This research examined two interrelated issues relevant to maternal and neonatal health in Pakistan, namely, the rising rates of C-section delivery and low rates of exclusive breastfeeding. By using the Andersen's health behavioral model to frame two empirical studies, the data from the Pakistan Demographic and Health Survey (PDHS) 2012-13 was used. The first empirical study examined the correlation between place of delivery and the odds of cesarean section in Pakistan. Not all Pakistani women have an equal chance of delivering at a health facility where C-section delivery takes place; therefore, the study modeled mode of delivery as a two-step process. In the first step, place of delivery was a function of medical indications and various sociodemographic and community factors. Women who delivered at a health facility were included in the second step, where C-section was a function of medical indications and type of facility (private, public). It is found that women who delivered at a private health facility were more likely to have a C-section, even after controlling for the effects of medical/clinical factors, which is concerning. Findings suggest that the private maternal health sector in Pakistan may be over-medicalizing childbirth. The second study examined this paradox of low exclusive breastfeeding in Pakistan, taking into account not only individual-level characteristics of the child and parents, but also place and mode of delivery, sociocultural factors, and community composition. The sample consisted of 1,044 children 0-5 months old, currently living with their mothers. Binary logistic regressions of exclusive and predominant breastfeeding found women who delivered vaginally, whether at home or health care facility were more likely than mothers who delivered via C-section to predominantly breastfeed their infant, and that mothers who delivered vaginally at a health care facility were more likely than their peers who delivered via C-section to exclusively breastfeed their infants. Collectively, the findings of both empirical studies suggest that private maternal health care services in Pakistan may be facilitating medically unnecessary C-sections, either for profit making or time management. An extended and integrated policy regarding medically unnecessary C-section delivery and low rates of exclusive breastfeeding is needed in Pakistan to address both issues together effectively.

Many women self-report discomfort, depression, mood changes, and irritability in conjunction with menstruation which has been termed Premenstrual Syndrome (PMS). Prior to the creation of the disease/disorder category PMS, disorders with similar symptoms like “hysteria” and “involutional melancholia” were ascribed to women reporting those types of complaints. These diagnoses were based on archaic claims about women’s anatomy and behavior. Modern medical researchers contend that women’s complaints have a physiological basis, yet they cannot definitively tie PMS to any specific physiological etiological pathway, either hormonal or neurological. This thesis explores the argument that the social norms for women’s roles and their associated behaviors are related to the appearance of a disease/disorder category named PMS in the United Kingdom and the United States. Many of women’s complaints may instead be symptoms of social problems (with social remedies) related to role conflict or role strain.

A positive physician-patient relationship is crucial for high quality and effective health care. Yet, cultural and language differences between providers and patients often challenge the establishment of effective physician-patient relationships. These challenges are especially evident in provider-refugee-patient interactions in which patients have experienced loss, torture, and trauma. Understanding of what constitutes a positive doctor-patient relationship is fundamental to diagnosis and treatment and is crucial for the delivery of quality care for diverse patient populations, including refugees. This qualitative, phenomenological case-study focuses on physician-reported experiences caring for refugees in order to identify what experiential factors contribute to effective therapeutic relationships.

BACKGROUND: People survive repeated health crises that used to be fatal and, at times, treatment intended to prolong life, prolongs death instead. Many people die in hospitals although they say they prefer to die at home. At the same time, research identifies multiple ways the American healthcare system is ill equipped to serve patients at the end of life. Presently, 20% of Americans die in Intensive Care Units (ICU), thus ICUs represent an important setting for learning about end-of-life care and death in America today. PURPOSE: To explore the nature of ICU care as perceived by family members, this qualitative study analyzed 693 reports from surveys mailed to family members of patients who died in the ICU of a major Boston hospital between 2009 and 2015. The study focused on experiences of received services as reported in responses to the survey’s three open-ended questions regarding helpful and unhelpful aspects of care surrounding the patient’s death. Family member experiences with social work services were also explored. METHODS: Data were assessed using the Family-centered Care (FCC) model, an emerging framework for provision of best practices in hospital settings. This framework emphasizes that patients, families, and health care providers work in partnership to set treatment goals. Since FCC has been correlated with better outcomes, one research objective here was to explore the extent to which family members’ experiences reflected the presence of FCC. The study also assessed family members’ experiences that fell outside the realm of FCC. Using NVivo software, analysis was guided by Braun and Clarke’s (2012) six-phase thematic analysis approach. FINDINGS AND IMPLICATIONS: Family members described numerous positive experiences. Deaths were humane and the delivery of FCC was evident. An in-depth data analysis provided illuminating details of FCC and explicated over 47 themes important to families’ ICU experiences. Families reported that they received emotional support, were well-informed, and were treated with respect. Findings suggest that FCC is possible in an ICU setting, supporting the use of FCC in ICU care and suggesting that it could profoundly improve the quality of end-of-life care. Responses concerning the role of social work were limited.

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<p>The Royal College of Physicians and Surgeons recognizes the role of health advocate as a central aspect of doctoring that can greatly impact the quality of care one receives. Current literature discussing physicians as health advocates is sparse, particularly in the area of medical training. This study aims to identify how medical residents negotiate between their identity as a physician, which is bound by the narrow confines of biomedicine, and a more comprehensive vision of health care that incorporates advocacy. A thematic narrative analysis of four weblogs authored by medical residents was employed to complete this study. The culture of medicine and the hidden curriculum surfaced as impediments to advocacy in residency training, resulting in residents experiencing a crisis in caring, compassion and communication. When residents were not able to care for their patients in ways that met their moral expectations of what it means to be a healer, they felt depersonalized and became disenchanted with medicine. Arthur Frank’s theory regarding the demoralization of medicine is used to illuminate the importance of dialogue within the doctor-patient relationship, as well as its impacts on health advocacy. This study explores the concept of advocacy and brings forth the question: Given what we know about medicalization and the culture of medicine, should physicians be health advocates for their patients when their training is restricted to biomedical interventions and notions of care?</p> / Master of Arts (MA)

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The current study examines racial differences in the management of Attention Deficit Hyperactivity Disorder (ADHD) among Black adolescents. This study also examines Black adults' reflection upon adolescent symptoms of ADHD. Drawing on literature from racial/ethnic disparities in diagnosis and treatment of ADHD, health care service utilization, health behaviors, structural racism and medicalization, this study examines the health behavior and health care utilization practices of Black people, analyzing the avenues through which racism structures the management of symptoms. This study also explores the ways in which management of adolescent symptoms of ADHD shape Black adults' self-management of symptoms in adulthood. To investigate such ideas data from the National Comorbidity Survey- Adolescent Supplement (NCS-A) and the Parent Self-Administered Questionnaire (PSA-Q) were analyzed to offer a descriptive picture of differences in management and treatment of adolescent ADHD symptoms. Ten interviews were conducted with Black adults to offer depth to reported interpersonal causes of racial differences in management and treatment and assist in placing such causes within a framework of structural racism. Interview questions focused on participant's articulation of the socio-political landscape in which adolescent symptoms of ADHD were experienced. Additional questions targeted processes around parent's management of symptoms, the school systems management of symptoms, participant's relationships to medical care providers and avenues to treatment. Quantitative findings suggest there are racial differences present in the management of adolescent ADHD and qualitative findings offer that these differences are reflective of a structural system of power and privilege that shapes Black people's engagement with and access to care for symptoms of ADHD. This research contributes to existent knowledge about reported racial differences in management of symptoms of ADHD, and has implications for the ways in which literature approaches racial disparities in diagnosis and treatment of ADHD among Black adolescents. / Doctor of Philosophy / The current study examines racial differences in the management of Attention Deficit Hyperactivity Disorder (ADHD) among Black adolescents. This study also examines Black adults’ reflection upon adolescent symptoms of ADHD. Drawing on literature from racial and ethnic disparities in diagnosis and treatment of ADHD, health care service utilization, health behaviors, structural racism and medicalization, this study examines the health behavior and health care utilization practices of Black people. This study also explores the relationship between adolescent and adult management of ADHD symptoms. To investigate differences by race data from the National Comorbidity Survey- Adolescent Supplement (NCS-A) and the Parent Self-Administered Questionnaire (PSA-Q) were analyzed. In addition, interviews were conducted with Black adults to offer depth and give context to the ways in which race and racism shaped quantitative findings. Interview questions focused on participant’s adolescent management of symptoms by familial networks and school systems, as well as participant’s adult relationships to medical care providers and symptom management. Quantitative findings suggest racial differences are present in the management of adolescent ADHD and qualitative findings offer that these differences are reflective of the ways in which racism shapes Black people’s engagement with and access to care for symptoms of ADHD. This research contributes to existent knowledge about reported racial differences in management of symptoms of ADHD, and has implications for the ways in which literature approaches racial disparities in diagnosis and treatment of ADHD among Black adolescents.

Ce mémoire vise à mettre à l'épreuve les contributions scientifiques des auteurs qui critiquent la médicalisation de l'enjeu suicidaire. Selon eux, l'idée d'une relation causale entre le suicide et la maladie mentale est devenue une évidence acceptée dans les milieux scientifiques et profanes. Cette conception dominante est critiquée car elle oriente les stratégies de prévention du suicide vers des interventions médicales, négligeant ainsi l'importance des facteurs structurels. Nous proposons d'explorer comment ces critiques résonnent avec le contexte québécois. Nous interrogeons également ces critiques en les replaçant au sein d'un large éventail d'approches concernant le suicide, y compris les expertises élaborées en sociologie, psychologie et épidémiologie. En étayant notre examen de la littérature par une démonstration de la complexité théorique du suicide, nous explorons la manière dont les experts intègrent les discours "médicalisés" parmi la diversité de ces connaissances. L'analyse proposée se concentre spécifiquement sur l'établissement d'une cartographie des représentations concernant les causes du suicide et les pratiques de prévention privilégiées. Pour mener cette analyse, nous étudierons les discours de douze professionnels québécois et analyserons le contenu de divers documents institutionnels rédigés par le gouvernement du Québec. / This master’s thesis aims to challenge the scientific contributions of authors who criticize the medicalization of concepts and treatments surrounding the topic of suicide. According to their arguments, the notion of a causal link between suicide and mental illness has become widely acknowledged within scientific and non-expert circles. This prevailing notion also plays a significant role in the public management of suicide, as it narrows down suicide prevention strategies to medical interventions. We intend to investigate how these critiques resonate within the context of Quebec. Furthermore, we also suggest interrogating these criticisms by situating them within a broad a broad range of approaches concerning suicide, including expertise from sociology, psychology, and epidemiology. By grounding our literature review in a demonstration of the intricate theoretical nature of suicide, we will delve into how professionals incorporate "medicalized" discourses within the scope of these competencies. The proposed analysis is specifically directed towards constructing a map of representations regarding the causes of suicide and prevention practices. To accomplish this, we will analyze the viewpoints of twelve Quebec-based professionals, as well as scrutinize the content of various institutional documents produced by the Quebec government.