A qualitative study of behavioral and social drivers of COVID-19 vaccine confidence and uptake among unvaccinated Americans in the US April-May 2021.

INTRODUCTION: Around one-third of Americans reported they were unwilling to get a COVID-19 vaccine in April 2021. This focus group study aimed to provide insights on the factors contributing to unvaccinated adults' hesitancy or refusal to get vaccinated with COVID-19 vaccines. METHOD: Ipsos recruited 59 unvaccinated US adults who were vaccine hesitant (i.e., conflicted about or opposed to receiving a COVID-19 vaccination) using the Ipsos KnowledgePanel. Trained facilitators led a total of 10 focus groups via video-conference in March and April 2021. Two coders manually coded the data from each group using a coding frame based on the focus group discussion guide. The coding team collaborated in analyzing the data for key themes. RESULTS: Data analysis of transcripts from the focus groups illuminated four main themes associated with COVID-19 vaccine hesitancy: lack of trust in experts and institutions; concern about the safety of COVID-19 vaccines; resistance towards prescriptive guidance and restrictions; and, despite personal reluctance or unwillingness to get vaccinated, acceptance of others getting vaccinated. DISCUSSION: Vaccine confidence communication strategies should address individual concerns, describe the benefits of COVID-19 vaccination, and highlight evolving science using factural and neutral presentations of information to foster trust.

Patient Experience in Obstetrics in a Military Patient Satisfaction Survey: Findings and Recommendations for Improvement.

INTRODUCTION: This study examines the care experience of obstetric patients within the Military Health System and compares them to those of medical and surgical care patients. Specifically, the study seeks to (1) examine how obstetric inpatient experience ratings differ from medical and surgical inpatient experience ratings, (2) understand specific aspects of care that drive overall experience ratings within this population, (3) test whether adherence to nursing practices such as hourly rounding and nurse leader visits affect experience ratings, and (4) describe ways that patient experience information can be presented to healthcare providers to improve performance. MATERIALS AND METHODS: Data for this study include Military Health System patient experience survey data (based on the Hospital Consumer Assessment of Healthcare Providers and Systems) collected from 2011 through 2019. Analysis includes data collected from 338,124 patients aged 18 years and older. Our analysis involved z-test comparisons of patient experience measure scores, trend analysis, logistic regression-based driver analysis, and correlations. RESULTS: Obstetric ratings are generally lower than those of medical and surgical patients; however, they have been improving at a slightly faster rate year over year. Effective nurse communications with patients are a particularly strong driver for improving their overall care experiences, and practices like hourly nurse rounding, nurse leader visits, and nurse-patient shift change conversations are positively correlated with obstetric patient experience ratings. CONCLUSIONS: This study contextualizes how obstetric inpatient experience ratings differ from those of medical and surgical care patients. Healthcare administrators and policymakers should be aware that obstetric patients may have unique needs and expectations that lead to patient experience ratings differing from those of medical and surgical patients. Effective nurse-patient communications, hourly rounding, nurse leader visits, and nurse-patient shift change conversations could be strategies used to improve obstetric experience ratings.

"To Conserve Fighting Strength": The Role of Military Culture in the Delivery of Care.

INTRODUCTION: There are ongoing discussions about reorganizing the delivery of health care within the US Armed Forces. The military cultural context of care has beneficial qualities for patients with orthopedic and extremity trauma acquired during deployments to conflict zones. METHODS: The study included 35 participants with lower limb amputations who had been discharged from the Amputee Patient Care Program ≥ 12 months prior to the study. Participants were interviewed using a lightly structured schedule designed to elicit accounts of community integration, which attended to reports of belongingness supported by accounts of social engagement in work, school, family, and social events. Interviews were analyzed using a modified content analysis approach. RESULTS: Participants generally described their postcare lives as "successful" that had been built on "good outcomes." For most former patients, remembering the social intensity of their rehabilitation program was an important element in their narratives of recovery. Weekly amputee clinics worked to alleviate stress and anxiety in participants' minds around the complexities of their injuries and care. CONCLUSIONS: Participants reported that features of their care were particularly valuable to their recovery and their current assessment of their injury related health. These features are present, in part because of the military cultural context that is part of the framework of care delivery.

Social relationships in rehabilitation and their impact on positive outcomes among amputees with lower limb loss at Walter Reed National Military Medical Center.

OBJECTIVE: To explore how the social context of the clinic influenced the way former patients with lower limb loss in the Military Advanced Training Center at Walter Reed National Military Medical Center evaluated their outcomes. DESIGN: Cross-sectional phenomenological-based interviews and observations. PATIENTS: Twenty individuals with lower limb amputation were recruited from a multidisciplinary military treatment programme for patients with lower-extremity traumatic limb-loss injured in Afghanistan or Iraq. METHODS: Lightly structured interviews were conducted either in person or over the telephone with former patients and clinical care-providers. Where possible, observation was conducted in conjunction with the interviews. The research team used content analysis of the data, consistent with ethnographic methods. RESULTS: Analysis of the therapeutic effect of social relationships developed in the clinical rehabilitation programme identified 3 areas of significance: enduring relationships with key care-providers, access to treatment team by patients, and peer support among patients. CONCLUSION: The social component of service delivery influences patients' outcomes from clinical care. These results could be translated across healthcare settings to improve patient outcomes.

The Center for Rehabilitation Sciences Research: Advancing the Rehabilitative Care for Service Members With Complex Trauma.

The Center for Rehabilitation Sciences Research (CRSR) was established to advance the rehabilitative care for service members with combat-related injuries, particularly those with orthopedic, cognitive, and neurological complications. The center supports comprehensive research projects to optimize treatment strategies and promote the successful return to duty and community reintegration of injured service members. The center also provides a unique platform for fostering innovative research and incorporating clinical/technical advances in the rehabilitative care for service members. CRSR is composed of four research focus areas: (1) identifying barriers to successful rehabilitation and reintegration, (2) improving pain management strategies to promote full participation in rehabilitation programs, (3) applying novel technologies to advance rehabilitation methods and enhance outcome assessments, and (4) transferring new technology to improve functional capacity, independence, and quality of life. Each of these research focus areas works synergistically to influence the quality of life for injured service members. The purpose of this overview is to highlight the clinical research efforts of CRSR, namely how this organization engages a broad group of interdisciplinary investigators from medicine, biology, engineering, anthropology, and physiology to help solve clinically relevant problems for our service members, veterans, and their families.

Long-term community reintegration: concepts, outcomes and dilemmas in the case of a military service member with a spinal cord injury.

PURPOSE: Despite growing knowledge about medical and functional recovery in clinical settings, the long-term issue of community reintegration with a spinal cord injury (SCI) in the military context remains virtually unexamined. Thus, the U.S. Department of Defense created the SCI Qualitative Research Program to advance knowledge about service members' reintegration into civilian life. The purpose of this paper is to better characterize the long-term outcomes related to the community participation experienced and desired vis-à-vis a case study of a military veteran who suffered a service-related traumatic SCI. METHODS: An in-depth anthropological interview was used with Jake, a 28-year old marine with a service-related C5/C6 SCI. Data were analyzed using content analysis. FINDINGS: Three significant themes were identified: opportunities for better engaging socially meaningful others may not be adequately included in so-called "client-centered" interventions; how management of the social self in inter-personal interactions and public spaces is critical to gaining broader societal acceptance; and how meaningful age normative relationships and activities are essential to establish lasting inclusive social connections. CONCLUSIONS: Jake's case challenges existing models of rehabilitation predominantly focused on physical capacity building. Study findings point to the need for rehabilitation to invest more resources in efforts to address the existential and social elements of long-term social reintegration. Implications for Rehabilitation Both the veteran with SCI and their meaningful support network face challenges socially reintegrating after injury and rehabilitation. Empowering clients to envision future possibilities in terms of family, intimate relationships, and meaningful work are important to successful long-term social reintegration. Addressing the existential desires and social capacities of the individual may be as important as addressing physical functioning skills after SCI.

Introduction to the special focus section.

The three articles presented in this special section of Medical Anthropology Quarterly are devoted to the ways that military servicemembers' bodies are figured, deployed, symbolized, and represented. These articles illustrate two issues that confront the members of many contemporary militaries exemplified here by examples from the United States and Turkey (Ben Ari 2001; Bickford 2011; Pengelly and Irwin 2010; Weiss 1998). The first is that they are embedded in a set of ethical relations with the state that deploys them to conflicts. Military service confers a level of prestige and status, but it also entangles those who serve in complex social dilemmas. They are refigured as celebrated heroes in their communities but may also, as illustrated in Aciksoz's and Wool and Messinger's articles (this issue), find themselves dependent on their families and loved ones, as well as on military and state institutions. Servicemembers are also placed in new and complex relationships with their own bodies, and they come to experience vulnerability, mortality, and morality in novel and distinct ways.

Labors of love: the transformation of care in the Non-Medical Attendant program at Walter Reed Army Medical Center.

In this paper, we explore the Non-Medical Attendant program at Walter Reed Army Medical Center in Washington, DC, which subsidizes the presence of war-injured soldiers' family members as they live for months or even years at Walter Reed during treatment and rehabilitation. We elaborate the ambiguities of the program and draw on ethnographic research to demonstrate how the program's vagaries combine with the context of an overburdened military medical system and the more familiar strains of family caregiving to place family members in a gray zone of care where the line between labors of love and institutionally compensated work is blurred.

Cooperation and contention in psychiatric work.

This article discusses the social organization of psychiatric work in the psychiatric emergency department of a public general hospital located in New York City, based on ethnographic research conducted from 1999 to 2001. Case studies of the care of two patients with ambiguous symptoms are discussed. The analysis applies the ''differences approach'' developed by Mol and colleagues which focuses on the way different professions provide divergent explanations and ontologies for symptoms and illness. The cases illustrate the ways in which social structural constraints are compelling psychiatry to become a multidisciplinary specialty.

Getting past the accident: explosive devices, limb loss, and refashioning a life in a military medical center.

I describe the refashioning of a sense of self and identity of a junior officer in the U.S. Army who was injured in Iraq. Ethnographic data for this article were collected between July 2006 and January 2008. The setting for this article is the U.S. Armed Forces Amputee Patient Care Program at Walter Reed Army Medical Center. Two models of rehabilitation are contrasted in the rehabilitation program. The first focuses on the refashioning of identity through a sports model of rehabilitation emphasizing physical functioning. The second approaches rehabilitation by emphasizing individual interests and the concern of a person who has a future life to develop. I conclude by arguing that understanding the process of rehabilitation from traumatic injury would benefit from a perspective that melds multiple dimensions, taking into account both the physical body and the social world that patients have inhabited and will inhabit.

Rehabilitating time: multiple temporalities among military clinicians and patients.

In this article I explore the different orientations to time experienced by clinicians and patients in the US Armed Forces Amputee Patient Care Program at Walter Reed Army Medical Center in Washington DC. In structuring, describing, and working with patients, clinicians rely on a rehabilitative program that is embedded in a narrative notion of time. This approach seeks to embed the grievous wounds patients have sustained along a trajectory of injured to well. Patients are often eager to adopt this approach to their injury but in many cases find that the linear flow of time, upon which this clinical approach relies, is not matched by their experience. Instead the past, the present, and the future can flow together so that patients are simultaneously experiencing these three time orientations. This can create the potential for misunderstanding and conflict between clinicians over adherence and the meaning of a good rehabilitative outcome.

Incorporating the prosthetic: traumatic, limb-loss, rehabilitation and refigured military bodies.

In this article, I look at the role that context of injury plays in the rehabilitation of military patients who sustained a limb amputation as a result of blast injury trauma in Afghanistan and Iraq. This article contrasts the technologically driven model of rehabilitation produced by the US Armed Forces Amputee Patient Care Program at Walter Reed Army Medical Center with a person centered approach building on work in medical anthropology. In this article, two case studies are contrasted illustrating the reasons behind the rejection of an upper extremity prosthetic device in one example and the acceptance of one in another. I argue that even in light of the incredible advances in medical technique and prosthetic technology, a body and functionality focussed rehabilitation must also pay attention to the subjective experiences of individual patients in terms of their present and their past.

Representations of the patient: conflicts of expertise in a psychiatric emergency department.

Representations are the socially and textually produced patients as presented in clinical discussion and the clinical chart. An understudied aspect of representations in medicine is the way in which they are used to highlight contests of expertise and authority between clinicians, which have consequences over control of critical hospital resources. The author uses ethnographic research in a public urban hospital psychiatry department in New York City to examine the rounds meetings of a psychiatric emergency room, exploring the way in which representatives of a variety of occupational groups portray patients as they present and debate alternative diagnoses. He uses narratives of rounds meetings to illustrate the interactions, debates, and work of psychiatric and nonpsychiatric clinicians as they struggle to diagnose and develop treatment plans for patients. The enhanced authority of nonpsychiatrist clinicians that emerges from successful contests of representations illustrates a possible future for psychiatry as a multidisciplinary medical specialty.

"That's not his only problem..." clinical teamwork in a psychiatric emergency room.

This article is a qualitative study of the social organization of clinical work in a psychiatric emergency room. The research involved observation of emergency room practices and interviews with the clinical staff members. Due to responsibility of ensuring confidentiality, audio taping was not possible. Observations and interviews were recorded by hand, and thus, except in brief instances, I describe talk rather than reproduce it verbatim. Psychiatry, I argue, should not be explored as a singular profession but as the team practice of a team of occupational groups. These groups are often seen as subordinate to psychiatric physicians, but as this paper will demonstrate these groups are often able to call upon their specific claims to expert knowledge to assume clinical authority over a patient's diagnosis and treatment. The successful pursuit of such a claim puts these clinical occupational groups in a position to challenge psychiatrists over crucial hospital resources such as beds. These groups' claim to authority emerges from two sources. The first is their specific histories and their clinical knowledge systems that initially developed independently of cosmopolitan medicine. The second is the political economic environment of urban hospital psychiatric departments which largely treat patients with opaque symptoms of unclear origin that defy easy psychiatric classification.