This dissertation was a mixed methods triangulation design combining quantitative and qualitative components. The purpose of this study was twofold. First, it examined the association between the frequency and quality of students’ online interactions with instructors and the quality of student-instructor relationship. Second, this study explored the meanings of student-instructor interactions mediated by online tools. Quantitative data were collected via an online survey from 320 undergraduate students enrolled at a public research university. Qualitative data sources were in-depth interviews with six undergraduate students and six professors, observations of student-instructor interactions on Facebook, and artifacts of student-instructor interaction via email. Hierarchical regression analysis showed that approximately one third of the variance in student-instructor connectedness was explained by the frequency of and satisfaction with face-to-face, email, Blackboard, and Facebook; the grade obtained in the class; and demographic variables. Significant predictors of connectedness were grade, frequency of face-to-face student interest-driven communication, satisfaction with the face-to-face interactions, and satisfaction with the email communication. The qualitative findings revealed that instructors held expectations of formal communication for email interactions, while students had expectations for response from instructors within one-two business days. The email practices identified for instructors included responding to student email within two days; compensating for limited face-to-face time; engaging students in communication about the class content; and dealing with student disengagement. Students adopted two main practices related to email: avoiding “emergency” emails to contact instructors, and using email to avoid face-to-face contact in some situations. For Facebook interactions, instructors expected that students initiate connections, while students expected that instructors signal their availability for connection with students. Instructors’ Facebook practices pointed out different approaches for accepting student friend requests; and performing interactions. Students’ practices on Facebook highlighted two patterns: initiating connections with instructors during the semester versus at the beginning of the semester. In addition, preserving connections beyond the boundaries of a class was a practice common to students and instructors.

The Resident-Medical Student Shadowing Program is a novel program in which first-year medical students shadowed a first-year resident during their clinical duties. It was developed to enhance the preparedness of medical students for clinical training. To examine the program’s effectiveness, a randomized control trial was conducted within a concurrent triangulation mixed methods study. Student participants were compared to controls using validated questionnaires. Participants’ experiences were further explored using semi-structured interviews. Results indicate that participation gave students an understanding of the clinical environment and their role within it, and taught them the skills and knowledge needed to perform that role. Students’ learning was enhanced by the relationship developed with their resident, facilitated by the residents’ approachability and relatability and their dedication to teaching. Residents, in turn, gained expertise in teaching and learned about professionalism. Suggestions for implementing this program in the future as well as future directions for research are discussed. / Measurement, Evaluation and Cognition

This program of research examines the experience of chronic pain in a community sample. While, it is clear that like patient samples, chronic pain in non-patient samples is also associated with psychological distress and physical disability, the experience of pain across the total spectrum of pain conditions (including acute and episodic pain conditions) and during the early course of chronic pain is less clear. Information about these aspects of the pain experience is important because effective early intervention for chronic pain relies on identification of people who are likely to progress to chronicity post-injury. A conceptual model of the transition from acute to chronic pain was proposed by Gatchel (1991a). In brief, Gatchel’s model describes three stages that individuals who have a serious pain experience move through, each with worsening psychological dysfunction and physical disability. The aims of this program of research were to describe the experience of pain in a community sample in order to obtain pain-specific data on the problem of pain in Queensland, and to explore the usefulness of Gatchel’s Model in a non-clinical sample. Additionally, five risk factors and six protective factors were proposed as possible extensions to Gatchel’s Model. To address these aims, a prospective longitudinal mixed-method research design was used. Quantitative data was collected in Phase 1 via a comprehensive postal questionnaire. Phase 2 consisted of a follow-up questionnaire 3 months post-baseline. Phase 3 consisted of semi-structured interviews with a subset of the original sample 12 months post follow-up, which used qualitative data to provide a further in-depth examination of the experience and process of chronic pain from respondents’ point of view. The results indicate chronic pain is associated with high levels of anxiety and depressive symptoms. However, the levels of disability reported by this Queensland sample were generally lower than those reported by clinical samples and consistent with disability data reported in a New South Wales population-based study. With regard to the second aim of this program of research, while some elements of the pain experience of this sample were consistent with that described by Gatchel’s Model, overall the model was not a good fit with the experience of this non-clinical sample. The findings indicate that passive coping strategies (minimising activity), catastrophising, self efficacy, optimism, social support, active strategies (use of distraction) and the belief that emotions affect pain may be important to consider in understanding the processes that underlie the transition to and continuation of chronic pain.

This thesis examines the impact of the engineering culture on women engineering students??? gendered and professional identities. It is simultaneously focused on exploring how identity shapes, and is shaped by, women???s experiences of the engineering culture and, the relationship between gendered and professional identities. The research is set within the context of existing research on women in engineering, much of which has focused either on women???s experiences in industry or experiences of staff in academia, failing to recognise the importance of higher education (HE) as a gatekeeper to the engineering professions. Furthermore, despite numerous initiatives aimed at increasing the percentage of women entering engineering, the proportion of women studying engineering has remained stable, around fifteen percent, for the last few years. The research is grounded in an interpretivist approach, although it adopts a multimethod research design. Specifically it draws upon qualitative interviews with 43 women and 18 men engineering students, a questionnaire with responses from 656 engineering undergraduates and two focus groups with 13 women engineering students from seven departments at one university. These datasets are analysed with the aid of NVivo and SPSS to explore women engineering students??? career choices; women???s experiences of the HE engineering culture; the relationship between engineering education culture and women???s identities; whether there are cultural nuances between engineering disciplines; and, implications for strategies to attract and retain more women in engineering. Key findings from the research are that women and men make career choices based on similar factors, including the influence of socialisers, knowledge of the engineering professions, skills, ability and attributes, and career rewards. However, the extent to which each of this factors are important is gendered. The research also highlights key characteristics of the HE engineering culture, including competition, camaraderie, gendered humour, intensity, more theoretical than practical, help and support for women students and reinforcement of gender binaries. These findings all suggest that women are assimilated into the engineering culture or, at least, develop coping mechanisms for surviving in the existing culture. These strategies reveal a complex and difficult balancing act between being a woman and being an engineer by claiming a rightful place as an engineer, denying gendered experiences and becoming critical of other women. The research also tackles two key issues, rarely discussed in the extant literature. Firstly the help and support women students receive from lecturers and other staff, and the negative impact this has, and may continue to have, on women. Secondly, the analysis of discipline differences shows that design and technology is significantly different from other engineering disciplines in terms of culture(s) and women???s experiences. The thesis concludes that women???s enculturation into engineering results in their ???doing gender??? in a particular way. This means that women???s implicit and explicit devaluing and rejection of femaleness, fails to challenge the gendered cultures of engineering and, in many ways, upholds an environment which is hostile to women.

Little research has identified the proactive psychosocial attributes and tactics that deaf individuals can use to maximise their potential with hearing peers. A comprehensive and systematic framework of psychosocial skills has also been absent in deafness-related research. / This study featured data gleaned from 49 participants from Australia, England, and the USA who were mostly highly educated, and vocationally and socially successful. These participants formed three groups: Oral Deaf (n=22), Hearing (n=19), and Culturally Deaf (n=8). All participants were over the age of 25 and self-regarded as maximising their potential in mainstream society. All hearing participants had had a close relationship with a deaf individual for more than one year and reported not having a disability. All deaf participants nominated whether or not they were culturally Deaf (CD) and reported not having an additional disability to deafness. / Most deaf participants reported pre-lingual deafness (n=18). All but one deaf participant reported greater than severe-to-moderate bilateral deafness. Eighteen (60%) deaf participants wore hearing aids, ten had a cochlear implant, and two had no assistive sensory device. Twenty-four (80%) deaf participants relied on speech-reading and all but one always used their voice to communicate. Nineteen (63%) deaf participants were educated solely in a mainstream school but only three (10%) were educated solely in a School for the Deaf. The majority (64%) of Oral Deaf (OD) participants had not learned Sign Language (SL) and only three continued or were fluent with SL. All CD participants used SL. Data trends also suggested that two CD participants were ‘purely’ CD, whereas the six other CD participants likely were ‘bi-cultural’. / This exploratory research used a framework of psychosocial themes used in a study with vocationally successful participants with a Learning Disability by Reiff, Ginsberg and Gerber (1995). These themes were grouped into Internal Decisions (Desire, Goal Orientation, and Reframing) and External Manifestations (Persistence, Goodness of Fit, Learned Creativity, and Social Ecologies). Control was the eighth theme that embraced all other seven themes. Reiff et al.’s framework was modified for the current study’s purposes so that the combined effect of the three thematic categories of Control, Internal Decisions, and External Manifestations equals Potential Maximisation. Potential Maximisation was therefore defined as the measure of a participant’s psychosocial attributes and tactics used in social and vocational contexts. / Screening surveys were used to glean demographic data and to determine the participants’ eligibility. Eligible deaf and hearing participants were then administered follow-up surveys. These follow-up surveys included identical items that were scored for the purposes of between-group statistical analyses. The follow-up survey for deaf participants featured additional deafness-specific items that were not in the follow-up survey for hearing participants. The follow-up survey items were allocated to themes in Reiff et al.’s (1995) framework. / Mixed-methods were administered on the data. Between- and within-group analyses were also conducted. Three between-group comparisons featured statistical analyses on each of the four variables of Control, Internal Decisions, External Manifestations, and Potential Maximisation. The results of the ANOVAs and t-tests (2-tailed) showed no significant differences in the mean scores for each of four variables. These trends indicated that 1) the deaf and hearing participants used similar or identical psychosocial attributes and tactics to maximise their potential, and that 2) hearing status and 3) deaf identity were not factors influencing the maximisation of psychosocial potential. / Three within-group analyses were then conducted. These included case studies, composite pictures, and reporting qualitative data trends. The case studies showed that the highest scoring participant provided comparatively numerous, richer, and detailed psychosocial attributes and tactics than the lowest scoring participant. The composite pictures further showed remarkable similarities, which, again, highlighted the participants’ use of similar psychosocial attributes and tactics. Qualitative data trends particularly illustrated that deaf participants also used additional psychosocial attributes and tactics for circumventing deafness-related challenges.

Background: People are living longer with chronic life-limiting illnesses such as cancer. Much is expected of lay cancer carers with the shift of complex non-acute care to the community and the pressures this can place on family relationships. The lay caregiving role does not appeal to all, yet willingness to care is often expected by others including health professionals. Carers who feel reluctant but committed to the role may experience adverse consequences. Reluctance to care is under-investigated, particularly in the cancer context, and its indicators may include a poor carer-patient relationship, perceived lack of choice and lifestyle disruption. Existing theories of caregiving do not adequately explain reluctance to care, and the concept remains under-developed. The assumptions underpinning this study are that: some cancer carers are reluctant to care, some carers may be reluctant toward specific aspects of the caregiving role or at different times during the cancer trajectory, and some reluctant carers will not want to reveal or discuss their unwillingness. Aim: The aim of the study was to gain a clearer understanding of lay carers’ reluctance to care for patients with recurrent cancer. Methods: A mixed methods design was used. In Phase I, data provided by a consecutive sample of carers (N = 98) of cancer patients corresponding to the patients’ final year were analysed to explore the context in which reluctance to care might exist or develop, and focusing on differences by spousal relationship and by gender in anxiety and depression, awareness of the stage of cancer, perceived social support, and perceived burden. In Phase II, a purposive sample of carers of patients with recurrent cancer (N = 16) were interviewed in-depth, using open-ended questions to generate qualitative data regarding their perceptions and experiences of caregiving and reluctance to care. Complementary data were obtained from a purposive sample of health professionals who interact with cancer carers (N = 13). The interview transcripts were analysed qualitatively to identify patterns and themes which would provide insights into the dimensions of reluctance to care. Results: In Phase I, spouses perceived greater family support but caregiving had a greater negative impact on their daily activities and social interaction. Non-spouses were more anxious than spouses, but reported greater social support, and less negative impact on their finances, daily schedule and health. Female carers were more anxious and depressed than males, who reported less burden and greater social support. Awareness of the stage of cancer was positively but weakly correlated with anxiety and depression. In Phase II, reluctance to care was experienced by both spouses and non-spouses and was not gender specific. Carers and health professionals held diverging perceptions and expectations of the lay caregiving role. Caregiving was an obligatory but invisible role and for some carers it led to exhaustion due to a lack of role boundaries. Carers were faced with forced choices. The lay caregiving role seemed to come as a non-negotiable package of expectations which gave carers the autonomy to accept their role rather than the choice to refuse it. Contextual factors which seem conducive to reluctance were overshadowed by carers’ commitment to the role, which suggests that their preferences were a lower priority despite the personal cost. There was indirect evidence of reluctance in others: family members distanced themselves from the caregiving situation, and health professionals were distanced from carers by their patient-centredness. Conclusions: This study has identified three fundamental dimensions of reluctance to care: the invisibility of the caregiving role, its lack of boundaries and its forced choices. Caregiving is often a sacrificial rather than reciprocal role, but reluctance is seen as an abnormal rather than realistic response to abnormal role expectations. The findings were limited by the extent to which carers disclosed reluctance and the extent to which reluctant carers remained in the role. As a result, reluctance to care may have been underestimated. Measuring this latent and taboo topic is likely to remain a challenge as the concept of reluctance to care continues to evolve. This study has established the importance of ongoing work on a topic which cannot remain hidden as the need for lay cancer care continues to expand.

Introduction: Ankle injuries are among the most prevalent acute musculoskeletal injuries, and are a significant burden on any health system. The interaction of the physiotherapist with the patient and their mutual understanding of impairments, function and recovery are important to achieving a satisfactory return to work and leisure activities. To date, little attention has focused on this interaction. There is a need for further exploration of differences and associations between outcome questionnaires that investigate similar domains of pain and function, and whether scores from such outcome measures are related to the patient’s perception of function and recovery. Of further interest is whether there are relationships between impairment measures and perceived function, and how actual performance of tasks might influence the patients understanding of their capabilities. To provide a more complete picture of these relationships, a ‘mixed methods’ approach using qualitative research methods within a quantitative study was thought to be most appropriate. The overall aim of this thesis was to utilise this research approach to investigate patients’ perceptions of their recovery and elucidate factors important to both therapists and patients that ultimately might enhance their understanding of recovery from an ankle injury. Literature reviews: Three literature reviews were undertaken. Firstly a review of systematic reviews investigating ankle sprains identified a wide variety of management strategies. There was a lack of strong evidence to support any particular management strategy. Hence clinicians are likely to have difficulty setting appropriate rehabilitation plans. Secondly a critical review identified a number of different outcome questionnaires that were utilised to gauge recovery level; however, justification for their selection was often lacking. This review also identified that little emphasis was placed on understanding the patients’ perception of their injury and the rehabilitation process. A final critical review investigated impairment and performance measures and identified four specific areas that were focused upon by clinicians during the treatment of ankle sprains: joint position sense, postural control, strength and performance during function. However, only weak evidence was found for there being a deficit in joint position sense, postural control and strength in the injured limb following an ankle sprain, and inconclusive evidence of deficits in physical performance of tasks related to function. Methods: Forty participants with an acute sprained ankle were recruited along with their treating physiotherapist. The participants completed a Global questionnaire, the Lower Limb Task Questionnaire (LLTQ) and the Short Form -36 (SF-36) Questionnaire at the initial visit, at discharge and at a six week follow up visit where they also undertook impairment testing involving, joint position sense, postural control and strength along with a functional performance test and selected functional activities. Ten participants were purposefully selected to undertake semi-structured interviews. The treating physiotherapists completed global questionnaires at the initial visit and at time of discharge. An interpretive hermeneutic approach was undertaken to examine the participants’ perceptions. Results: There were equal numbers of males and female participants and the average age of participants was 30.5 years. The relationship between questionnaires for the domains of pain and function varied between low and high degrees of association. The global limitations scores between the participants and physiotherapists were similar at the initial visit, whereas on discharge the participants had a significantly lower score (p<0.05) compared to the physiotherapists. With respect to impairment testing, there was a significant difference (p<0.05) between the uninjured limb compared to the injured limb for the joint position sense and performance agility hop test. All other comparisons of impairments were not significant (p>0.05). There was no association between questionnaire scores and impairment measures (p>0.05). Additionally there were no significant associations between previous injury and questionnaire scores and impairment measures. Finally in relation to the performance of specific functional tests there was a significant difference (p<0.05) between the six week follow up LLTQ score and the score following actual performance of the test. The findings of the participants’ interviews identified three key concerns. Firstly, that participants have a limited understanding of questionnaires, and secondly, that there is a difference in understanding of ‘recovery’ between the therapist and the patient at time of discharge. Thirdly, there was dissociation between outcome measures and the patient’s perception of their own recovery. Conclusions: This study revealed a lack of understanding and effective communication concerning physiotherapy practice in relation to ankle sprains. It was apparent that questionnaires purporting to measure similar constructs are at times dissimilar in scores and are not related strongly. Care needs to be taken in selecting and interpreting outcome measures particularly in relation to questionnaires. It was also apparent that caution should be exercised when considering the influence of impairment measures upon function. Physiotherapists should be aware that patients may perceive a lack of confidence in their level of function at the time of discharge. As a result physiotherapists need to incorporate strategies to improve patient confidence in their management plan.

This thesis examines the role of local government elected members to progress urban sustainability, and the views of Māori leaders’ on governance and sustainability. It is set within a wider context of local government reform and changing expectations of governance and captures a point in time in the evolution of Pākehā and Māori governance structures in Aotearoa New Zealand. The thesis contributes to the paucity of scholarship in these fields. Local government has evolved from the early provincial legislatures, to acknowledge Te Tiriti o Waitangi and recognise the importance of sustainable development. The Local Government Act 2002 fundamentally changed the role and purpose of New Zealand local government. At the heart of both Te Tiriti o Waitangi and the LGA was the aspiration for community and Māori participation in local governance and progress towards sustainable development. The ‘three-house concept’ described in the Raukawa Trustees partnership-two cultures development model (Winiata 2005) and the Community Sector Taskforce (2006) model is reflected in the structure of this thesis. It provides for a Pākehā House, a Tikanga Māori House and a Treaty House – a conceptual space where Māori and Pākehā values and practices can come together in mutual respect. The Pākehā House of the thesis establishes a broader role for New Zealand elected members to promote urban sustainability by focusing on cross-sector collaboration and multi-level governance. While multi-level governing was found to be widespread across urban territorial authorities, an elected member focus on collaboration was notably absent. Aotearoa New Zealand’s urban local authorities had begun mainstreaming sustainable development practices. Environmental management and restoration activity was widespread. Initiatives progressing social and cultural well-being were gaining prominence. The Tikanga Māori House recognises that the LGA 2002 had failed to bring about transformation of Māori participation in local government. Where the Māori voice struggled to be heard, the Act’s discretionary provisions had tended to preserve the status quo. Two paths to the future are offered: firstly, constitutional change - a new system of local government that recognises the validity of tino rangatiratanga as an equal authority, which could be modeled on the working examples of Treaty-based governance presented in this thesis. Secondly, improvements to the current system of local government are recommended. They are: - Hui and whanaungatanga, as a path to consensus decision-making. - Iwi authorities be recognised as local authorities, to provide opportunities for urban Māori to participate in local government. - The status of iwi management plans be lifted, and they be mandatory in the way that a district plan is mandatory. - The mana whenua relationship be strengthened to increase the capacity of mana whenua to consult with tauiwi in their rohe, and exercise kaitiakitanga and manaakitanga. These improvements need to be based on an effective parallel model of Māori representation, or Māori wards and seats. The Treaty House presents a case for strengthening a partnerships approach to governance. The effective inclusion of both Pākehā and Māori communities alike is identified as a prerequisite for further progress towards urban sustainability in Aotearoa New Zealand.

This thesis examines the role of local government elected members to progress urban sustainability, and the views of Māori leaders’ on governance and sustainability. It is set within a wider context of local government reform and changing expectations of governance and captures a point in time in the evolution of Pākehā and Māori governance structures in Aotearoa New Zealand. The thesis contributes to the paucity of scholarship in these fields. Local government has evolved from the early provincial legislatures, to acknowledge Te Tiriti o Waitangi and recognise the importance of sustainable development. The Local Government Act 2002 fundamentally changed the role and purpose of New Zealand local government. At the heart of both Te Tiriti o Waitangi and the LGA was the aspiration for community and Māori participation in local governance and progress towards sustainable development. The ‘three-house concept’ described in the Raukawa Trustees partnership-two cultures development model (Winiata 2005) and the Community Sector Taskforce (2006) model is reflected in the structure of this thesis. It provides for a Pākehā House, a Tikanga Māori House and a Treaty House – a conceptual space where Māori and Pākehā values and practices can come together in mutual respect. The Pākehā House of the thesis establishes a broader role for New Zealand elected members to promote urban sustainability by focusing on cross-sector collaboration and multi-level governance. While multi-level governing was found to be widespread across urban territorial authorities, an elected member focus on collaboration was notably absent. Aotearoa New Zealand’s urban local authorities had begun mainstreaming sustainable development practices. Environmental management and restoration activity was widespread. Initiatives progressing social and cultural well-being were gaining prominence. The Tikanga Māori House recognises that the LGA 2002 had failed to bring about transformation of Māori participation in local government. Where the Māori voice struggled to be heard, the Act’s discretionary provisions had tended to preserve the status quo. Two paths to the future are offered: firstly, constitutional change - a new system of local government that recognises the validity of tino rangatiratanga as an equal authority, which could be modeled on the working examples of Treaty-based governance presented in this thesis. Secondly, improvements to the current system of local government are recommended. They are: - Hui and whanaungatanga, as a path to consensus decision-making. - Iwi authorities be recognised as local authorities, to provide opportunities for urban Māori to participate in local government. - The status of iwi management plans be lifted, and they be mandatory in the way that a district plan is mandatory. - The mana whenua relationship be strengthened to increase the capacity of mana whenua to consult with tauiwi in their rohe, and exercise kaitiakitanga and manaakitanga. These improvements need to be based on an effective parallel model of Māori representation, or Māori wards and seats. The Treaty House presents a case for strengthening a partnerships approach to governance. The effective inclusion of both Pākehā and Māori communities alike is identified as a prerequisite for further progress towards urban sustainability in Aotearoa New Zealand.

Master of Philosophy (Medicine) / Health care evaluation serves the purpose of monitoring the quality of health care provided by Health Care Providers (HCP), so that health care services can be provided most effectively and efficiently. Patient satisfaction studies are widely used to assess the quality of outpatient care. A client satisfaction study was conducted at an HIV health care facility in Sydney, Australia during 2007-2008. There were three objectives: 1.) To validate a questionnaire for future determination of client satisfaction in HIV health care facilities. 2.) To identify the levels of satisfaction of clients, and investigate any dissatisfaction and unmet needs towards HIV health care. 3.) To provide recommendations for improving client satisfaction levels in HIV health care. This research used a mixed method approach and consisted of two phases. The first phase was a quantitative survey conducted with 166 clients (both HIV positive and negative) at Albion Street Centre (ASC) using a newly-devised questionnaire. Clients were asked to answer demographic questions, rate their levels of satisfaction with each aspect and each HCP category, and provide suggestions for improvement. Quantitative statistical analysis was conducted to obtain a general view of client satisfaction levels. Dissatisfaction and unmet needs of clients were then investigated in-depth in the second phase of the research through qualitative face-to-face semi-structured interviews. Twenty-two clients (both HIV positive and negative) at ASC were interviewed individually and asked about their attitudes, perceptions, and experiences towards their HCP and the HIV health care services received. Thematic analysis was used to categorise and interpret the qualitative data. More than 90% of the clients were satisfied with most of the aspects covered in the survey, with a mean overall satisfaction score of 84 out of 100. Clients were most iii satisfied with the “technical quality” and “interpersonal manner” of the HCP, and were least satisfied with “waiting time” and “availability of HCP”. The HCP category with which the clients has the highest level of satisfaction was “nurses” (86%), followed by “psychologists” (84%), then “doctors” (83%). Clients who were HIV negative, had a full time job, visited ASC less frequently, or did not possess any type of Health Care Card were more satisfied with the services overall. No common dissatisfaction or unmet needs towards HIV health care service were identified. “Technical quality of HCP” and “the relationship with HCP” were the two most important determinants of client satisfaction, which outweighed the inconvenience contributed by the poor availability of HCP and the location of ASC. The maintenance of “confidentiality/privacy” was shown to be fundamental in HIV health care facilities. The multi-disciplinary nature of ASC increased the degree of convenience and satisfaction level among clients. Suggestions for improvement in client satisfaction levels include increasing the attractiveness of the physical environment and the variety of educational reading materials in the waiting area; introducing beverages, and encouraging clients to be involved in their treatment decisions. Health care administrative staff in particular are reminded not to neglect the importance of the availability of HCP, accessibility, and physical environment when establishing a new HIV health care facility. The mixed method approach (quantitative survey and qualitative interviews) proved beneficial. It increased the validity of the findings by assessing client satisfaction levels using more than one method. This enabled clarification of ambiguities noted in the initial survey through probes used in the interviews, and also allowed investigation of the determinants of client satisfaction through understanding their experiences in HIV health care. Future client satisfaction studies would benefit from using this approach.