to all adolescent and young adult survivors of hematopoietic cell transplantation, this study provides insight into the trajectory towards self-care, the reliance on informal caregivers, and the experiences of critical transitions in early survivorship. The findings also shed light on the extensive, unexpected, and persistent life disruptions that participants experienced. By exploring deeper understanding of the survivorship trajectory of adolescents and young adults after hematopoietic cell transplantation, these findings can be used to inform clinical practice, guide future research, and shape policy.

In the US, breast cancer is one of the most common forms of cancer in women. When a woman is diagnosed with breast cancer it is often expected that she will receive support from her partner. However, this may not always be the case as some women find that their partners are either non-supportive or abusive. This can have a profound effect on the decisions women make regarding their treatment. The aim of this study was to explore and describe the journey of decision-making among women diagnosed with breast cancer while living with a non-supportive or abusive partner. Despite the highly-stigmatized topic, multiple recruitment sites were utilized

to recruit eight women who were diagnosed with breast cancer, who had non-supportive or abusive partners, and who were willing to be interviewed one to two times. Techniques from Grounded Theory methodology, informed by Symbolic Interactionism were used for analyzing data for this Qualitative Descriptive study. Results showed that the lack of support in the women’s relationships proved to be stressful, confusing, and disheartening. It affected their sense of self and heightened their need to rely on other inner and outer sources of support in multiple ways that were unique to each woman’s situation. However, despite a potentially fatal diagnosis and a non-supportive partner, participants were resourceful, found ways to stand up for themselves, and persevered. The women provided insight into how they utilized strategies that helped them work through a process to make decisions regarding treatment and to “move on” with their lives. Results are useful for clinicians’ ability to understand how a non-supportive or abusive partner may impact decisions made by a woman diagnosed with breast cancer and how to help with their processes of “moving on” after treatment.

Caring for infants after first stage palliative surgery for single ventricle heart defect (SVHD) can result in challenges beyond the usual parenting responsibilities secondary to medicalized care at home, demanding care routines, the potential for social and financial constraints, and impact on family relationships. Current descriptive studies provide valuable information about factors contributing to caregivers’ adaptation and coping with these medically fragile infants. However, these studies fail to capture the nuances of caregivers’ experiences during the most critical “interstage” period (time between the first and second surgical procedures). Therefore, in this dissertation, I explored and analyzed the impact on the caregivers and family’s daily lives, among mothers and fathers, after two to four months of caring for their interstage infants at home. Grounded theory, influenced by Constructivism, guided the dissertation methodology. In-depth interviews amongst English and Spanish-speaking mothers or fathers were conducted using a semi-structured interview guide. The data analysis led to the development of two grounded theories about the interstage caregivers: 1) A Continuous Process of Compromise During the Interstage Period Amid COVID 19 Pandemic and 2) Developing a Sense of Self-Reliance as an Interstage Caregiver. The first theory reflects the caregivers’ process of adapting to their infants' care during the interstage period, and it consists of two categories: 1) Accepting and adapting to a restrictive home environment, and 2) Reconciling what is and what is yet to come. These categories occurred simultaneously but also fed into each other in a continuous cycle. The second theory describes the context and action of the caregivers throughout the trajectory towards the development of a sense of self-reliance. It consists of three categories: 1) Owning caregiving responsibilities despite grave fears, 2) Figuring out how “to make it work” in the interstage period, and 3) Gaining a sense of self-reliance. Together, these categories bring insight into caregiving processes experienced by our sample participants. Our findings illuminated the extensive disruptions in everyday life experienced by the caregivers. The findings deepen our understanding of the experiences of caregivers who have to live under imposed restrictions and reduced access to their support systems. It highlights the need for healthcare providers to be cognizant of stressors and challenges that caregivers in our sample faced and to provide necessary supportive interventions. This study responds to a gap recently identified by the American Heart Association to address the needs of the family of interstage caregivers through qualitative research.

Post-partum depression (PPD) is a significant mental health problem for women during the reproductive years and is highly prevalent among Saudi women. Studies have shown, Saudi women experience higher rates of PPD (up to 38.5%) compared to 12% of new mothers in the United States. PPD is associated with cognitive impairment and the potential for deficits in social cognitive function, which is the ability to identify, perceive, interpret, and respond to social stimuli. Social cognition has several components, including emotion recognition, empathy, and theory of mind (ToM). Impaired social cognition can impact the mother’s ability to care for her infant, read infant cues, and can potentially affect the infant’s development. However, there is little research on Saudi women with PPD and its effect on social cognition. The aim of this study is to compare social cognitive performance in Saudi women with and without PPD, examine the relationship between biological, psychological, and social variables on social cognition, and identify predictors of social cognition. Participants were screened at 6 weeks postpartum for depressive symptoms and assigned to either PPD or without PPD group using the Edinburgh Postnatal Depression Scale (EPDS). Participants completed a demographic form and measures of social cognition including Emotion Recognition Task (ERT), Interpersonal reactivity Index (IRI), and Reading the Mind Test (RMET). In addition, participants completed the Multidimensional Scale of Perceived Social Support (MPSS), the Generalized Anxiety Disorder-7 (GAD-7), and the Perceived Stress Scale (PSS). Variables related to maternal characteristics (planned pregnancy, delivery mode) and infant characteristics (birth weight, gestational age) were extracted from medical records. Descriptive and inferential statistics were used to assess group differences, correlations, and predictors of social cognition. One hundred and twenty-five eligible women (60 with PPD and 65 without PPD) consented, enrolled, and completed all study measures. No significant differences were noted between groups based on age, income, education, and employment status. Women who had a C-section or an unplanned pregnancy or whose child was born less than 38 weeks gestation with a birth weight less than 3033 grams were more likely to screen positive for PPD. Women with PPD performed significantly worse on emotional recognition (58.6 vs. 70.3, p<.001), and better on the empathy (69 vs. 65.2, p<.001) and ToM (22.8 vs. 20.6, p<.001) compared to women without PPD. Stress and anxiety were higher and social support was lower in the PPD group compared to controls (p<.001). Stepwise linear regression showed that anxiety scores accounted for 17% of the variance of emotional recognition (F=13.54, p <.001), income and age accounted for 16% of the variance of empathy (F=6.79, p=.002), and stress and birth weight accounted for 17% of the variance of ToM (F=6.9, p=.002). Age, income, anxiety, stress, and child’s birth weight affected social cognition in this sample of Saudi women with PPD. This study highlights decreased ability among participants with PPD to recognize emotions, increased empathy, and heightened ability to interpret the mind of others through the eyes (ToM). This may reflect a maternal hypersensitivity to social stimuli due to their condition and/or a stressed or anxious state. Further research is needed to assess the functional impact of these findings on maternal health, mother-infant attachment, and development.

Background: Latina older adult women disproportionately suffer from type 2 diabetes (diabetes) and symptoms of depression and/or anxiety. These disease states are associated with serious declines in health outcomes and a three-fold reduction in treatment compliance. Few studies have examined this phenomenon exclusively among Latina older adult women or have captured the impact of intersectional identity on their experiences, values or problem-solving methods related to self-management.

Purpose: The purpose of this study was to examine how Latina women, 60 and over, emotionally experience both diabetes and interactions with care providers during help-seeking and care engagement.

Methods: This qualitative study used constructivist Grounded Theory methodology to explore the experience of English-speaking, Latina women, 60 years and older, diagnosed with diabetes and experiencing symptoms of depression or anxiety. Twenty-one phone interviews were conducted (N=16), with the use of a semi-structured interview guide. The Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were administered to assess the presence and extent of participant symptoms of depression and/or anxiety.

Findings: Participant data informed the creation of a theory, titled The Secret Self-Management Loop (SSML). This theory reflects four interconnected categories, or phases: 1) having a negative relationship origin story; 2) doubting provider motivation; 3) reacting to doubts about provider; and, 4) engaging in secret self-management. These phases cumulatively reinforced participants’ lack of trust in their providers and the medical system. In response to this lack of trust, participants employed a number of strategies they did not disclose to their providers, including the use of traditional medicines on the advice of lay providers and family and self-adjusting their prescribed antihyperglycemic medications. Participants also identified their own anecdotal benchmarks for diabetes management and valued these over diagnostic tests traditionally used by endocrinologists. Insufficient time with providers and providers’ lack of familiarity with Latino/a/x cultural practices were primary sources of emotional disconnection that underpinned this lack of trust.

Conclusion: The four-phase SSML is a dynamic and continual process that negatively influences disclosure within the patient-provider dyad and distorts providers’ ability to adequately render care for Latina older adult women experiencing diabetes and symptoms of depression and/or anxiety.

Implications: These findings have clinical, educational and research implications for nurses, physicians and other care providers working with Latino/a/x older adults living with diabetes and symptoms of depression and/or anxiety. Specifically, these findings illuminate the need for strategies and interventions to improve bonds and increase disclosure within the patient-provider dyad. Interventions promoting patient empowerment, increased diversity in the healthcare fields, and provider training in Latino/a/x cultural practices represent potential solutions to the current disconnect between Latina older adult women and their providers.

Women around the world are at risk for HIV because they are in close, long-term relationships with male partners who are unfaithful, abusive, and/or use alcohol or illicit drugs. HIV risk is particularly high among couples that migrate for work and experience extended periods of physical separation. This study used Constructivist Grounded Theory methodology to explore women's perceptions of and experiences with HIV risk among a community sample of migrant farmworkers of Mexican descent in southern California. Twenty women with a history of a close, long-term risky relationship participated in one or two in-depth interviews. After initial coding, focused coding identified the most significant areas of interest and categories were formed. Theoretical sampling helped to fill the gaps and detail how participants navigated and responded to risk in their relationships. A Community Advisory Board comprised of stakeholders and farmworker women from the target community offered insight and advice into research design and preliminary data interpretations.

Results are presented in a theory grounded in women's words, consisting of two simultaneous, overlapping processes. The first is a process of expanding perspective. While explaining their perceptions of partner risk, women repeatedly used metaphors of eyesight and "seeing" risk over a fluid five-phase process that included being blinded by vulnerabilities, making the discovery, weighing priorities, adopting a risk perspective, and assessing the consequences. While expanding their views of what HIV risk meant to them, women were also simultaneously pushing back against the actions of their abusive, unfaithful, and/or addicted long-term male partners. In this second process, called "gaining leverage," participants did not feel that they had overcome the danger of their risky relationships. Instead, they felt they were gaining leverage over risk in small but important ways through the use of three specific categories of action: fighting the bad (pushing back against a partner's actions using personal resources), finding the good (navigating complex external resources while avoiding additional harm), and fortifying the self (helping themselves "move forward" in the aftermath of risky relationships). Future interventions should focus on the ways in which migrant women cognitively, socially and emotionally navigate their perceptions of and responses to risky relationships.

Background: Health is considered to be a fundamental human right internationally. Many disciplines including nursing, medicine, psychology and sociology have attempted to define health. However, many definitions, including the historical definition offered by the World Health Organization do not take into consideration understandings of disease at the molecular, individual, and societal levels. Most, if not all, definitions have been derived from organizations or academic perspectives, while few have been developed from the perspective of the public. Aim: This study was conducted to explain, describe, analyze and interpret the perceptions of health and illness from the perspective of a sample of Omani men who have T2DM. Methodology: A qualitative thematic analysis was done using Grounded Theory techniques and informed by Symbolic Interactionism. Participants were recruited from a tertiary Polyclinic in one city in Oman and interviewed face-to-face in Arabic. An Arabic demographic questionnaire designed for the study was administered before the interview which was based on a semi-structured interview guide. Audiotapes were transcribed in Arabic and translated to English. Transcripts were checked for accuracy and all identifiers were removed. Then the transcripts were coded and analyzed based on the six steps as described by Braun and Clarke (2006). Data analysis was influenced by Symbolic Interactionism throughout each step of the process. Results: Four main themes with multiple subthemes were identified. We entitled Theme 1, Perceptions and definitions of health, and it had five subthemes including: Definitions of overall health; impressions of mental health, stress and emotions; health is primarily experienced as physical; health is something you do; and health is understood in relation to illness. Theme 2 was titled Factors that facilitate or impede participants’ T2DM self-management, had five subthemes including: Health is a personal experience (my own), actual and expected social support; the lack of positive cultural / community influences on health; fear as a motivator and as a stressor; and avoiding knowing about illness. Theme 3 was titled, Personal experiences with healthcare systems and it had no subthemes. Theme 4 was named, The dynamics between perceptions of health and self-care actions, and it had 3 subthemes including: Struggling with craving control, rationalization for less health maintenance (stress at work and no time to exercise), and culture influenced health beliefs and attitudes about health maintenance. Conclusions: This study was limited to participants with uncontrolled diabetes. Despite this, they all verbalized appreciation of health and its importance to their life. Health is a multifaceted concept that needs to be looked at from different perspectives; it is not solely a responsibility of individuals or healthcare settings independently. The involvement of individuals, clinics, as well as government organizations, sites of teaching, and social settings could help strengthen the health of communities while reducing the burden of chronic illness for people, young and old.

Projected rapid Latino population growth in California from 15 million to 25 million by 2060, and a Latino overrepresentation in the state's criminal justice system will drive a rapid increase of Latinos in the state's prisons. A gap exists in the literature on the coping processes of Latina mothers whose sons have been incarcerated. This qualitative research study of 17 low income, Spanish-language-dominant mothers in Southern California was undertaken to fill that gap and to sensitize future studies to the nuances of coping experienced by Latina mothers whose sons were incarcerated. Data collection and analysis of open-ended interviews were done using a constructivist grounded theory methodology.

Findings revealed that the initial response of the mothers to their son's incarceration resulted in perceptions of devastation, leading to pain, crying, lethargy, loss of sleep, and suicidal thoughts; the combination of which brought the mothers to the point of "dejarse caer," or giving up, falling to pieces or falling down. Three motivators would engage them to move towards "No dejarse caer," or not giving up, not falling to pieces, and not falling down. These motivators included their other children who still needed them, their now incarcerated sons, and their earlier image of themselves as capable mothers. Once they had come to the decision of "no dejarse caer", they would engage two key processes.

The first was "self-care," which described how these mothers, with extremely limited access to mental health care, developed three mechanisms to give care to themselves: working the mind, working with others, and working with God. The second process was mothering which consisted of nurturing, providing and protecting. They continued to mother their non-incarcerated children as before, but had to develop new ways to mother their incarcerated sons. These two core concepts were integrated in a circular fashion. The mothers engaged in self-care in order to engage in mothering and conversely, the mothering behavior kept them engaged in self-care. The implications for nursing practice and future research is touched upon.

This dissertation examines how clinicians are making decisions about prescribing opioids in the midst of a public health crisis. In the first paper, I used a qualitative study design to understand how, why, and when clinicians use risk mitigation strategies when prescribing opioids. For three risk mitigation strategies – the opioid agreement, urine drug testing, and risk screening checklists – I identified two groups of clinicians: Adopters, who found them useful and valuable and Non-adopters, who found them awkward and disruptive. In the second paper, I examined how clinicians made decisions about assuming new patients’ existing opioid prescriptions and identified three approaches: the Staunch Opposers, who were highly averse to continuing opioid prescriptions for new patients; the Cautious and Conflicted Clincians, who felt uneasy about prescribing opioids, but were willing to manage new patients’ prescriptions if the patient was perceived as trustworthy and if the dose and medication type fell within their comfort zone; and the Rapport Builders, who were the most willing to assume a new patient’s opioid prescription, even if the prescription was for a high dose. In the third study, I examined a sample of visits of patients seen by primary care clinicians for low back pain from 2013-2017 and analyzed whether receipt of an opioid prescription was associated with comorbidities that would indicate the prescription was potentially appropriate or inappropriate. I found that visits for which patients had selected NSAID contraindications, including kidney disease and concurrent or long-term use of anticoagulants or antiplatelet medications, had higher odds of the receipt of an opioid prescription, reflecting potentially appropriate prescribing. However, visits where patients had relative contraindications for opioids, such as concurrent benzodiazepine prescriptions or a history of substance use disorder, had significantly elevated odds of opioid receipt, reflecting potentially inappropriate prescribing. Findings from this dissertation expand and extend a conceptual model for decision-making around prescribing. I identified several new constructs that may influence prescribing, including (1) the nature of the patient-clinician relationship, (2) the management of risks to both the patient and clinician, (3) ethical considerations, and (4) the prescriber’s identity and role as a clinician.