Enhancing Quality of Life for People who are Blind or Low Vision Using Computing Technology

Thesis (Ph.D.)--University of Washington, 2016-08

The use of motivational interviews by nurses to promote health behaviors in adolescents: a scoping review protocol

Adolescents - defined as young people between 10 and 19 years of age1 - are, in general, a relatively healthy segment of the population.2 However, the developmental changes that take place during adolescence may affect their subsequent risk for diseases and for a variety of health-related behaviors. In fact, early onset of preventable health problems (e.g. obesity, malnutrition, STDs) and the engagement in health risk behaviors (e.g., sedentary life style, excessive alcohol consumption, unprotected sex) during adolescence, are likely to put them at greater risk for physical and mental health problems at a later stage in life. Moreover, health related problems and health risk behaviors may disrupt adolescents' physical and cognitive development and therefore may affect their ability to think and act in relation to decisions about their health in the future.1 In summary, health-related behaviors in adolescence, apart from their influence on the continuum of "health-disease", they also have the potential to influence future behaviors. In fact, several studies have shown that past behaviors are good predictors of future behaviors .3,4 Thus, promoting healthy practices during adolescence and taking measures to better protect young people from health risks are essential for the prevention of health problems in adulthood.5 According to the World Health Organization, the main problems affecting young people include mental health problems (such as behavioral disorders, eating disorders, suicide, anxiety or depression), the use of substances (illegal substances, alcohol and tobacco), interpersonal violence, nutrition (a proper nutrition consists of healthy eating habits and physical exercise), unintentional injuries (which are a leading cause of death and disability among young people, with road traffic injuries accounting for about 700 deaths per day), sexual and reproductive health (for example, risky sexual behaviors, early pregnancy and childbirth) and HIV (resulting from sexual transmission and drug injection).5,6 On the other hand, the number of children and youth with chronic health conditions has increased dramatically in the past four decades7 as larger numbers of chronically ill children survive beyond the age of 10.8 Despite the lack of data on adolescents' health making it difficult to determine the prevalence of chronic illnesses in this age group9, it is known that one in ten adolescents suffers from a chronic condition worldwide.10 In fact, national population based studies from Western countries show that 20-30% of teenagers have a chronic illness, defined as one that lasts longer than six months.8 The most prevalent chronic illness among adolescents is asthma and the one with the highest incidence is diabetes mellitus, particularly type II.9 Traditionally, healthcare professionals have been mainly investing in health education activities, through the transmission of knowledge with a view to creating habits, customs and behaviors, and promoting healthy lifestyles. However, empowering people does not only consist of giving them the right information11 , i.e. good information is not enough to cause people to make changes.12 The motivation or desire to change unhealthy behaviors and habits depends on many factors, namely intrinsic motivation, control over personal decisions, self-confidence and perception of effectiveness, personal ambivalence, and individualized assistance.12 Many professionals assume that supplying knowledge is sufficient for behavioral changes; however, even very good advice often fails to generate behavioral change. After all, people continue to engage in unhealthy behaviors despite clearly knowing what they should do and how to change. "What is lacking is the motivation to apply that knowledge".13, p.1233 In fact, behavioral change is a complex phenomenon with multiple determinants that also includes motivational variables. It is associated with ambivalent processes expressed in the dilemma between keeping the current status and moving on to new ways of acting. For example, telling adolescents that if they keep on engaging in a certain behavior, they are increasing the risk of developing a long-term condition such as cardiovascular disease, stroke or diabetes is rarely enough to trigger the desired behavioral change; people are more likely to change when they believe that the change is really effective and that they are able to implement it.12 Therefore, it is essential to provide specific training for "healthcare professionals to master motivational techniques, avoid confrontation with the users, and facilitate behavioral changes".14 In this context, motivating patients to make behavioral changes is also an important nursing task where change in lifestyle is a major element of patients' treatment and preventive interventions.15 One of the nurse's goals is to help improve a patient's health or help them to manage existing health conditions. Once nurses are in a position where they have to focus on accomplishing tasks and telling patients what needs to be accomplished16, the role of the nurse is expanding even more into the use of motivational strategies.17 MI is bringing nurses back to therapeutic communication and moving them closer to successful health promotion and disease management, by promoting behavior change and empowering their patients. As the nursing profession evolves, MI is seen as a challenge and the basis of nurse's interactions with individuals, families and communities.16, 17 In the same way, MI may be taken as an essential tool in the provision of nursing care to adolescents, being itself a workspace with possible therapeutic effects regarding problems, clarification of doubts, and development of skills.18 In fact, MI may be particularly applicable in work with adolescents because of their specific developmental stage. Adolescents attempt to establish their own autonomy and identity while struggling with social interactions and moral issues, which leads to ambivalence.19 Consistent with the developmental challenges during adolescence, "MI explicitly honors autonomy, people's right and irrevocable ability to decide about their own behavior"20 while allowing the person to explore possibilities for change of risky or maladaptive behaviours.19 MI can be defined as a directive, client-centred counselling style for eliciting behavior change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style of interpersonal relationship.21 It is a set of strategies and techniques widely used in clinical practice based on the transtheoretical model of change. The Stages of Change model describes five stages of readiness—precontemplation, contemplation, preparation, action, and maintenance—and provides a framework for understanding behavior change.22 The MI has been widely tested and applied in different areas, such as modification of addictive behaviors, interventions with offenders in the context of justice, eating disorders, promotion of therapeutic adherence among chronic patients, promotion of learning in school settings or intervention with adolescents at risk.18,23 In general, clinical practice has been adopting the perspective of motivation as something relatively immutable, i.e., the adolescent is either motivated for change/treatment and, in these conditions, the professional's role is to help him/her, or the adolescent is not motivated and then change/treatment is not feasible. Alternatively the theoretical model underlying the MI technique postulates that the individual's adherence to change/treatment depends on his/her motivation, which can change throughout the therapeutic intervention. As several studies found positive results for effects of MI24-26 and its use by health professionals is encouraged23,27 nurses may play an important role in patients' process of change. As nurses have a crucial role in clinical contexts, they can facilitate the process of ending risk behaviors and/or adopting positive health behaviors through some motivational techniques, namely with adolescents. A considerable number of systematic reviews about MI already exist pointing to some benefits of its use in the treatment of a broad range of behavioral problems and diseases.13,28,29 Some of the current reviews focus on examining the effectiveness of MI for adolescents with diverse health risks/problems 30-32. However, to date there are no reviews that present and assess the evidence for the use of nurse-led MI in adolescents. Therefore, we have little knowledge of what works for whom (which adolescent subpopulation) under what circumstances (in which setting, for what problem) in relation to motivational interviewing by nurses. There is a clear need for scoping or mapping the use of MI by nurses with adolescents to identify evidence gaps and to inform opportunities for future development in nursing practice. On the other hand, information regarding nurse-led implemented and evaluated interventions, techniques and/or strategies used, contexts of application and adolescents subpopulation groups is dispersed in the literature33-36 which impedes the formulation of precise questions about the effectiveness of those interventions conducted by nurses and therefore the realization of a systematic review. In other words, it is known that different kind of motivational interventions have been implemented in different contexts by nurses, however does not exist a map about all the motivational techniques and/or strategies used. Furthermore the literature does not clarify which is the role of nurses at cross professional motivational intervention implemented programs and finally the outcomes and evaluation of interventions are unclear. Thus, the practical implication of this mapping will be clarifying all these aspects. Without this clarification is not possible to proceed to the realization of a systematic review about the effectiveness of the use of motivational interviews by nurses to promote health behaviors in adolescents, in a particular context and/or health risk behavior; or regarding the effectiveness of certain technique and/or strategy of MI. Consequently, there are important questions about the nature of the evidence in this area that need to be answered before formulating a precise question of effectiveness. This scoping review aims to respond to these questions. An initial search of the JBI Database of Systematic Reviews & Implementation Reports, Cochrane Database of Systematic Reviews, , Database of promoting health effectiveness reviews (DoPHER), The Campbell Library, Medline and CINAHL, has revealed that currently there is no Scoping Review (published or in progress) on the subject. In this context, this scoping review will examine and map the published and unpublished research around the use of MI by nurses implemented and evaluated to promote health behaviors in adolescents; to establish its current extent, range and nature and identify its feasibility, outcomes and gaps in the evidence defining research priorities in this field. This scoping review will be informed by the JBI methodology37 that suggests a five stage methodological framework for conducting scoping reviews which includes: identifying the research question, searching for relevant studies, selecting studies, charting data, collating, summarizing and reporting the results.

"Natural Enemies" or Intentional Allies? Teachers' & Parents' Perspectives on Middle School Boys of Color

This study examined the perspectives and “shared knowledge” of parents and teachers of boys of color. The following overarching research question guided this study: “What do parents and teachers want each other to know about their middle school son or student of color regarding academics, engagement, and behavior?” Additionally, it explored the challenges and opportunities for shared knowledge and understanding of their (respective) son’s’ or students’ academics and engagement. The methodology was qualitative in nature and the intent in conducting this case study was to describe, interpret, and explain the “shared knowledge” between these stakeholders at a predominantly minority middle school. A sample of seven parents and seven teachers from one school in a mid-Atlantic state participated in interviews and focus groups. Results indicated that parents and teachers of boys of color viewed each other as “intentional allies.” Results further showed that parents and teachers were aware of the challenges faced by boys of color in and out of school. That awareness was reflected in strategies that both groups employed to support, prepare, and protect their son/students. Lastly, the study found that teachers received no formal training in building parent-teacher partnerships, but gathered experimental knowledge on how to build those relationships. These findings have implications for teacher education programs, schools, parents, and teachers.

Towards an Orthodox Marxian Reading of Subsumption(s) of Academic Labour

This paper deploys an orthodox Marxian reading of the concept of subsumption of labour under capital. It does so through a brief, critical overview of the components of the Marxian conceptual instrument of subsumption of labour under capital (formal, real, hybrid and ideal subsumption). Recapitulating Marx’s concept, it sheds some light on the consequences of such a reading as a way of understanding the current transformation of the global higher education sector into a capitalist production sector per se. The reconstruction is then considered here as an attempt to approximate the specifics of the subsumption of labour under capital within the higher education sector. Moreover, the paper aims at showing that a discussion of the university dominated by capital with reference to the functioning or constituting of markets does not provide real opportunities for the understanding and solution of such problems as precarization, exploitation or acceleration of academic work. Thus, it joins a wider stream of Marxist higher education research and could be seen as a conceptual contribution to a critique of the political economy of higher education.

Sensitivity and specificity of parallel or serial serological testing for detection of canine Leishmania infection

In Brazil, human and canine visceral leishmaniasis (CVL) caused by Leishmania infantum has undergone urbanisation since 1980, constituting a public health problem, and serological tests are tools of choice for identifying infected dogs. Until recently, the Brazilian zoonoses control program recommended enzyme-linked immunosorbent assays (ELISA) and indirect immunofluorescence assays (IFA) as the screening and confirmatory methods, respectively, for the detection of canine infection. The purpose of this study was to estimate the accuracy of ELISA and IFA in parallel or serial combinations. The reference standard comprised the results of direct visualisation of parasites in histological sections, immunohistochemical test, or isolation of the parasite in culture. Samples from 98 cases and 1,327 noncases were included. Individually, both tests presented sensitivity of 91.8% and 90.8%, and specificity of 83.4 and 53.4%, for the ELISA and IFA, respectively. When tests were used in parallel combination, sensitivity attained 99.2%, while specificity dropped to 44.8%. When used in serial combination (ELISA followed by IFA), decreased sensitivity (83.3%) and increased specificity (92.5%) were observed. Serial testing approach improved specificity with moderate loss in sensitivity. This strategy could partially fulfill the needs of public health and dog owners for a more accurate diagnosis of CVL.

‘You, my body, and my mind, one of these will go’: Madness as Disguise in Samuel Beckett's Murphy and Endgame

ithin the wide topic of disguise in literature, we could signal a subcurrent which can be found in a number of literary texts: the idea of madness as a disguise, i.e. the creation or invention of a ‘false self’ as a mask which is presented to the world and which conceals the real self. In The Divided Self (1960), R. D. Laing deals with the “personality, false self, mask, front or persona that (...) [schizophrenic] wear” (73). Using as a basis Laing’s theories on schizophrenia and the creation of a false-self system, we will analyze two works by Samuel Beckett: Murphy and Endgame, where we find the uses of madness as disguise in a series of ways: through the usage of ‘disguised’ language (what we could refer to as schizophrenese) which acts as a mask for real meaning; through odd ‘schizophrenic’ behaviour on the part of the characters (which screens real intentions), and, mainly, through the creation of a ‘false self’ which acts as a disguise and barrier between the inner self and the real world. These two works by Samuel Beckett, where real intentions and meanings are continuously concealed and disguised in a desperate attempt to preserve the inner self, lend themselves to an analysis of madness as disguise, precisely the one we attempt to carry out in our paper.

Turning conflict into coexistence: cross-cutting ties and institutions in the agro-pastoral borderlands of Lake Naivasha basin, Kenya

The Maasai/Kikuyu agro-pastoral borderlands of Maiella and Enoosupukia, located in the hinterlands of Lake Naivasha’s agro-industrial hub, are particularly notorious in the history of ethnicised violence in the Kenya’s Rift Valley. In October 1993, an organised assault perpetrated by hundreds of Maasai vigilantes, with the assistance of game wardens and administration police, killed more than 20 farmers of Kikuyu descent. Consequently, thousands of migrant farmers were violently evicted from Enoosupukia at the instigation of leading local politicians. Nowadays, however, intercommunity relations are surprisingly peaceful and the cooperative use of natural resources is the rule rather than the exception. There seems to be a form of reorganization. Violence seems to be contained and the local economy has since recovered. This does not mean that there is no conflict, but people seem to have the facility to solve them peacefully. How did formerly violent conflicts develop into peaceful relations? How did competition turn into cooperation, facilitating changing land use? This dissertation explores the value of cross-cutting ties and local institutions in peaceful relationships and the non-violent resolution of conflicts across previously violently contested community boundaries. It mainly relies on ethnographic data collected between 2014 and 2015. The discussion therefore builds on several theoretical approaches in anthropology and the social sciences – that is, violent conflicts, cross-cutting ties and conflicting loyalties, joking relationships, peace and nonviolence, and institutions, in order to understand shared spaces that are experiencing fairly rapid social and economic changes, and characterised by conflict and coexistence. In the researched communities, cross-cutting ties and the split allegiances associated with them result from intermarriages, land transactions, trade, and friendship. By institutions, I refer to local peace committees, an attempt to standardise an aspect of customary law, and Nyumba Kumi, a strategy of anchoring community policing at the household level. In 2010, the state “implanted” these grassroots-level institutions and conferred on them the rights to handle specific conflicts and to prevent crime. I argue that the studied groups utilise diverse networks of relationships as adaptive responses to landlessness, poverty, and socio-political dynamics at the local level. Material and non-material exchanges and transfers accompany these social and economic ties and networks. In addition to being instrumental in nurturing a cohesive social fabric, I argue that such alliances could be thought of as strategies of appropriation of resources in the frontiers – areas that are considered to have immense agricultural potential and to be conducive to economic enterprise. Consequently, these areas are continuously changed and shaped through immigration, population growth, and agricultural intensification. However, cross-cutting ties and intergroup alliances may not necessarily prevent the occurrence or escalation of conflicts. Nevertheless, disputes and conflicts, which form part of the social order in the studied area, create the opportunities for locally contextualised systems of peace and non-violence that inculcate the values of cooperation, coexistence, and restraint from violence. Although the neo-traditional institutions (local peace committees and Nyumba Kumi) face massive complexities and lack the capacity to handle serious conflicts, their application of informal constraints in dispute resolution provides room for some optimism. Notably, the formation of ties and alliances between the studied groups, and the use of local norms and values to resolve disputes, are not new phenomena – they are reminiscent of historical patterns. Their persistence, particularly in the context of Kenya, indicates a form of historical continuity, which remains rather “undisturbed” despite the prevalence of ethnicised political economies. Indeed, the formation of alliances, which are driven by mutual pursuit of commodities (livestock, rental land, and agricultural produce), markets, and diversification, tends to override other identities. While the major thrust of social science literature in East Africa has focused on the search for root causes of violence, very little has been said about the conditions and practices of cooperation and non-violent conflict resolution. In addition, situations where prior violence turned into peaceful interaction have attracted little attention, though the analysis of such transitional phases holds the promise of contributing to applicable knowledge on conflict resolution. This study is part of a larger multidisciplinary project, “Resilience in East African Landscapes” (REAL), which is a Marie Curie Actions Innovative Training Networks (ITN) project. The principal focus of this multidisciplinary project is to study past, present, and future thresholds and sustainable trajectories in human-landscape interactions in East Africa over the last millennia. While other individual projects focus on long-term ecosystem dynamics and societal interactions, my project examines human-landscape interactions in the present and the very recent past (i.e. the period in which events and processes were witnessed or can still be recalled by today’s population). The transition from conflict to coexistence and from competition to cooperative use of previously violently contested land resources is understood here as enhancing adaptation in the face of social-political, economic, environmental, and climatic changes. This dissertation is therefore a contribution to new modes of resilience in human-landscape interactions after a collapse situation.