자연주의적 탐구조사(Naturalistic Inquiry)

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Qualitative research for education: An introduction to theories and methods

Objective This review evaluates the effectiveness of quality improvement (QI) strategies in reducing disparities in health and health care. Data sources We identified papers published in English between 1983 and 2011 from the MEDLINE® database, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science Social Science Index, and PsycINFO. Review methods All abstracts and full-text articles were dually reviewed. Studies were eligible if they reported data on effectiveness of QI interventions on processes or health outcomes in the United States such that the impact on a health disparity could be measured. The review focused on the following clinical conditions: breast cancer, colorectal cancer, diabetes, heart failure, hypertension, coronary artery disease, asthma, major depressive disorder, cystic fibrosis, pneumonia, pregnancy, and end-stage renal disease. It assessed health disparities associated with race or ethnicity, socioeconomic status, insurance status, sexual orientation, health literacy/numeracy, and language barrier. We evaluated the risk of bias of individual studies and the overall strength of the body of evidence based on risk of bias, consistency, directness, and precision. Results Nineteen papers, representing 14 primary research studies, met criteria for inclusion. All but one of the studies incorporated multiple components into their QI approach. Patient education was part of most interventions (12 of 14), although the specific approach differed substantially across the studies. Ten of the studies incorporated self-management; this would include, for example, teaching individuals with diabetes to check their blood sugar regularly. Most (8 of 14) included some sort of provider education, which may have focused on the clinical issue or on raising awareness about disparities affecting the target population. Studies evaluated the effect of these strategies on disparities in the prevention or treatment of breast or colorectal cancer, cardiovascular disease, depression, or diabetes. Overall, QI interventions were not shown to reduce disparities. Most studies have focused on racial or ethnic disparities, with some targeted interventions demonstrating greater effect in racial minorities--specifically, supporting individuals in tracking their blood pressure at home to reduce blood pressure and collaborative care to improve depression care. In one study, the effect of a language-concordant breast cancer screening intervention was helpful in promoting mammography in Spanish-speaking women. For some depression care outcomes, the collaborative care model was more effective in less-educated individuals than in those with more education and in women than in men. Conclusions The literature on QI interventions generally and their ability to improve health and health care is large. Whether those interventions are effective at reducing disparities remains unclear. This report should not be construed to assess the general effectiveness of QI in the health care setting; rather, QI has not been shown specifically to reduce known disparities in health care or health outcomes. In a few instances, some increased effect is seen in disadvantaged populations; these studies should be replicated and the interventions studied further as having potential to address disparities.

Closing the quality gap: revisiting the state of the science (vol. 3: quality improvement interventions to address health disparities).

Individuals with psychiatric disabilities are less likely to enter college and, after enrolling in college, are more likely to drop out. In response, psychiatric rehabilitation practitioners have used a program called supported education (SEd) to improve retention rates for college students with psychiatric disabilities. As an emerging research paradigm, resilience offers a new direction for understanding and implementing SEd. Congruent with the objectives of SEd, this article presents ways that resilience research can be used to improve the retention of students with psychiatric disabilities in 2- and 4-year colleges.

Increasing Resilience: Strategies for Reducing Dropout Rates for College Students with Psychiatric Disabilities

OBJECTIVE
Illicit drug use is identified in Healthy People 2010 as a leading health indicator because it is associated with multiple deleterious health outcomes, such as sexually transmitted diseases, human immunodeficiency virus, viral hepatitis, and numerous social problems among adolescents and adults. Improved understanding of the influence of stressful or traumatic childhood experiences on initiation and development of drug abuse is needed.


METHODS
We examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age categories: <or=14 years, 15 to 18 years, or as an adult (>or=19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use.


RESULTS
Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug addiction, and parenteral drug use. Compared with people with 0 ACEs, people with >or=5 ACEs were 7- to 10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use. The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%, 64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong graded relationship to lifetime drug use.


CONCLUSIONS
The ACE score had a strong graded relationship to the risk of drug initiation from early adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to account for one half to two third of serious problems with drug use, progress in meeting the national goals for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing childhood experiences by pediatric practice.

Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study

In this qualitative study, four participants diagnosed with a mental illness were interviewed to explore their experiences while attending a post-secondary school. Each participant described how education helped them to find a sense of purpose in their lives. Education is also described as a means of transition from the patient role to other roles such as student or worker. However, the symptoms and stigma associated with their mental illness has created additional challenges for them while in a school setting. Supportive professors and counselors were viewed as helpful in overcoming these barriers.

The meaning of higher education for people diagnosed with a mental illness: four students share their experiences.

The Canadian Occupational Performance Measure was used as a tool to compare goals for intervention identified by seven clients living in a long-term residential program and diagnosed with schizophrenia, with their goals as identified by the occupational therapist. In-depth interviews were conducted in conjunction with the use of the Canadian Occupational Performance Measure. Data analysis revealed an overarching theme that described the clients' concerns as, “I want to accomplish goals outside of the residence program.” During the analysis, however, the data revealed that the occupational therapist primarily focused her attention on goals to be achieved within the residence program, emphasizing programming and symptom management as each client's priorities for intervention, rather than community involvement. The findings reveal how data from the Canadian Occupational Performance Measure was used to reveal client/therapist disconnect in goal setting and the need to continue to examine client-centered pract...

Are We Really Client-Centered? Using the Canadian Occupational Performance Measure to See How the Client's Goals Connect With the Goals of the Occupational Therapist

While there is a considerable body of knowledge investigating the efficacy of constraint-induced movement therapy (CIMT), there is a need for information focusing on parents’ experiences when their children receive these services. This qualitative research study initially explored the experiences of four parents with children who are diagnosed with cerebral palsy (CP) and who participated in CIMT using a group format. Additionally, the richness of the information shared by parents provided insights on other important issues related to family supports when raising a child and the availability of resources for children diagnosed with CP. Response analysis from in-depth interviews with parents resulted in three themes: (a) Everything in my family changed when my child was diagnosed with CP and the support I feel from my family makes all the difference in how I cope. (b) It was so hard to get the information and support that I needed for my child. (c) The group format enhanced CIMT for my child and pr...

Parents’ Experiences with Services and Treatment for Their Children Diagnosed with Cerebral Palsy

This qualitative study explored the experiences of five men and one woman who were parents, substance dependent, and receiving treatment. Data collected by observation and in-depth interviewing were analyzed using constant comparison method and thematic analysis. Findings were grouped into three categories: surviving my childhood and becoming an adult, the struggles of trying to be a parent, and the roles of spouses and extended family members. An overarching metathematic category, the destructive path and powerful appeal of addiction, describes why the participants reported feeling most comfortable in the role of drug addict and found order in the chaos in the addictive lifestyle.

The Destructive Path of Addiction: Experiences of Six Parents Who are Substance Dependent

This qualitative study explores the experiences of five men and one woman who were parents, substance dependent, and receiving treatment at a year-long drug treatment program. The qualitative research methods of observation and in-depth interviewing were used to collect and analyze information about their experiences. This paper discusses themes related to the role of spouses and extended family members who assumed primary responsibility for children during a parent's drug addiction. Participants reported how, when they were unable to care for their children, these responsibilities fell to other family members, giving rise to many conflicts. Initially they were grateful for the support, especially while the participants were actively using drugs, because this provided them with more opportunities to continue their addictive lifestyle. Eventually, power struggles emerged when the participants were in recovery and attempted to reenter their children's lives as parental figures.

Laurie Knis-Matthews

Papers

The meaning of higher education for people diagnosed with a mental illness: four students share their experiences.

Are We Really Client-Centered? Using the Canadian Occupational Performance Measure to See How the Client's Goals Connect With the Goals of the Occupational Therapist

Parents’ Experiences with Services and Treatment for Their Children Diagnosed with Cerebral Palsy

The Destructive Path of Addiction: Experiences of Six Parents Who are Substance Dependent

The Role of Spouses and Extended Family Members as Primary Caretakers of Children During a Parent's Drug Addiction