Situated Knowledge and Assumptions

Maxwell (2005) explained that traditionally a researcher's background, identity, and experiences were framed as biases that negatively affected the study’s findings. However, qualitative researchers have argued that one can not separate one’s self, nor

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one’s real world experiences, from the research process. According to Maxwell (2005), “any view from someone’s perspective is shaped by the social and theoretical lens of the observer” (p. 39). There is no objectivity. Maxwell posits that researchers must be able to identify the influence of experiential knowledge and assumptions about thought processes and analysis of data. Knowledge of this process helps readers understand how the personal experiences of the researcher can influence study results. After all, experiential knowledge is lived experience. It is a way of knowing that incorporates actual experiences from which researchers ascribe meaning—the ultimate goal of qualitative research (Berg, 2008).

Personal Experiences. It is not a coincidence that I come to this study about CHWs in a primary healthcare setting. I believe it is the universal order my life, to learn and grow personally and professionally from this experience. I am included among the one in four people, in the U.S., diagnosed with a chronic disease. I am a diabetic. Nearly twelve years ago my doctor prescribed for me two forms of insulin that I needed to take three times a day. He included instructions for a particular diet to assist in the management of my disease. Approximately two years later, I continued the struggle to lose weight and manage my blood sugar levels. In hindsight, my lack of progress was directly related to not having access to the necessary tools and information I needed to make better choices (i.e., healthier food, exercise, etc.). At a deeper level, I lacked self- awareness. Once there was self-awareness, I acknowledged and accepted responsibility for the micro (personal) level reasons why I was unhealthy.

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Now, I have realized that there were risk factors that influenced my overall health status, too. Those risk factors included my family heritage and medical history of diabetes, obesity, and high blood pressure. Likewise, race/ethnic disparities and the socioeconomic status in which I grew up resulted in limited access to healthier food choices and regular healthcare. On a broader level, factors such as the historical and sociopolitical contexts, policies, and practices I encountered while growing up in the 1960s played a role. Moreover, knowledge of health care was much more limited during that period.

Today, there is an increase in awareness of how family medical history, diet and exercise can prevent chronic diseases. Rogers (2013) contends that one should not assess or consider individuals solely based on their behaviors. One must examine the influence of factors beyond the control of the individual. This approach is the person-in- environment perspective which involves micro, mezzo, and macro factors that impact all our lives (Rogers, 2013).

Micro Level

The micro level is the individual’s characteristics, gender, race, age, medical history, and psychological and cognitive development, as well as SES and disability status (Rogers, 2013). According to the American Diabetes Association (2015), because I am an African-American woman, I am nearly two times more likely than people in other groups to develop diabetes.

Mezzo Level

The individual’s immediate cultural environment is the mezzo level. This level includes family members, friends, colleagues, cultural heritage, background, community,

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work environment, social institutions systems, and access to resources at the local level (Rogers, 2013). Growing up in the South, my cultural traditions, lifestyle, social activities, and professional environments all center around food. On any given day or holiday, I am confronted with many more opportunities to eat unhealthy food than to eat healthy food. I have found that making healthier food choices is more difficult when family; friends, co-workers, and others encourage and reinforce unhealthy eating. Still, unlike millions of people in the U.S., for most of my adult life, I have had access to healthcare. During my childhood, I did not go to a doctor for regular checkups, and I seldom recall going to a physician when I was sick. This may help explain why I have never felt comfortable with my doctors. I do not think I ever seriously managed my health positively until I finally connected with a physician, Dr. Carter, whom I now understand provided me with culturally responsive health care (Gay, 2010).

Dr. Carter spent time talking with and getting to know me. We not only discussed my medical history; we discussed all aspects of my background, as well as my personal, family, social, emotional, spiritual, educational, and professional life. I believed that Dr. Carter’s attention to detail and her genuine interest in me (culturally responsive approach) would lead to an improvement in my health status. She began by asking me to think about what I wanted for my life. She then asked me to envision the physical, mental, and spiritual health I would need to realize my goals. Using the information relevant to me and from my cultural background, Dr. Carter helped me identify and set realistic SMART (Specific, Measurable, Achievable, Realistic and Time-phased) goals. Within 30 days, I had lost ten pounds, and my blood sugar levels began to decline. I am no longer in need of insulin. A year after meeting Dr. Carter, I had lost nearly 100 pounds and increased my

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exercise regimen that lowered my A1C 2 levels. The lower A1C levels resulted in a change in my medication status from taking insulin three times per day to a pill, Metformin 100 mg., on an as-needed basis (Pro Re Nata). I may always have a diagnosis of diabetes; however, I have successfully managed my health. Furthermore, with Dr. Carter’s medical guidance, care, and concern, I will continue toward my goal of optimal health.

My healthcare plan includes remaining insulin-free. I now look forward to going to the doctor for my routine check-ups. I now feel empowered to seek primary health care providers who support and encourage me, and to ask and get answers to my questions about my wellbeing. Moreover, I see my physician as a collaborator working with me to ensure a holistic approach to my health.

Macro Level

The macro level consists of broader social factors that impact an individual’s life and health status (Rogers, 2013). Included here are governmental and systems’ policies and practices, educational policy, media, societal norms, economic conditions and opportunities (Kirk and Okazawa-Ray, 2010). I believe these macro-level factors can inhibit an individual’s health status because of the historical, social, and political progression of healthcare systems in the US. For example, traditionally, the U.S. health care systems have not empowered patients to manage their health (Funnell, 2000). Historically, healthcare policies and practices and knowledge about a patient’s health

2_{The A1C “reflects your average blood sugar level for the past two to three months.} Specifically, the A1C test measures what percentage of your hemoglobin — a protein in red blood cells that carries oxygen — is coated with sugar (glycated). The higher your A1C level, the poorer your blood sugar control and the higher your risk of diabetes complications” (Mayo Clinic, 2015, n. p.).

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belonged to the doctors and other medical staff (Funnell, 2000). Healthcare providers dictated what the patient was to do, and the patient played a passive recipient role. Healthcare experts insist a paradigm shift must occur for patients and healthcare providers to work as a team to ensure better health outcomes for patients (CDC, 2012). While I think making this shift in healthcare policies is essential, I also believe that in addition to teamwork, there are factors that influence health outcomes. I will discuss other factors below in more detail.

Educational and Professional Experiences. I am a first generation college graduate with bachelor and masters degrees in social work. As a social worker, I have been afforded the opportunity and privilege to work with many diverse individuals, families, groups, and communities in a variety of settings. These settings include a child welfare agency, a mental health hospital, a women’s prison, a residential substance abuse treatment program for women and their children, and several non-profit community- based service organizations. I have always worked with people from diverse cultural, racial and ethnic groups, which have helped shape and mold me to become the person I am today.

After thirty plus years of social work practice, I entered graduate school to pursue my doctorate. I wanted to learn methods and ways of thinking that would enable me to promote systemic change. I am interested in the type of change that allows people to live, work, and socialize in a world where everyone has respect, dignity, and opportunities for justice. I firmly believe that many of the people, whom I have worked with, were doing their best despite policies and practices that may have marginalized them. Given the complexities of the multilayered systems within our communities, I believe professionals,

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regardless of their disciplines, who are committed to social justice, require a broad spectrum of knowledge and practical skills to affect social justice. I argue that we cannot affect social change, such as healthcare reform, only at the individual level. Rather, change agents must be active advocates and adopt models and interventions to initiate systemic change at all levels: micro, mezzo, and macro.

I am currently a doctoral candidate in Educational Foundations and Inquiry (EDFI). I am gaining knowledge of the perspectives and methods of multidisciplinary approaches to affect and sustain social action and change. Through my scholarship in EDFI, I have significantly expanded my worldviews to include applying an interpretative, normative, and critical lens to my practice (Phillips, 2010). This study about CHWs provided me a unique opportunity to draw on the scholarship of education, social work, and healthcare, in addition to qualitative inquiry, the use of multiple theories, and various approaches to learning. In doing so I collaborated with practitioners, policy makers, educators, researchers and other allies to inform, teach, educate, create, and critique interventions and strategies that promote better health outcomes for diverse people, and communities.

I became interested in conducting research about CHWs through my role as an instructor at Midlands Technical College in South Carolina. I taught a six-week educational and training course for individuals seeking certification as a CHW. In my role as an instructor, I have gained insight into the educational and training needs of CHWs from multiple perspectives. I frequently discussed recommendations for the design of the state’s certification training program with students, employers, and other HeART initiative stakeholders. As an instructor and contributor in the development and

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design of the CHW curriculum, I administered the certification exam to students statewide.

The culmination of my educational, personal and professional experiences provides the technical knowledge needed to interpret and make meaning of the data gathered during this study (Maxwell, 2005). I believe my experiential knowledge will help strengthen and facilitate understanding of the cultural factors that exist with PHC providers and the diverse patients receiving CHW services. On a personal level, it is important to help inform healthcare and social service systems, administrators, providers, CHWs, and patients about ways to work collaboratively to promote better health outcomes in our communities.