Medicine and Health Sciences Commons^™

Nurse-Led Brief Intervention For Enhancing Safe Sex Practice Among Emerging Adults In Hong Kong Using Instant Messaging: Feasibility Study, Sharon Hoi Lam Pak, Man Ping Wang, Anne M. Teitelman, Janet Yuen Ha Wong, Daniel Yee Tak Fong, Edmond Pui Hang Choi

College of Nursing Faculty Papers & Presentations

BACKGROUND: The incidence of sexually transmitted infections has been increasing throughout the world. Additionally, substantial changes in emerging adults' attitudes toward sex and the popularization of premarital sex could further affect the diagnosis and treatment of sexually transmitted infections. With the high acceptability and effectiveness of instant messaging (IM) interventions for health promotion, there is potential for such interventions to improve condom use knowledge and promote safer sex practice.

OBJECTIVE: The study evaluates the feasibility of a nurse-led IM intervention to promote safer sex practices in emerging adults.

METHODS: A 30-minute adaptive IM intervention and a 5-day booster dose of …

A Conceptual Analysis Of Sbirt Implementation Alongside The Continuum Of Prep Awareness: Domains Of Fit And Feasibility., Lesley M. Harris, Kerr C. Jelani, Blake D. Skidmore, Smita Ghare, Andrea Reyes-Vega, Vania Remenik-Zarauz, Harideep Samanapally, Rana U. Anwar, Rishikesh Rijal, Kendall Bryant, Martin T. Hall, Shirish Barve

Faculty Scholarship

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a supplementary intervention that can be incorporated into the Pre-Exposure Prophylaxis (PrEP) Care Continuum, complementing initiatives and endeavors focused on Human Immunodeficiency Virus (HIV) prevention in clinical care and community-based work. Referencing the Transtheoretical Model of Change and the PrEP Awareness Continuum, this conceptual analysis highlights how SBIRT amplifies ongoing HIV prevention initiatives and presents a distinct chance to address identified gaps. SBIRT's mechanisms show promise of fit and feasibility through (a) implementing universal Screening (S), (b) administering a Brief Intervention (BI) grounded in motivational interviewing aimed at assisting individuals in …

Exploring Opportunities To Expand And Improve Prep Uptake In Vulnerable Us Communities., Pedro B. Carneiro

Dissertations and Theses

The implementation of preexposure prophylaxis (PrEP) in the United States has fallen short of meeting both 2020 and projected 2030 milestones, with less than one-third of those who would benefit most from PrEP choosing to initiate it. High discontinuation rates and persistently elevated HIV incidence underscore the need for improvement. However, opportunities exist to enhance PrEP uptake, supported by a growing pipeline of PrEP innovations. To achieve this, effective implementation of available tools to combat HIV and the inclusion of all communities as stakeholders are essential. One such tool is event-driven (ED) PrEP, also known as PrEP 2-1-1, which is …

Factors Influencing The Use Of Multiple Hiv Prevention Services Among Transport Workers In A City In Southwestern Uganda, Benjamin Betunga, Phionah Atuhaire, Catherine Nakasiita, Christa Kanyamuneza, Proscovia Namiiro, Joseph Tugume, Matovu Hairat, Ahmed Sarki, Benedicto Mugabi, Birungi Lilian, Richard Mugisha Richard Mugisha, Edward Kumakech, John Baptist Asiimwe

School of Nursing & Midwifery, East Africa

The use of multiple HIV prevention services has been found to decrease the risk of acquiring HIV when tailored to individuals at risk of HIV exposure, including transport workers. Therefore, we assessed the uptake of multiple HIV prevention services (≥2) and associated factors among transport workers in a city in Southwestern Uganda. This cross-sectional study comprised motorcycle taxi riders, motor vehicle and truck drivers, aged 18 to 55 years who were selected and responded to an interviewer-administered questionnaire, between November 2021 and February 2022. Data was analyzed using descriptive statistical and modified Poisson regression analyses. Out of 420 participants, 97.6% …

A Survey With Interventional Components Delivered On Tablet Devices Versus Usual Care To Increase Pre-Exposure Prophylaxis Uptake Among Cisgender Black Women: A Pilot Randomized Controlled Trial, Mandy J Hill, Angela M Heads, Robert Suchting, Angela L Stotts

Journal Articles

BACKGROUND: Cisgender (cis) Black women in the USA are more likely to become HIV positive during their lifetime than other women. We developed and implemented a behavioral intervention, Increasing PrEP (iPrEP), the first pilot randomized controlled trial (RCT) aimed at motivating cis Black women to be willing to use PrEP for HIV prevention and attend an initial PrEP clinic visit following an emergency department visit.

METHODS: Eligible participants were Black cisgender women ages 18-55 years who acknowledged recent condomless sex and substance use. Participants were randomized to iPrEP or usual care (UC). iPrEP is a survey-based intervention designed to raise …

Examining The Role Of Autonomy Support, Goal Setting, And Care Coordination Quality On Hiv Prep Adherence In Black Men Who Have Sex With Men: Hptn 073, Donte T Boyd, Laron E Nelson, Mandy J Hill, Darren Whitfield, S Raquel Ramos, Samuel Akyirem, Lynda Emel, Leo Wilton, Lisa Hightow-Weidman, Steve Shoptaw, Manya Magnus, Kenneth H Mayer, Estelle Piwowar-Manning, Stephaun E Wallace, Sheldon D Fields, Darrell P Wheeler

Journal Articles

Autonomy support is a concept that is derived from self-determination theory. Autonomy refers to the freedom to act as one chooses. The current study aimed to examine if autonomy support was associated with dried blood spot validated pre-exposure prophylaxis (PrEP) adherence, and whether the association was mediated by PrEP adherence goal setting and progress toward PrEP adherence goals. Our sample was drawn from Black men who have sex with men (MSM) from across three cities (Chapel Hill, NC; Los Angeles, CA; and Washington, DC) in the United States between February 2013 and September 2014. We used logistic regression to evaluate …

The Effect Of An Educational Handout On Knowledge, Awareness And Attitudes Of Pre-Exposure Prophylaxis (Prep) Among Participants At A Needle And Syringe Exchange Site, Mckenzie Buckel

DNP Projects

Background: In 2018, the total number of HIV cases in the United States was 1.2 million. Almost 186,500 of these cases were attributed to intravenous drug use. With the adherence to pre-exposure prophylaxis (PrEP) there is approximately a 49% decrease in the rates of HIV among people who inject drugs and the most significant barrier to PrEP among this population is a lack of awareness and knowledge.

Objective: The purpose of this study was to determine participants’ of a needle and syringe exchange site knowledge, awareness and attitudes of PrEP after reviewing an educational handout about PrEP.

Methods: A quasi …

Perspectives On The Use Of Molecular Hiv Data For Public Health, Margaret Watson

Electronic Theses and Dissertations

Background. Effective HIV treatment and pre-exposure prophylaxis can drastically reduce the risk of acquiring HIV and prevent most future transmission, but these advances are not accessible to many who could most benefit from them. Advances in use of molecular sequence data to inform prevention efforts, paired with supportive interventions, have the potential to identify clusters of rapid HIV transmission and focus prevention resources toward areas of highest need. Although molecular cluster detection has been successfully used in other areas of public health, advocates for people with HIV have raised concerns about the application of this approach because of HIV …

Exploration And Analysis Of Attitudes And Determinants Toward Undetectable Equals Untransmittable (U=U) Among Minority Women, Roberta Marie Thimbriel

Open Access Theses & Dissertations

Purpose: To explore and assess awareness of and attitudes toward "undetectable equals untransmittable" (U=U) and associations with social-ecological factors among minority women. Population: Ethnic minority women 18 years and older residing in the El Paso, TX, US - Juarez, Mexico border region. Methods: A cross-sectional convergent parallel mixed methods study using in-depth interviews and a survey instrument was conducted among a purposive sample. Thematic analysis was done on qualitative data, and descriptive, bivariate and binary logistic regression analyses were done on quantitative data. Results: The majority of the participants (66.7% interviewees and 50.7% survey) were Hispanic, in their early-mid thirties, …

Freedom As Prevention: Mechanisms Of Autonomy Support For Promoting Hiv Pre-Exposure Prophylaxis Use And Condom Use Among Black Msm In 3 Us Cities-Hptn 073, Laron E Nelson, Donte T Boyd, Geetha Beauchamp, Lynda Emel, Leo Wilton, Darren Whitfield, S Raquel Ramos, Wale Ajiboye, Mandy J Hill, Donaldson F Conserve, Portia Thomas, Lisa Hightow-Weidman, Steve Shoptaw, Manya Magnus, Kenneth H Mayer, Estelle Piwowar-Manning, Sheldon D Fields, Darrell P Wheeler, Hptn 073 Study Team

Journal Articles

Healthcare providers who use controlling or coercive strategies may compel short-term enactment of HIV and sexually transmitted infection prevention behaviors but may inadvertently undermine their client's motivation to maintain those behaviors in the absence of external pressure. Autonomous motivation refers to the self-emanating and self-determined drive for engaging in health behaviors. It is associated with long-term maintenance of health behaviors. We used structural equation modeling to investigate whether autonomy support was associated with increased odds of therapeutic serum levels of pre-exposure prophylaxis, through a pathway that satisfies basic psychological needs for autonomous self-regulation and competence regarding pre-exposure prophylaxis use. We …

Pilot Testing The Effectiveness Of Whether A Survey-Driven Tablet-Based Intervention Increased Willingness Of Black Women To Attend To An Initial Prep Clinic Visit: The Protocol For The Pilot Randomized Controlled Trial Design And Methods, Mandy J Hill, Angela M Heads, Charles Green, Robert Suchting, Angela L Stotts

Journal Articles

No abstract provided.

Recognizing And Disrupting Stigma In Implementation Of Hiv Prevention And Care: A Call To Research And Action, Sarit A. Golub, Rachel A. Fikslin

Publications and Research

Introduction: There is robust evidence that stigma negatively impacts both people living with HIV and those who might benefit from HIV prevention interventions. Within healthcare settings, research on HIV stigma has focused on intra-personal processes (i.e. knowledge or internalization of community-level stigma that might limit clients’ engagement in care) or inter-personal processes (i.e. stigmatized interactions with service providers). Intersectional approaches to stigma call us to examine the ways that intersecting systems of power and oppression produce stigma not only at the individual and interpersonal levels, but also within healthcare service delivery systems. This commentary argues for the importance of analysing …

Behavioral Intervention To Increase Condom Use Among Men Who Take Pre-Exposure Prophylaxis And Have Sex With Men, Marek J. Piszczatowski

Evidence-Based Practice Project Reports

In the absence of an effective vaccine, the introduction of pre-exposure prophylaxis (PrEP) in 2012 offered a promising new approach to human immunodeficiency virus (HIV) prevention. However, the introduction of a single-pill regimen which helps to prevent HIV transmission created, in men who have sex with men (MSM) population, a phenomenon referred to as risk compensation resulting in PrEP replacing consistent condom use as a preventive measure (Freeborn & Portillo, 2018; Kumar et al., 2020; Montaño et al., 2018; Ramchandani & Golden, 2019; Traeger et al., 2018). The purpose of the evidence-based practice project was to implement a single, one-on-one …

Implications Of Educational Counseling On Prep Uptake In Msm At A Community Health Clinic, Thanh T. Dinh

Doctoral Projects

HIV pre-exposure prophylaxis (PrEP) medication is 99% effective at preventing HIV acquisition if used daily (CDC, 2020; FDA, 2019). Despite its effectiveness and wide availability, PrEP uptake and adherence remained low, especially among MSM of color (Bradley et al., 2019; Kuhns et al., 2017). Prior studies have shown that participants exposed to PrEP information, counseling, and education were more likely to show interest in PrEP and uptake of PrEP. Although various studies support the effectiveness of educational interventions in increasing PrEP uptake, it has not been widely implemented in the practice setting in communities that would benefit from it. The …

Implementation Of Client-Centered Care Coordination For Hiv Prevention With Black Men Who Have Sex With Men: Activities, Personnel Costs, And Outcomes—Hptn 073, Darren L. Whitfield, La Ron E. Nelson, Arnošt Komárek, De Anne Turner, Zhao Ni, Donte T. Boyd, Tamara Taggart, S. Raquel Ramos, Leo Wilton, Geetha G. Beauchamp, Lisa Hightow-Weidman, Steven J. Shoptaw, Manya Magnus, Kenneth H. Mayer, Sheldon D. Fields, Darrell P. Wheeler

GW Authored Works

Background: Black men who have sex with men (MSM) experience disproportionate rates of HIV infection in the USA, despite being no more likely to engage in sexual risk behaviors than other MSM racial/ethnic groups. HIV pre-exposure prophylaxis (PrEP) has been shown to reduce risk of HIV acquisition; however, rates of PrEP use among Black MSM remain low. Clinical, psychosocial, and structural factors have been shown to impact PrEP use and adherence among Black MSM. Care coordination of HIV prevention services has the potential to improve PrEP use and adherence for Black MSM, as it has been shown to improve HIV-related …

Prep Education Intervention, Kristina Jung Msn, Fnp-Bc

Doctor of Nursing Practice Projects

Background: The nation’s HIV infection rate is alarming, yet only a small percentage of eligible individuals are prescribed pre-exposure prophylaxis (PrEP). This sluggish PrEP uptake may be related to lack of knowledge among non-HIV specialist providers. Thus, interventions toexpand providers’ use of PrEP as an HIV prevention strategy are needed.

Objectives: The project aim was to develop an intervention to improve retail nurse practitioners’ (NP) knowledge for PrEP clinical practice, comfort screening for “at-risk HIV” patients, confidence prescribing PrEP, and likeliness to prescribe PrEP in the next six months.

Methodology: An online PrEP tutorial was implemented for retail clinic NPs. …

Evaluating Racial And Ethnic Disparities In Access To Primary Care Among Gay And Bisexual Men In The Us, A Population At High-Risk Of Hiv Infection, Jessica S. Kiernan, April D. Kimmel

Graduate Research Posters

BACKGROUND: 69% of new HIV diagnoses in the US are among gay and bisexual men, with disparities by race and ethnicity. Primary care providers increasingly provide HIV prevention. Racial and ethnic disparities in primary care access are well-documented, but their persistence among gay and bisexual men is unknown. We examined racial and ethnic disparities in access to primary care among this population.

METHODS: We used nationally representative person-level sociodemographic, health status and utilization data, and data on organizational- and socially determinant barriers to care, from the National Health Interview Survey, 2013-2018. Outcomes were: 1) general physician visit

RESULTS: The sample …

Exploring Thai Physicians’ Perceptions Of And Willingness To Prescribe Pre-Exposure Prophylaxis (Prep), Brandi E. Moore

Public Health Theses

Background: Oral pre-exposure prophylaxis (PrEP) is a daily medication that can prevent HIV infection. PrEP may further support HIV prevention initiatives in Thailand, particularly as it becomes more accessible in the country’s government clinics and hospitals. While studies have explored perceptions of PrEP for at-risk people in Thailand, there has been limited investigation into Thai physicians’ opinions of and willingness to prescribe PrEP. Methods: Using convenience sampling, this cross-sectional study recruited 132 Thai physicians to complete an anonymous, online survey. The survey assessed physicians’ concerns about PrEP, experience with PrEP, and willingness to prescribe PrEP. Bivariate and multivariable logistic regressions …

The Impact Of Staff Education On Nurses And Medical Assistants' Knowledge Of Hiv Prevention And Screening, Eurekia Denise Samuel

Walden Dissertations and Doctoral Studies

AbstractIn some U.S. ambulatory clinics, limited time is available for patient education during primary care, which is a barrier to increasing the recommended annual screening for HIV of persons with risk factors between the ages of 13 and 64. One solution to removing this barrier is the expansion of the role of frontline staff so that patient education, particularly in the areas of secondary prevention and routine testing, can occur at the beginning of the visit during initial checking in and assessments. At the project site, a rural ambulatory clinic in the southern United States, however, the frontline staff lacked …

An Examination Of Hiv Risk, Testing And Prevention Intervention Participation Among Vulnerable Youth, Bianca V. Lopez

Dissertations and Theses

Background: Young gay, bisexual and other men who have sex with men (YGBM) of color are disproportionately affected by HIV and bear the burden of the disease in the United States. Gay and bisexual men – referred to in surveillance systems as men who have sex with men (MSM) – continue to be the risk group most severely affected by HIV in the United States. The dissertation study explored factors related on HIV prevention intervention participation, HIV testing and sexual risk behaviors among YGBM ages 13-29 in the Bronx. Additionally, this dissertation endeavored to study the concept of “intervention fatigue”, …

Bahamas National Implementation Project: Proposal For Sustainability Of An Evidence-Based Hiv Prevention Intervention In A School Setting, Bo Wang, Lynette Deveaux, Sonja Lunn, Veronica Dinaj-Koci, Samiran Ghosh, Xiaoming Li, Sharon Marshall, Glenda Rolle, Nikkiah Forbes, Bonita Stanton

Journal Articles

BACKGROUND: Sustained implementation of school-based prevention programs is low. Effective strategies are needed to enhance both high-level implementation fidelity and sustainability of prevention programs.

OBJECTIVE: This proposed study aims to determine if the provision of either biweekly monitoring and feedback and site-based assistance and mentorship or both to at-risk and moderate-performing teachers with monitoring through an enhanced decision-making platform by the Ministry of Education (MOE) and Ministry of Health (MOH) based on the real-time implementation data will increase national implementation fidelity and result in sustained implementation over time.

METHODS: This study will target government schools including 200 grade 6 teachers …

Implementing An M-Health Program To Prevent Hiv In Msm And Tgw, Marja Cormack-Price

Nursing Master's Theses

Clinical Problem: Rates of HIV in the LGBTQ population, specifically persons from the men who have sex with men (MSM) and transgender women (TGW) group, have a higher rate of HIV when compared to the public. These rates continue to increase and remain most prevalent amongst this group. It has been identified that high risk sexual behaviors (HRSB) lead to higher rates of HIV transmission and acquisition. According to the literature, the use of social media is prevalent in the LGBTQ community as they tend to use social media in sex seeking behaviors.

Significance: There is an urgency and importance …

Initiating Prep In Primary Care: Addressing The Adolescent And Young Adult High Risk Populations, Igor G. Mocorro

Doctor of Nursing Practice (DNP) Projects

Problem: Adolescents and young adults (AYA) ages 13 to 24 comprise a quarter of the new HIV diagnoses in the United States. Lack of access to HIV-preventive therapies such as pre-exposure prophylaxis (PrEP) reduces opportunities to prevent HIV infection in this population. Initiating PrEP in AYA significantly reduces the negative health outcomes of HIV, but it is evident that many clinicians are still reluctant to initiate PrEP in AYA patients based on perceived threats and barriers.

Context: Primary care clinics, including school-based clinics, have an opportunity to offer HIV prevention services including PrEP. This project, the Adolescent and Young Adult …

Factors Associated With Prep And Pep Uptake Among The Latinx Population, Santiago Gudiño-Rosales, Melva Thompson-Robinson, Johanna Andrews

Calvert Undergraduate Research Awards

Advanced Undergraduate Winner

Uptake of PrEP and PEP amongst LatinX population has been low, despite being a population disproportionately affected by HIV. Systemic barriers and cultural factors affect general LatinX approaches to healthcare and may impact uptake of these medications. The purpose of this study is to assess the factors that are associated with the likelihood to take PrEP and PEP in the LatinX population. In this cross-sectional study, survey data was collected from 169 LatinXs from January - March 2020. Using the Sexual Health Model as the theoretical framework, the survey examined the following four constructs to identify factors …

Leveraging Technology To Blend Large-Scale Epidemiologic Surveillance With Social And Behavioral Science Methods: Successes, Challenges, And Lessons Learned Implementing The Unite Longitudinal Cohort Study Of Hiv Risk Factors Among Sexual Minority Men In The United States, H. Jonathon Rendina, Ali J. Talan, Nicola F. Tavella, Jonathan Lopez Matos, Ruben H. Jimenez, S. Scott Jones, Brian Salfas, Drew Westmoreland

Publications and Research

The use of digital technologies to conduct large-scale research with limited interaction (i.e., no in-person contact) and objective endpoints (i.e., biological testing) has significant potential for the field of epidemiology, but limited research to date has been published on the successes and challenges of such approaches. We analyzed data from a cohort study of sexual minority men across the United States, collected using digital strategies during a 10-month period from 2017 to 2018. Overall, 113,874 individuals were screened, of whom 26,000 were invited to the study, 10,691 joined the study, and 7,957 completed all enrollment steps, including return of a …

The Intersection Of Social Stress, Mental Well-Being, And Sexual Health Among Black Women In Emerging Adulthood, Brandi Galloway

Theses and Dissertations

With an estimated 37,000 new HIV infections each year, HIV continues to be a major public health concern. HIV affects some populations more than others. Young Black women, in particular, are disproportionately affected by HIV. While being a woman does not typically increase a person’s HIV risk, being Black and being a woman does.

Data indicate that individual-level factors do not fully address the differences in HIV and STIs between Black emerging adult women and their White counterparts. Thus, it is critical to better understand contextual factors such as social stress and mental-wellbeing which might better account for these disparities. …

Acceptability Of A Vaginal Ring To Prevent Hiv And Pregnancy: Integrating Multiple Qualitative Methods, Dana Watnick

Dissertations and Theses

Heterosexual vaginal sex can simultaneously put women at risk for unintended pregnancy and sexually transmitted infections, such as HIV, disproportionately impacting poor women around the world. Both unintended pregnancy and HIV are persistent public health concerns associated with negative outcomes for mothers, families and communities. The current mix of prevention tools available to women to protect against unintended pregnancy and HIV is limited. Multipurpose Prevention Technologies (MPTs) are innovative products that simultaneously offer protection against pregnancy and HIV. However, MPTs will only be effective in reducing unintended pregnancy and incident HIV if women are willing to use them. With an …

Hiv Prevention Via Mobile Messaging For Men Who Have Sex With Men (M-Cubed): Protocol For A Randomized Controlled Trial, Patrick Sean Sullivan, Ryan J. Zahn, Sarah Wiatrek, Cristian J. Chandler, Sabina Hirshfield, Rob Stephenson, Jose A. Bauermeister, Mary Ann Chiasson, Martin J. Downing, Deborah J. Gelaude, Aaron J. Siegler, Keith Horvath, Erin Rogers, Ana Alas, Evelyn J. Olansky, Heather Saul, Eli S. Rosenberg, Gordon Mansergh

Publications and Research

Background:

Men who have sex with men (MSM) continue to be the predominately impacted risk group in the United States HIV epidemic and are a priority group for risk reduction in national strategic goals for HIV prevention. Modeling studies have demonstrated that a comprehensive package of status-tailored HIV prevention and care interventions have the potential to substantially reduce new infections among MSM. However, uptake of basic prevention services, including HIV testing, sexually transmitted infection (STI) testing, condom distribution, condom-compatible lubricant distribution, and preexposure prophylaxis (PrEP), is suboptimal. Further, stronger public health strategies are needed to promote engagement in HIV care …

Effectiveness Of Community Outreach Hiv Prevention Programs In Vietnam: A Mixed Methods Evaluation, Lora L. Sabin, Katherine Semrau, Mary Bachman Desilva, Le T T Loan, Jennifer J. Beard, Davidson H. Hamer, Jordan Tuchman, Ted Hammett, Nafisa Halim, Manisha Reuben, Aldina Mesic, Taryn Vian

Nursing and Health Professions Faculty Research and Publications

Background

In 2014, Vietnam was the first Southeast Asian country to commit to achieving the World Health Organization’s 90–90-90 global HIV targets (90% know their HIV status, 90% on sustained treatment, and 90% virally suppressed) by 2020. This pledge represented further confirmation of Vietnam’s efforts to respond to the HIV epidemic, one feature of which has been close collaboration with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Starting in 2004, PEPFAR supported community outreach programs targeting high-risk populations (people who inject drugs, men who have sex with men, and sex workers). To provide early evidence on program impact, …

Using The Consolidated Framework For Implementation Research To Investigate Daily Pre-Exposure Prophylaxis (Emtricitabine/Tenofovir Df) Implementation Via Community-Based Hiv Testing Sites In Florida, Deanne E. Turner

USF Tampa Graduate Theses and Dissertations

Background: Pre-exposure prophylaxis (PrEP) is a daily pill that can reduce a person’s chances of acquiring HIV. HIV testing and counseling is a critical point during which non-clinical staff could intervene, discuss and/or refer clients for PrEP. However, not all HIV testing/counseling staff take part in PrEP implementation in the same way. This study investigated: 1) the underlying PrEP implementation subgroups of staff who perform HIV testing and 2) PrEP implementation as a function of key constructs from the Consolidated Framework for Implementation Research (CFIR).

Methods: This study was a mixed methods concurrent triangulation design, in which qualitative and quantitative …