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University of Florida Thesis Or Dissertation

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University of Florida Thesis Or Dissertation SHORT-TERM MEDICAL MISSIONS IN URBAN NICARAGUAN HEALTHCARE SYSTEMS: AN ETHNOGRAPHY OF PATIENT USE AND A SOCIAL NETWORK ANALYSIS OF INTEGRATION By JESSICA-JEAN CASLER A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2016 © 2016 Jessica-Jean Casler To all the family, friends, and mentors who have supported this journey – in Texas, Florida, and Nicaragua – you have made my heart bigger, my life richer, and my understanding of this world greater ACKNOWLEDGMENTS I have found that the hardest part of doing research is leaving pieces of your heart everywhere you go. I have been blessed by always managing to find the right people to guard those pieces. I must thank my families, the one in Texas that raised me, supported me and sent me out here. You have always welcomed me back home with wide and warm, open arms when I have needed rest, perspective, and a reminder of my roots. My family in Florida who helped me to find new depths of myself and my abilities - you too have nurtured me, pushed me, and helped me achieve what at times seemed impossible. My family in Nicaragua, there is so often a lack of words to describe what has transpired and grown between us. You gave me a home, but also the embrace and intimacy of family when I was so far away from my others. There was no long-drawn out negotiation of how close we could be or how much we would be willing to do for each other. It was an overwhelming reception despite the fact we shared no blood, had not yet shared tears or frustrations or even passions, the things that have made my families in the past. We shared our hearts, and let them do the work making up for the vast differences in our pasts and presents. It was the most close thing to unexplainable and unconditional love I have ever seen. These are the families I thank deeply and often. Throughout this process they have become intertwined and grown even stronger. Without any of them I would have not been able to pursue this dream or imagine the new ones that have come through this process. I know I will always continue the work of growing love by sharing the knowledge and stories others have so graciously shared with me. 4 Additionally, I would like to specifically thank Lance Gravlee, an incredible mentor, role model, and friend. He continually encouraged me in all phases of this project and without his genuine and overwhelming faith in me and our discipline, this journey would have not been nearly as enjoyable, productive, or memorable. I also want to thank Richard Kernaghan, a mentor, teacher, friend, and colleague I feel so fortunate to know. He helped open up areas of my writing and thinking that I had not previously imagined possible. He nurtures creativity and freedom among his students in ways that are not often found within academia. Chris McCarty, thank you so much for helping me always focus on the bigger picture. I have no idea how you do everything you do and remain one of the most present and thoughtful people I have had the pleasure of meeting at the University of Florida. And to Allyson Hall, I have been so grateful for your expertise and guidance. 5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 LIST OF TABLES ............................................................................................................ 9 LIST OF FIGURES ........................................................................................................ 10 LIST OF ABBREVIATIONS ........................................................................................... 11 CHAPTER ABSTRACT ................................................................................................................... 12 1 INTRODUCTION .................................................................................................... 14 Why Study STMMs ................................................................................................. 16 Specific Research Questions .................................................................................. 18 Research Setting .................................................................................................... 20 The History of Nicaragua’s Healthcare System ................................................ 20 Before the dictatorship ............................................................................... 21 The Somoza regime ................................................................................... 23 The revolution ............................................................................................ 25 The Contra war .......................................................................................... 26 Neoliberal reform in Nicaragua .................................................................. 27 Matagalpa, Nicaragua ...................................................................................... 31 Research Methods .................................................................................................. 34 Participant Observation .................................................................................... 34 Structured Interviews ........................................................................................ 38 Unstructured and Semi-structured Interviews ................................................... 39 Social Network Analysis ................................................................................... 39 Data Collection Challenges ..................................................................................... 40 Data Analysis .......................................................................................................... 43 Participant Observation and Interviews ............................................................ 43 Social Network Analysis ................................................................................... 44 Findings .................................................................................................................. 45 2 FROM FIELD SCHOOL TO FIELDWORK: INCORPORATING COMMUNITY- BASED PARTICIPATORY RESEARCH PRINCIPLES INTO DISSERTATION RESEARCH ............................................................................................................ 48 CBPR and Solo Research ...................................................................................... 48 Tallahassee, Florida: CBPR Field School (EFS) ..................................................... 49 Matagalpa, Nicaragua: Dissertation Research ........................................................ 51 CBPR Practices and Applied Research .................................................................. 52 Deriving Questions from the Community .......................................................... 53 Reciprocal Learning Spaces and Opportunities ............................................... 54 6 Usefulness of Data ........................................................................................... 55 Discussion of Challenges ........................................................................................ 56 Individual Challenges ....................................................................................... 57 Departmental Challenges ................................................................................. 57 Disciplinary Changes ........................................................................................ 58 3 SHORT-TERM MEDICAL MISSIONS IN NICARAGUA’S HEALTHCARE SYSTEM: A SOCIAL NETWORK ANALYSIS ......................................................... 60 Global STMMs ........................................................................................................ 60 Methods .................................................................................................................. 62 Network Data .................................................................................................... 63 Ethnographic Data ............................................................................................ 66 Network Diagramming ............................................................................................ 67 Social Network Measures ....................................................................................... 72 Results .................................................................................................................... 75 Limitations ........................................................................................................ 77 Discussion ........................................................................................................ 78 Conclusion ........................................................................................................ 83 Policy Recommendations ................................................................................. 85 4 HEALTH LANDSCAPES: BROADENING, CONTEXTUALIZING AND COMPLICATING HEALTH SPACE ........................................................................ 87 Vignette #1 Jessi .................................................................................................... 87 Health Landscapes ................................................................................................. 89 Vignette #2 Rosa ...................................................................................................
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