My body, our illness: Negotiating relational and identity tensions of living with mental illness

This thesis uses an autoethnographic methodology informed by narrative theory to interrogate my experiences of relational and identity tensions as both a consumer of mental health services and an advocate for the care, autonomy and acceptance of those who identify with concepts of mental illness recovery. In doing so I am using my personal diaries and medical records from the past seven years as archival data to assist me in recovering and reconstructing narratives that represent meaningful truths about these experiences. I also call on heavily what Carolyn Ellis (2004) calls relational ethics because I know that while I am sharing my stories I am also sharing the stories of those closest to me, specifically my friends, family and treatment providers. Wherever possible I use pseudonyms and changing identifying information, however when that is not possibly I think thoughtfully and reflexively about what sharing the story could do to them and to our relationship. Finally, I propose that this autoethnographic inquiry is a work of advocacy itself. We live in a world today were there are false boundaries between the mad and the sane and the sick and the well. However, I know a world much more fluid and fragmented than that. I hope to bring the reader into that world through the storying of my experience

Discourses of Madness and Me: Critical Examinations of Western Discourses of Madness and Psychiatry

This paper is a critical examination of western medical paradigms alongside histories of psychiatry that argues for a culturally situated approach to mental health advocacy that maintains the importance of the physiological foundations of traditional biomedical approaches to disease. In doing so, I examine the discourses of madness, and society’s attempts to control and “fix” what is deemed “mad” through a historical lens. My position and critique utilizes a reflexive narrative process embracing my identities both as a consumer of mental health services and as an advocate for those with mental illnesses

The Richmond Maker Museum: The Evolution of Process

The Richmond Maker Museum is a working museum design, offering an inside look at past achievements, juxtaposed with the unlimited future possibilities of an evolving, active maker culture. It is a dynamic place designed to allow makers to showcase skills, take risks, engage the public, and grow their craft in real time. The museum displays finished pieces, introduces makers, demonstrates the processes they employ in their work, and invites the community to meet the artisans who, through skill, ingenuity, and hard work, make the artifacts on display. This type of educational museum experience does not currently exist on this scale in Richmond. While other local museums invite visiting artists and offer lectures, the Richmond Maker Museum takes interaction to a new level, introducing visitors to the routines and procedures of each artisan’s daily practice. Maker culture is a tightly woven network of craftsmen—woodworkers, metalworkers, glassblowers, etc. It celebrates traditional fabrication techniques, while also introducing modern technologies such as laser cutting and three-dimensional printing. The social and educational aspects of the maker movement have created a revolution, revitalizing public appreciation for the role of the maker and the importance of craftsmanship

Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies

Background Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan. Methods Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers. Results All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio-cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services. Conclusion Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis-affected communities in RH programming to increase understanding and use of this life-saving care

Meeting the demand of women affected by ongoing crisis: Increasing contraceptive prevalence in North and South Kivu, Democratic Republic of the Congo

Context Over 20 years of conflict in the DRC, North and South Kivu have experienced cycles of stability and conflict, resulting in a compromised health system and poor sexual and reproductive health outcomes. Modern contraceptive use is low (7.5%) and maternal mortality is high (846 deaths per 100,000 live births). Program partners have supported the Ministry of Health (MOH) in North and South Kivu to provide good quality contraceptive services in public health facilities since 2011. Methods Cross-sectional population-based surveys were conducted in the program areas using a two-stage cluster sampling design to ensure representation in each of six rural health zones. Using MOH population estimates for villages in the catchment areas of supported health facilities, 25 clusters in each zone were selected using probability proportional to size. Within each cluster, 22 households were systematically selected, and one woman of reproductive age (15–49 years) was randomly selected from all eligible women in each household. Results Modern contraceptive prevalence among women in union ranged from 8.4% to 26.7% in the six health zones; current use of long-acting or permanent method (LAPM) ranged from 2.5% to 19.8%. The majority of women (58.9% to 90.2%) reported receiving their current method for the first time at a health facility supported by the program partners. Over half of women in four health zones reported wanting to continue their method for five years or longer. Conclusion Current modern contraceptive use and LAPM use were high in these six health zones compared to DRC Demographic and Health Survey data nationally and provincially. These results were accomplished across all six health zones despite their varied socio-demographic characteristics and different experiences of conflict and displacement. These findings demonstrate that women in these conflict-affected areas want contraception and will choose to use it when good quality services are available to them

“Provide care for everyone please”: Engaging Community Leaders as Sexual and Reproductive Health Advocates in North and South Kivu, Democratic Republic of Congo

Background: Inadequate infrastructure, security threats from ongoing armed conflict, and conservative socio-cultural and gender norms that favour large families and patriarchal power structures contribute to poor sexual and reproductive health (SRH) outcomes in North and South Kivu provinces, Democratic Republic of the Congo (DRC). In order to expand contraceptive and post-abortion care (PAC) access in North and South Kivu, CARE, the International Rescue Committee and Save the Children provided technical support to the Ministry of Health and health facilities in these regions. Partners acknowledged that community leaders, given their power to influence local customs, could play a critical role as agents of change in addressing inequitable gender norms, stigma surrounding SRH service utilization, and topics traditionally considered taboo within Congolese society. As such, partners actively engaged with community leaders through a variety of activities such as community mapping exercises, values clarification and transformation (VCAT) activities, situational analyses, and education. Methods: This manuscript presents findings from 12 key informant interviews (KIIs) with male political and non-political community leaders conducted in six rural health zones of North and South Kivu, DRC. Transcripts were analysed thematically to explore community leaders’ perceptions of their role in addressing the issue of unintended pregnancy in their communities. Results: While community leaders in this study expressed overall positive impressions of contraception and strong support for ensuring access to PAC services following spontaneous and induced abortions, the vast majority held negative beliefs concerning women who had induced abortion. Contrasting with their professed opposition to induced abortion, leaders’ commitment to mediating interpersonal conflict arising between community members and women who had abortions was overwhelming. Conclusion: Results from this study suggest that when thoughtfully engaged by health interventions, community leaders can be empowered to become advocates for SRH. While study participants were strong supporters of contraception and PAC, they expressed negative perceptions of induced abortion. Given the hypothesized link between the presence of induced abortion stigma and care-avoidance behavior, further engagement and values clarification exercises with leaders must be integrated into community mobilization and engagement activities in order to increase PAC utilization

“They Love Their Patients”: Client Perceptions of Quality of Postabortion Care in North and South Kivu, the Democratic Republic of the Congo

Background: Postabortion care (PAC) is a lifesaving intervention that, when accessible and of good quality, can prevent the majority of abortion-related deaths. However, these services are only sporadically available and often of poor quality in humanitarian settings. CARE International, the International Rescue Committee, and Save the Children strengthened the Congolese Ministry of Health to provide PAC, including voluntary contraceptive services, in North and South Kivu, DRC. Objective: We aimed to gain understanding of the demographic and clinical characteristics of PAC clients, the experiences of women who sought PAC at supported health facilities, and the women’s perceptions of the quality of care received. We also explored how client perspectives can inform future PAC programming. Methods: A PAC register review extracted sociodemographic and clinical data on all PAC clients during a 12-month period between 2015 and 2016 at 69 supported facilities in 6 health zones. In-depth interviews were conducted between September 2016 and April 2017 with 50 women who sought PAC in the preceding 3 months at supported health facilities. Interviews were recorded, transcribed, and translated into French for analysis. Thematic content analysis was subsequently used as the data analytic approach. Results: In 12 months, 1,769 clients sought PAC at supported facilities; 85.2% were at less than 13 weeks gestation. Over 80% of PAC clients had a uterine evacuation, and of these, 90% were treated with manual vacuum aspiration. The majority (75.2%) of PAC clients chose voluntary postabortion contraception. All but one interview participant reported seeking PAC for a spontaneous abortion, although most also reported their pregnancy was unintended. Clients were mostly made aware that PAC was available by community health workers or other community members. Experiences at the supported facilities were mostly positive, particularly in regards to client-provider interactions. Most women received contraceptive counseling during PAC and selected a modern method of contraception immediately after treatment. However, knowledge about different methods of contraception varied. Nearly all women said that they would advise another woman experiencing abortion complications to seek PAC at a supported health facility. Conclusions: The findings demonstrate the successful implementation of good-quality, respectful PAC in North and South Kivu. Overall, they suggest that the organizations’ support of health workers, including competency-based training and supportive supervision, was successful

Factors Related to Accelerometer-determined Patterns of Physical Activity in Adults: The Houston TRAIN Study

Meeting U.S. Physical Activity (PA) Guidelines has health benefits. Yet, little is known about the factors related to changes in PA over time, particularly among minority populations. PURPOSE: To examine sociodemographic, PA preferences, and health factors related to accelerometer-derived patterns of 1-year PA change in the Houston Travel Related Activity in Neighborhoods (TRAIN) Study, a majority-minority cohort. METHODS: Participants wore an ActiGraph wGT3X-BT monitor and completed self-report surveys at baseline and follow-up. Valid wear time was defined as ≥ 4 days, ≥ 10 hrs/day. PA was stratified by meeting Guidelines using total MVPA, defined by Freedson. Four PA patterns were defined: (i) ‘maintain high’ activity above Guidelines, (ii) ‘increased’ to meet Guidelines, (iii) ‘decreased’ from meet to not meet Guidelines, and (iv) ‘maintained low’ activity. Multinomial logistic regression was used to examine associations between studied factors and each PA pattern, with the ‘maintain high’ group as referent. RESULTS: Complete data were available for 153 adults (19% maintained high activity, 8.5% increased, 13% decreased, 59.5% maintained low activity). Controlling for all variables, males (OR = 0.3, 95% CI = 0.1, 0.9) had lower odds of being in the ‘maintain low’ group. Blacks (vs. whites, OR = 18.8, 95% CI = 2.6, 275.0), those liking biking (vs. strongly liking, OR = 4.6, 95% CI = 1.3, 15.6), and older participants (vs. younger, on continuous scale, OR = 1.1, 95% CI = 1.0, 1.1) had higher odds of being in the ‘maintain low’ group. Factors directly associated with being in the ‘increased’ group were being black (vs. white, OR = 17.9, 95% CI = 1.3, 120.9), strong dislike for biking (vs. strongly liking OR = 25.2, 95% CI = 1.6, 401.3), and having more chronic diseases (vs. less, on continuous scale, 95% CI = 1.5, 11.7). Having low educational attainment (vs. high, OR = 0.04, 95% CI = 0.0, 0.9) was inversely associated with being in the ‘increased’ group. No studied factors were significantly associated with being in the ‘decreased’ group. CONCLUSION: PA patterns are dynamic and suggest that sociodemographic, PA preferences, and health factors relate to change patterns over time. Future studies should examine the role of these factors over longer follow-up periods, and consider these factors when designing interventions

Comparison of Perioperative Outcomes Between Holmium Laser Enucleation of the Prostate and Robot-Assisted Simple Prostatectomy

Objectives: To compare perioperative outcomes for patients undergoing holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple prostatectomy (RSP) for benign prostatic hypertrophy (BPH).Methods: Patient demographics and perioperative outcomes were compared between 600 patients undergoing HoLEP and 32 patients undergoing RSP at two separate academic institutions between 2008 and 2015.Results: Patients undergoing HoLEP and RSP had comparable ages (71 vs 71, p = 0.96) and baseline American Urological Association Symptom Scores (20 vs 24, p = 0.21). There was no difference in mean specimen weight (96 g vs 110 g, p = 0.15). Mean operative time was reduced in the HoLEP cohort (103 minutes vs 274 minutes, p < 0.001). Patients undergoing HoLEP had lesser decreases in hemoglobin, decreased transfusions rates, shorter hospital stays, and decreased mean duration of catheterization. There was no difference in the rate of complications Clavien grade 3 or greater (p = 0.33).Conclusions: HoLEP and RSP are both efficacious treatments for large gland BPH. In expert hands, HoLEP appears to have a favorable perioperative profile. Further studies are necessary to compare long-term efficacy, cost, and learning curve influences, especially as minimally invasive approaches become more widespread