Rosemary Frasso

Practical Guidance and Ethical Considerations for Studies Using Photo-Elicitation Interviews

Photo-elicitation is a qualitative interviewing technique that has gained popularity in recent years. It is the foundation for photovoice projects and is a tool well-suited for community-based participatory research. Photo-elicitation yields rich data, and interview participants say these interviews encourage community awareness and engagement. This article draws on 9 studies, conducted by researchers at 3 institutions (the University of Pennsylvania, the Philadelphia Veterans Affairs Medical Center, and the Geisel School of Medicine at Dartmouth) in partnership with community-based organizations and students, in which 303 participants completed photo-elicitation interviews. We offer 8 practical suggestions for overcoming challenges encountered during photo-elicitation research and for managing ethical concerns about the use of visual data in public health research. Our guidelines can inform study design, protocol development, and institutional review board approval.

Shared Decision Making and Treatment Decisions for Young Children With Autism Spectrum Disorder

OBJECTIVE To describe influences on shared decision making between primary care pediatricians and parents of young children with autism spectrum disorder (ASD). METHODS We conducted a qualitative study using key informant interviews with 20 pediatricians of varying experience from 10 primary care practices and 20 English-speaking parents of young children (aged 2-5 years) with a parent-reported diagnosis of ASD. Subjects were recruited through purposive sampling. Interviews were audiotaped, transcribed verbatim, and analyzed using an integrated approach to data analysis. Differences in coding were resolved by consensus. We achieved thematic saturation and ceased recruitment after 20 interviews were completed within each group. RESULTS Three primary themes emerged: 1) pediatricians and parents reported knowledge gaps by pediatricians about ASD treatments and community resources as well as ambiguity regarding the pediatricians role in ASD care; 2) there was little communication between parents and pediatricians about treatment choices; 3) use of complementary and alternative medical treatments created conflict between pediatricians and parents, and as a result, parents may independently pursue treatments, without the benefit of discussing safety and efficacy with pediatricians. Despite these barriers, parents desired increased support and guidance from their pediatricians, including for complementary and alternative medicine. CONCLUSIONS Much work is needed to effectively foster shared decision making in the context of ASD treatment decisions in primary care, including pediatrician training in ASD to enhance knowledge about evidence-based and novel treatments, clinical practice guidelines, and community resources.

Pre-teen literacy and subsequent teenage childbearing in a US population

BACKGROUND While literacy is a key factor in health across the life course, the association of literacy and teenage childbearing has not been assessed in the US. STUDY DESIGN Prospective cohort study using standardized reading data from 12,339 girls in the seventh grade in the 1996-97 or 1997-98 academic years of the Philadelphia Public School System linked to birth records from the city of Philadelphia (1996-2002). RESULTS Less than average reading skill was independently associated with two and a half times the risk of teen childbearing than average reading skill (aHR 2.51, 95% CI: 1.67-3.77). Above average reading skill was associated with less risk (aHR 0.27, 95% CI 0.17-0.44). A significant interaction (p<.05) between reading skill and race/ethnicity indicated that Hispanic and African American girls had greater risk of teen-childbearing by literacy. CONCLUSIONS Literacy strongly predicts risk of teenage childbearing independent of confounders. The effects of literacy were stronger among girls with Hispanic or African American race/ethnicity.

Community-generated recommendations regarding the urban nutrition and tobacco environments: a photo-elicitation study in Philadelphia.

Introduction Overweight, obesity, and tobacco use are major preventable causes of disability, disease, and death. In 2010, 25% of Philadelphia adults smoked, and 66% were overweight or obese. To address these health threats, the Philadelphia Department of Public Health launched Get Healthy Philly, an initiative to improve the city’s nutrition, physical activity, and tobacco environments. The objective of this assessment was to identify residents’ perspectives on threats to health and opportunities for change in the local food and tobacco environments. Methods Participants (N = 48) took photographs to document their concerns regarding Philadelphia’s food and tobacco environments and participated in photo-elicitation interviews. We coded photographs and interview transcripts and identified key themes. Results Participants proposed interventions for nutrition 4 times more often than for tobacco. Participants spontaneously articulated the need for multilevel change consistent with the ecological model of health behavior, including changes to policies (food assistance program provisions to encourage healthful purchases), local and school environments (more healthful corner store inventories and school meals), and individual knowledge and behavior (healthier food purchases). Participants often required interviewer prompting to discuss tobacco, and they suggested interventions including changes in advertising (a local environmental concern) and cigarette taxes (a policy concern). Conclusion Participants were well versed in the relevance to health of nutrition and physical activity and the need for multilevel interventions. Their responses suggested community readiness for change. In contrast, participants’ more limited comments regarding tobacco suggested that prevention and control of tobacco use were perceived as less salient public health concerns.

Understanding Inequities in Home Health Care Outcomes: Staff Views on Agency and System Factors

Results regarding staff perspectives on contributing factors to racial/ethnic disparities in home health care outcomes are discussed. Focus group interviews were conducted with home health care staff (N = 23) who represented various agencies from three Northeastern states. Participants identified agency and system factors that contribute to disparities, including: (a) administrative staff bias/discretion, (b) communication challenges, (c) patient/staff cultural discordance, (d) cost control, and (e) poor access to community resources. Participants reported that bias can influence staff at all levels and is expressed via poor coverage of predominantly minority service areas, resulting in reduced intensity and continuity of service for minority patients.

Variation of Blunt Traumatic Injury with Age in Older Adults: Statewide Analysis 2011-14

Introduction Traumatic injury is a leading cause of death and disability in adults ≥ 65 years old, but there are few epidemiological studies addressing this issue. The aim of this study was to assess how characteristics of blunt traumatic injuries in adults ≥ 65 vary by age. Methods Using data from the a single-state trauma registry, this retrospective cohort study examined injured patients ≥ 65 admitted to all Level I and Level II trauma centers in Pennsylvania between 2011 and 2014 (n=38,562). Patients were stratified by age into three subgroups (age 65–74; 75–84; ≥85). We compared demographics, injury, and system-level across groups. Results We found significant increases in the proportion of female gender, (48.6% vs. 58.7% vs. 67.7%), white race (89.1% vs. 92.6% vs. 94.6%), and non-Hispanic ethnicity (97.5% vs. 98.6% vs. 99.4%) across advancing age across age groups, respectively. As age increased, the proportion of falls (69.9% vs. 82.1% vs. 90.3%), in-hospital mortality (4.6% vs. 6.2% vs. 6.8%), and proportion of patients arriving to the hospital via ambulance also increased (73.6% vs. 75.8% vs. 81.1%), while median injury severity plateaued (9.0% all groups) and the proportion of Level I trauma alerts (10.6% vs. 8.2% vs. 6.7%) decreased. We found no trend between age and patient transfer status. The five most common diagnoses were vertebral fracture, rib fracture, head contusion, open head wound, and intracranial hemorrhage, with vertebral fracture and head contusion increasing with age, and rib fracture decreasing with age. Conclusion In a large cohort of older adults with trauma (n= 38,000), we found, with advancing age, a decrease in trauma alert level, despite an increase in mortality and a decrease in demographic diversity. This descriptive study provides a framework for future research on the relationship between age and blunt traumatic injury in older adults.

County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care:

Approximately 20% of the roughly 2.5 million individuals incarcerated in the United States have a serious mental illness (SMI). As a result of their illnesses, these individuals are often more likely to commit a crime, end up incarcerated, and languish in correctional settings without appropriate treatment. The objective of the present study was to investigate how correctional facility personnel reconcile the ethical challenges that arise when housing and treating individuals with SMI. Four focus groups and one group interview were conducted with employees (n = 24) including nurses, clinicians, correctional officers, administrators, and sergeants at a county jail in Pennsylvania. Results show that jail employees felt there are too many inmates with SMI in jail who would benefit from more comprehensive treatment elsewhere; however, given limited resources, employees felt they were doing the best they can. These findings can inform mental health management and policy in a correctional setting.

The Association Between Pregnancy Intention and Breastfeeding

Background: Although breastfeeding is associated with proven benefits to both mother and child, there are many factors that influence a mother’s decision to breastfeed. Pregnancy intentionality at the time of conception is associated with postpartum maternal behavior including breastfeeding. Research aim: We sought to understand how maternal and paternal pregnancy intentions were associated with breastfeeding initiation and duration in a nationally representative sample. Methods: We used a cross-sectional, retrospective study of the CDC National Survey of Family Growth data to examine the link between pregnancy intentionality and breastfeeding initiation and duration among women ages 15 to 44 years. Results: We found that whereas the mother’s intention to have a child was a factor in how long she breastfed, the paternal intention to have a child predicted whether the mother breastfed at all. Additionally, Hispanic mothers were most likely to breastfeed and breastfed the longest of any other group. Age and education were also positive predictors of ever breastfeeding. Conclusion: Understanding the father’s and mother’s attitudes toward the pregnancy and influence on breastfeeding intention is important for intervention planning.

Perceptions about supervised injection facilities among people who inject drugs in Philadelphia

BACKGROUND People who inject drugs (PWID) are at high risk for infectious diseases, skin and soft tissue infections, and overdose. However, these harms are all avoidable when sterile injection equipment, hygienic places to inject, and medical care are accessible. Unfortunately, many PWID in the U.S lack these resources. The most vulnerable are forced to inject in public spaces, where individual risks are high and communal harms are sometimes many. Supervised Injection Facilities (SIFs) are an established intervention for reducing these harms. Despite positive experiences in other countries, little research explores how PWID in the U.S. perceive the value of such facilities. METHODS We conducted a freelisting exercise with PWID (n=42) and healthcare providers (n=20) at a syringe exchange program (SEP) that provides comprehensive clinical and social services in Philadelphia to inform in-depth semi-structured interviews with PWID (n=19) at the same location. RESULTS Participants expressed support for a potential SIF as a valuable public health intervention. They suggested that an SIF would improve PWID health while reducing the public disorder associated with injecting drugs in public. The latter was especially important to participants without stable housing, whose decision to inject furtively in secluded places was often motivated by desire not to upset community members, and particularly children. These participants acknowledged that such seclusion elevated the risk of fatal overdose. Despite similarly positive perceptions about an SIF, participants with stable housing reported that they would prefer to continue injecting at home. CONCLUSION Results both confirm and extend prior research about PWID and SIFs. Participants expressed support for SIFs as in prior survey research in the U.S. and in other countries. Facility location and housing status were identified as important determinants of facility use. Results extend prior research by illuminating PWID perceptions in the U.S. including motivations grounded in concern for public order.

Adverse events in veterans affairs inpatient psychiatric units: Staff perspectives on contributing and protective factors

OBJECTIVES This study sought to identify risk factors and protective factors in hospital-based mental health settings in the Veterans Health Administration (VHA), with the goal of informing interventions to improve care of persons with serious mental illness. METHODS Twenty key informants from a stratified sample of 7 VHA inpatient psychiatric units were interviewed to gain their insights on causes of patient safety events and the factors that constrain or facilitate patient safety efforts. RESULTS Respondents identified threats to patient safety at the system-, provider-, and patient-levels. Protective factors that, when in place, made patient safety events less likely to occur included: promoting a culture of safety; advocating for patient-centeredness; and engaging administrators and organizational leadership to champion these changes. CONCLUSIONS Findings highlight the impact of systems-level policies and procedures on safety in inpatient mental health care. Engaging all stakeholders, including patients, in patient safety efforts and establishing a culture of safety will help improve the quality of inpatient psychiatric care. Successful implementation of changes require the knowledge of local experts most closely involved in patient care, as well as support and buy-in from organizational leadership.