Qualitative Secondary Analysis Research Articles

Madrid immigrants' perceptions of urban food environments and their dietary behaviours.

Large cities are home to several groups of immigrants who undergo important changes in their environmental conditions and lifestyles that significantly modify their risk of chronic diseases. Quantitative evidence indicates that both their health and diet worsen over time; much less is known about the qualitative mechanisms that cause these changes. The aim of this article is to understand how immigrants in the city of Madrid perceive the relation between the urban food environment and dietary behaviour. Based on a Social Ecological Framework, we conducted a secondary qualitative analysis derived from data from 41 immigrant residents, collected in eight focus groups (FGs), conducted in two neighbourhoods in the city of Madrid. We identified the following main categories: 1) Transnational identity and dietary behaviour in the neighbourhood; 2) Transitions in dietary behaviour; and 3) Societal/structural factors determining dietary behaviour in the neighbourhood. The participants in the FGs mentioned that they try to maintain traditional dietary customs and perceive that the taste of their typical dishes is better than those of Spanish dishes. Contradictorily, some participants considered their traditional dietary patterns to be less healthy than Mediterranean ones (consuming olive oil, vegetables, fish). Some participants acknowledged having adapted to the latter voluntarily or through dietary negotiations with their children. Immigrant families with two working parents have difficulties cooking homemade food and resort to less healthy options, such as eating fast food or ready-made meals. Due to their low purchasing power, they buy both ethnic products and other products, as well as considering the prices and offers in supermarkets. Our study highlights several structural mechanisms connecting the physical and social urban food environment with dietary behaviours among immigrant residents of a large city.

The vagina problem: a step too far in parent–child sex communication with young children

ABSTRACT Parents describe a want for better sex education for their young children compared to their own myth and silence-led experiences while growing up. However, introducing the vagina has proved a challenging step too far for many parents. This study arose from a secondary qualitative data analysis of 20 focus groups with parents in Ireland about how they engaged in body and sexuality communication and socialisation practices with young children, aged 4 to 9 years old. Though parents often utilised euphemisms, the language applied to male bodies tended to be generic, while euphemisms for female bodies tended to be family-specific. The language used in talking about the female body evaded reference to the vagina and talking about its functions. Protecting the child from knowledge about the sexual body was aligned with maintaining innocence and delaying the child’s transition to adulthood. Parents demonstrated a commitment to stop using myths but still placed boundaries around their young children’s sex education, albeit boundaries that were being redefined. Perpetuating intergenerational taboos, placing boundaries on knowledge of the sexual body, impacts a child’s ability to fully integrate their body into their sense of self.

Comparison of Transportation Use Among Older and Younger Persons Experiencing Homelessness

Regardless of age, transportation determines access to necessary services and supports, including food, healthcare, shelter, and social connection for persons experiencing homelessness (PEH). This study compared experiences and perceptions of transportation among PEH aged <49 years old to PEH aged 50+ years. We conducted a secondary qualitative data analysis of semi-structured interviews with 18 PEH staying in emergency shelters in Salt Lake County, Utah. Using thematic analysis, we identified three points of comparison between older and younger PEH: 1) Modes of transportation used; 2) Reasons for using public transit; and 3) Perceptions of public transit. While there are some similarities across transportation modes used (e.g., public transit, dedicated homeless-services shuttle, walking), older PEH also reported using taxi services when it could be afforded or shared with others. In addition, older PEH more often discussed using public transit to get to healthcare appointments, while younger PEH reported needing transit to get to places of employment. Though both participant groups described the prohibitive costs of transit, OPEH recommended that to use transit most successfully there need to be places to sit and rest when walking, as well as more publicly available bathrooms and crosswalks for safety. This age-based comparison offers insight into ways to increase transportation equity and support PEH of all ages who similarly have unmet mobility needs.

Using an intersectional life course perspective to understand familial environment and its impact on sexuality development among Asian American sexual minority college students

There is a dearth of research understanding the sexual health of Asian American adolescents, and even more so for those who identify as sexual minorities (lesbian, gay, bisexual, queer, asexual, and other sexual orientations). This study is a secondary qualitative analysis focused on young adults’ recollections of their formal and informal sex education experiences in childhood and adolescence using a sub-sample of in-depth interviews from students who self-identified as both Asian and sexual minorities living in the USA (n = 9). Results were organised into three sections: (1) latent cultural factors (e.g. stigma surrounding sex, self-sufficiency, filial piety); (2) the downstream effects of latent cultural factors (e.g. sex-related discussions, rules disallowing dating, role of lateral family members); and (3) the impact of deficient familial sex-related discussions (e.g. Internet, resentment). Study findings underscore the links between identity concealment and relationship concealment that are unique to Asian sexual minority individuals. We suggest that interventions involving Asian American US youth and their families should be culturally informed and promote cross-generational sex-related discussion. Future research should further explore the role of chosen family and non-parental family members as a point of intervention as they can be helpful sources of informal sex education.

Persistent depression in pregnant refugee and migrant women living along the Thai-Myanmar Border: a secondary qualitative analysis.

Background Antepartum depression affects around 15% of pregnant women worldwide, and may negatively impact their infants’ physical, cognitive and social development, and confer a greater risk of emotional dysregulation in their children. Risk factors for antepartum depression disproportionately affect women from resource-sparse settings. In particular, pregnant refugee and migrant women face many barriers to diagnosis and care of mental health conditions, yet this group is under-represented in the literature. This study explores what refugee and migrant women living along the Thai-Myanmar border perceive as being contributory and protective factors to their antepartum depression, through secondary qualitative analysis of responses to clinical interviews for depression. Methods Previous research investigating perinatal depression in pregnant refugee and migrant women on the Thai-Myanmar border involved assessing 568 women for depression, using the Structured Clinical Interview for the diagnosis of DSM-IV Disorders (SCID). This study analyses a subsample of 32 women, diagnosed with persistent depression during the antepartum period. Thematic analysis of responses to the SCID and social and demographic surveys was undertaken to investigate factors which contribute towards, or protect against, persistent antepartum depression. Results Major themes which women described as contributing towards persistent antepartum depression were financial problems, interpersonal violence, substance misuse among partners, social problems and poor health. Factors women considered as protecting mental wellbeing included social support, accessible healthcare and distractions, highlighting the need for focus on these elements within refugee and migrant settings. Commonly expressed phrases in local Karen and Burmese languages were summarised. Conclusions Knowledge of factors affecting mental wellbeing in the study population and how these are phrased, may equip stakeholders to better support women in the study area. This study highlighted the limitations of contextually generic diagnostic tools, and recommends the development of tools better suited to marginalised and non-English speaking groups.

Gustavo Gutierrez and the Economic Realities of Africa: An African Theological Reflection

The purpose of this study is to find out how Gustavo Gutierrez used theological reflection and praxis to effectively impact the economic and social life of his home country, Peru and Latin America at large and to establish the lessons African theologians can imbibe from him. The methodology used was a secondary qualitative analysis of literature. In this regard the works of Gutierrez were reviewed. Key strands of African theological reflection were reviewed. The analysis of various perspectives was done to establish their respective impact on the socio-economic life of their people. The key findings are that African theologians were preoccupied with theological phenomenon at seminar and conference levels in coming up with various strands of African theological reflections. On the other hand, Gutierrez did his theological reflection from the point of view of the suffering poor thereby reflecting on what type of theology was needed to permanently change the narratives of the poor. The concluding lessons for African Theologians include a preferential option for the poor, social ministries in the Church should demonstrate incarnation, divine spirituality should entail a commitment to the poor and oppressed, and the establishment of concrete corrective actions. The importance of the Church Community in the divine enterprise for taking ample notice of the presence of the poor and working without fail to change their story. This is a scholarly contribution to harnessing the synergy among strands of African theology towards effective and practical advocacy and activities towards the eradication of abject poverty from Africa and the development of the continent. The paper contributes to the search for practical steps to reduce or end the abject poverty and poor development trajectory in Africa. Keywords: Theology, Economic, poverty, oppressed poor, incarnational ministry

Adapting telehealth to address health equity: Perspectives of primary care providers across the United States.

Telehealth has the potential to increase access to care for medically underserved patients. This qualitative study aimed to identify telecare practices used during the COVID-19 pandemic to meet the needs of patients experiencing homelessness, patients with disabilities, and patients with language preference other than English (LOE). We conducted a secondary qualitative data analysis of 47 clinician interviews at Federally Qualified Health Centers (FQHCs) around the country. Using thematic analysis, transcripts were coded by line-by-line by five qualitative researchers. A multidisciplinary team of telehealth experts, researchers and primary care clinicians reviewed memos and excerpts to generate major themes. We identified six main areas demonstrating how community providers developed strategies or practices to improve access to care for vulnerable patients: reaching patients experiencing homelessness, serving deaf and hard of hearing patients, improving access for patients with disabilities, serving patients with LOE, improving access for mental and behavioral health services, and educating patients about telehealth. During the pandemic, FQHCs developed innovative solutions to provide access to care for the unhoused, including using telehealth in shelters, vans, and distributing devices like mobile phones and tablets. Telehealth reduced transportation burdens for patients with disabilities and reduced no-show rates for mental health services by adapting group therapy via telehealth features (like break-out rooms) and increasing provider capacity. Our study identified strategies adopted by FQHCs to serve underserved populations during the COVID-19 pandemic. Our findings highlight the need for enduring strategies to improve health equity through telehealth..

“Recovery is about change, so you have to change everything”: Exploring the evolution of recovery capital among women in substance use disorder treatment

Recovery capital is a framework in addiction research aiming to understand substance use disorder recovery holistically by considering individuals' access to resources across the four domains of human, physical, social, and community capital. Each domain is opposed by negative capital. The underrepresentation of women's experiences in substance use research and the limited understanding of substance use treatment's effect on recovery capital limits our understanding of how treatment programs can support women in developing and maintaining recovery capital. This secondary qualitative analysis of data collected from the RENEW study explores the experiences of n = 19 women enrolled in substance use disorder treatment in Connecticut at baseline. Interviews occurred at two time points three months apart between February 2020 and April 2021 and discussed participants' experiences with treatment and the resources they have access to early in recovery. Thematic analysis identified four main themes related to recovery capital development. First, the direct effects of treatment, defined as clinical pathways to recovery capital, promoted resource growth primarily in the domains of human and physical capital. Second, non-clinical pathways, including indirect effects of treatment, facilitated maintenance of treatment-related improvements in human, social, and community capital. Third, interactions between domains promoted recovery capital resource growth across domains. Finally, goals and expectations for treatment motivated resource development across study time points. This study's findings have important implications for operationalization of the recovery capital framework and highlight the importance of more robust integration of non-clinical interventions to improve the experiences of women in treatment for substance use disorders.

Qualitative Description of the Exertional Symptoms of Participants with Persistent Symptoms of Lyme Disease during a Low Intensity Resistance Training Intervention

Introduction: Greater emphasis needs to be placed on approaches to improve the health-related quality of life of patients with persistent symptoms of Lyme disease (PSLD), but little information exists to inform an exercise professional’s expectations of their supervision of resistance training (RT) programs with PSLD patients. In order to build this knowledge base, a secondary qualitative analysis was performed to explore the RT exertional symptoms of PSLD patients that participated in a 4-week study investigating the feasibility of an RT intervention. Methods:  Comments regarding exertional symptoms that were recorded in a daily exercise log were the main source of data for this secondary analysis. A manifest content analysis was performed in order to identify recurrent themes of exertional symptoms experienced by this sample of PSLD patients during RT. Results: The reported findings revealed that strain, discomfort, crepitus, tightness, shaking, and control loss were the major themes of exertional symptoms recorded during the RT intervention. Conclusions: These results provide insights intended to inform the expectations of supervisors of exercise (personal trainers, physical therapists, exercise researchers, etc.) when directing RT programming with patients with PSLD.

Queering Cisgender LGB+ Women’s Sexual Health Scripts

ABSTRACT The invisibility of lesbian, gay, and bisexual (LGB+) women in sexual health research is of particular concern when it comes to understanding and supporting their sexual health practices. We conducted a qualitative secondary analysis of sexual health decision-making interviews among 22 LGB+ cisgender women who ranged in age from 20 to 26 (M = 23.1 years, SD = 1.8 years). Participants were mostly bisexual (n = 9), White (n = 13), and all reported at least some college education. Results showed that LGB+ women both reify and push against heteronormativity in their sexual partnerships. By queering definitions of “sex” beyond heterosexual intercourse, leaning into trust as a foundation of new sexual partnerships, and promoting accessible and realistic hygienic strategies for STI prevention, LGB+ women queer, or reimagine, new sexual scripts. These results highlight the need for relationship and sexual health scholars to direct focus toward the promotion of holistic sexual and relationship education and research which reflects LGB+ women’s various sexual desires, goals and needs. Understanding LGB+ women’s sexual scripts and health outcomes will ensure that this population continues to be validated and supported by clinicians, researchers, and educators.

Secondary Data Analysis: Using existing data to answer new questions

Secondary data analysis is a cost-effective, accessible, and efficient means of utilizing existing data to answer new research questions. The manuscript provides an overview of the secondary data analysis process, as well as benefits and limitations inherent in the research method. An exemplar of pediatric focused research using a publicly available dataset is presented to facilitate understanding of the process. Novice and experienced researchers benefit from exploring the quantitative and qualitative secondary data analysis options available.

Enhancing Logistics Distribution Efficiency for Indonesian Navy Warships in Operations Area

The Indonesian Navy faces challenges in maintaining the readiness of warships deployed in external operation areas due to inefficiencies in logistics distribution. Understanding current practices and identifying bottlenecks is crucial for devising strategies to enhance logistics efficiency. This study aims to investigate the current logistics distribution practices of the Indonesian Navy, identify primary bottlenecks and inefficiencies, explore opportunities for optimization, and propose strategies for increasing logistics distribution efficiency to support warships in external operation areas. Utilizing Creswell's qualitative research framework, this study analyzes existing secondary data from academic journals, reports, and governmental documents related to naval logistics in Indonesia. The study reveals the current logistics distribution practices and procedures of the Indonesian Navy, identifies primary bottlenecks and inefficiencies within the existing system, explores opportunities for optimization of logistics processes and infrastructure, and proposes a comprehensive strategy for increasing logistics distribution efficiency to support the readiness of Indonesian Navy warships in external operation areas. By leveraging qualitative research methods and secondary data analysis, this study provides valuable insights into enhancing logistics distribution efficiency for Indonesian Navy warships, contributing to improved readiness and operational effectiveness in external operation areas.

COMPARATIVE ANALYSIS OF JACQUES DERRIDA IN THE CONTEXT OF MARXISM

Deconstruction has challenged conventional notions of dichotomies, literary interpretations, and Marxist ideological hierarchy in support of a broader focus on justice and ethical behavior. This research aims to ascertain the areas of overlap and difference between deconstruction and Marxism, as well as Derrida's understanding of Marxism. The utilization of qualitative textual and secondary source analysis in this study has resulted in a thorough understanding of the philosopher's perspectives within their relevant context. The study's findings elucidate Derrida's viewpoints on Marxism in the context of current concerns and provide optimism for reassessing socialist ideas. This research aims to elucidate Derrida's perspectives on Marxism and the process of deconstruction.

Using implementation mapping to refine strategies to improve implementation of an evidence-based mobile market intervention: a study protocol.

The Veggie Van model is a mobile market model that is efficacious in increasing fruit and vegetable consumption for lower-income participants. The model is currently being evaluated for its effectiveness in a multi-state trial. Preliminary implementation data, collected through process measures surveys and implementation interviews, indicate that there are several barriers to implementation among partner organizations and implementation fidelity to the Veggie Van model was low. Consideration and planning for implementation ought to occur early and often throughout the research process order to ensure Veggie Van model effectiveness. This paper describes the step-by-step process for creating strategies to enhance implementation of Veggie Van model components. Implementation mapping is a systematic process to develop implementation strategies through engagement with key stakeholders. We conducted a series of interviews (n = 31 representatives) with partner organizations (n = 8) to identify facilitators and barriers to Veggie Van model implementation. We then applied interview findings to an Implementation Mapping process to develop theory and practice-driven strategies to be integrated into existing implementation tools and technical assistance. We identified implementation outcomes (e.g., staff implement the Veggie Van model component of nutrition education with fidelity) and performance objectives (e.g., offer nutrition education, in the form of food lessons and/or food demonstrations, at least bi-weekly) to achieve them. We conducted a secondary qualitative analysis of the findings from implementation interviews with partner organizations to identify behavioral determinants (e.g., attitudinal beliefs, social support) which were combined with the performance objectives to generate change objectives (e.g., view the Veggie Van model as advantageous to an organization and communities served). To achieve the change objectives, we developed implementation strategies that would be integrated into existing Veggie Van training resources including an online toolkit, webinars and trainings, an annual mobile market conference, and technical assistance. The development of theory and practice-driven implementation strategies will enable us to improve our implementation tools, thereby improving fidelity to the Veggie Van model among organizations and increasing the likelihood of its effectiveness. Detailing the design of a multifaceted implementation strategy using Implementation Mapping also provides a model to design similar strategies for other community-based interventions.

Going beyond compliance: A qualitative study of the practice of surgical safety checklist

BackgroundThe World Health Organization Surgical Safety Checklist (SSC) is a tool designed to enhance team communication and patient safety. When used properly, the SSC acts as a layer of defence against never events. In this study, we performed secondary qualitative analysis of operating theatres (OT) SSC observational notes to examine how the SSC was used after an intensive SSC re-implementation effort and drew on relevant theories to shed light on the observed patterns of behaviours. We aimed to go beyond assessing checklist compliance and to understand potential sociopsychological mechanisms of the variations in SSC practices. MethodsDirect observation notes of 109 surgical procedures across 13 surgical disciplines were made by two trained nurses in the OT of a large tertiary hospital in Singapore from February to April 2022, three months after SSC re-implementation. Only notes relevant to the use of SSC were extracted and analyzed using reflexive thematic analysis. Data were coded following an inductive process to identify themes or patterns of SSC practices. These patterns were subsequently interpreted against a relevant theory to appreciate the potential sociopsychological forces behind them. ResultsTwo broad types of SSC practices and their respective sub-themes were identified. Type 1 (vs. Type 2) SSC practices are characterized by patience and thoroughness (vs. hurriedness and omission) in carrying out the SSC process, dedication and attention (vs. delegation and distraction) to the SSC safety checks, and frequent (vs. absence of) safety voices during the conduct of SSC. These patterns were conceptualized as safety-seeking action vs. ritualistic action using Merton's social deviance theory. ConclusionRitualistic practice of the SSC can undermine surgical safety by creating conditions conducive to never events. To fully realize the SSC's potential as an essential tool for communication and safety, a concerted effort is needed to balance thoroughness with efficiency. Additionally, fostering a culture of collaboration and collegiality is crucial to reinforce and enhance the culture of surgical safety.

The use of metaphors by service users with diverse long-term conditions: a secondary qualitative data analysis.

Long-term conditions and accompanied co-morbidities now affect about a quarter of the UK population. Enabling patients and caregivers to communicate their experience of illness in their own words is vital to developing a shared understanding of the condition and its impact on patients' and caregivers' lives and in delivering person-centred care. Studies of patient language show how metaphors provide insight into the physical and emotional world of the patient, but such studies are often limited by their focus on a single illness. The authors of this study undertook a secondary qualitative data analysis of 25 interviews, comparing the metaphors used by patients and parents of patients with five longterm conditions. Analysis shows how similar metaphors can be used in empowering and disempowering ways as patients strive to accept illness in their daily lives and how metaphor use depends on the manifestation, diagnosis, and treatment of individual conditions. The study concludes with implications for how metaphorical expressions can be attended to by healthcare professionals as part of shared care planning.

"They must have seen it, you know." Body talk, extension talk, and action talk: A qualitative study on how palliative care patients and their significant others express experiencing these nonverbal cues.

Communication about life-threatening disease and palliative care is essential but often experienced as difficult by those concerned and has mainly been studied in terms of its verbal components. Despite the fundamentality of nonverbal communication, its dimensions in care, especially in the communication by patients and their significant others, has not been as extensively examined. Drawing on a secondary qualitative content analysis of data from 23 interviews-15 with patients in specialized palliative home care in Sweden and 8 with their significant others-this study aims at understanding and characterizing how patients verbally express experiences of conveying nonverbal cues about life-threatening disease and its consequences and how their significant others express perceiving these cues. Patients expressed experiences of nonverbal communication in the form of cues conveying meaning about their disease and its consequences, often beyond their control. Whether and how the patients reinforced these cues verbally, depended on individual needs, care for others, and evaluations of relationships. Significant others acknowledged the presence of nonverbal cues and tried to interpret their meaning. Both patients and significant others emphasized the importance of nonverbal cues and actively related to how cues in the form of bodily appearance, aids, objects and acts, serve communicative functions about disease and its consequences. These dimensions of nonverbal communication are characterized as: body talk, extension talk and action talk. This study contributes to an international knowledge base on the complexities of nonverbal communicative aspects in these dimensions and how it affects patients and significant others. Professionals should be aware that dimensions of care, such as prescribed aids, from the patients' perspective can be perceived as nonverbal cues that might "speak of" disease progression.

Identifying Stigmatizing Language Used by Israelis and Germans With a Mild Neurocognitive Disorder, Their Relatives, and Caregivers of People With Alzheimer's Disease.

The purpose of the study was to examine and compare the dementia-related discourse and language used by people with mild neurocognitive disorder (MND), their family members, and family caregivers of people with Alzheimer's disease in Israel and Germany. This secondary qualitative analysis included focus groups and semistructured interviews. Thematic analysis was used to reveal the main discourses and stigmatic language used regarding dementia and people with dementia. Israeli and German stakeholders. Forty-four Israeli and 44 German participants: 28 people with MND, 20 family members of people with MND, and 40 family caregivers of people with Alzheimer's disease. Two main discourses were identified: the tragedy and the biomedical discourse. The tragedy discourse included several subthemes: "Dementia as the worst-case scenario," "Nothing can be done about dementia," and "People with dementia are not human." The biomedical discourse stressed pathologic aspects of the condition. Similarities and differences were found between Israeli and German participants. The study indicates that, despite culture and language differences, the use of stigmatic discourse and stigmatizing language is common among people with close exposure to dementia in Israel and Germany. Efforts should be increased to develop a person-centered and dementia-friendly language.

RECOMMENDATIONS REGARDING THE DESIGN OF PAIN ASSESSMENT AND MANAGEMENT TOOL FOR OLDER ADULTS WITH HEART FAILURE

Abstract Nearly 80% of all patients with heart failure (HF) are older adults (≥65 years of age) who are at high risk for frequent hospitalizations. Older adults with HF may delay in responses to pain that could trigger the burden of HF symptoms such as dyspnea due to the increased cardiovascular workload and oxygen demands. However, there is a concern that healthcare providers may be poorly prepared to assess and manage pain when reported by specific populations. This qualitative secondary analysis examined the design recommendations of HF providers for a comprehensive home-based pain assessment and management tool for older adults with HF. The study used in-depth interviews with 20 healthcare providers specializing in HF across different states. Participants provided various recommendations, including a checklist of questions about the patient’s past experience with pain, their living environment, and any activities that trigger pain. While some participants preferred electronic tools, such as an mHealth app, for data collection and analysis, they acknowledged the limitations of using technology for older adults. The tool should be straightforward, easy to navigate, and involve patients in the design process to ensure their motivation and buy-in. The tool should also consider the caregiver’s input. In conclusion, this study highlights the importance of a comprehensive assessment of pain symptoms and daily activities to provide personalized care for older adults with HF. The design recommendations provided by healthcare providers can aid in the development of a unique home-based pain assessment and management tool for older adults with HF.

PATIENT-CLINICIAN RELATIONSHIPS IN HOME HEALTH CARE

Abstract Patient-clinician relationships are fundamental attributes of high-quality home health care (HHC); yet little is known about patient-clinician relationships in HHC (where 5 million Medicare beneficiaries receive care annually). The objective of the study was to describe perspectives of HHC patients and HHC clinicians about patient-clinician relationships in HHC. We conducted a secondary qualitative analysis of semi-structured interviews (n=34) from a completed qualitative study investigating perspectives of older adult HHC patients (or caregivers as proxy) and their HHC clinicians (17 pairs) on discharge preparedness in a large HHC organization in North-Carolina. A conceptual model of patient-clinician relationships guided content analysis of the interview data. HHC patients identified as White (65%) and black (35%). Most HHC patients reported female sex (53%) and average age was 83 years (range= 69-93). Clinicians were registered nurses and physical therapists. Across the patient-clinician pairs, HHC patients valued relationships with clinicians with shared commonalities and those who provided reciprocal informational exchange and respected their autonomy. HHC clinicians valued relationships in which they felt helpful and respected as a healthcare professional. Relational conflicts arose when there was discordance in expectations of care (e.g., type of HHC services provided). Conflicts also arose when organizational constraints, such as disruptive scheduling, limited HHC visit time, and when limited continuity of care prevented the formation of patient-clinician relationships. Relational conflicts and organizational constraints influence patient-clinician relationships in HHC. Multi-level interventions (targeting modifiable factors at the patient, clinician, and organizational levels) are needed to improve the patient-clinician relationships and the quality of HHC.