Shimrit Keddem

Unmet psychosocial needs of Pennsylvanians with cancer: 1986-2005.

The purpose of the current study was to identify unmet psychosocial needs of cancer survivors, understand the distribution of needs across subgroups, and compare unmet needs in 2005 with those identified by Houts et al. in 1986.

More Than Just An Eyesore: Local Insights And Solutions on Vacant Land And Urban Health

Vacant land is a significant economic problem for many cities, but also may affect the health and safety of residents. In order for community-based solutions to vacant land to be accepted by target populations, community members should be engaged in identifying local health impacts and generating solutions. We conducted 50 in-depth semi-structured interviews with people living in Philadelphia, Pennsylvania, a city with high vacancy, about the impact of vacant land on community and individual health and safety, as well as ideas for solutions to vacant land. Participants described a neighborhood physical environment dominated by decaying abandoned homes and overgrown vacant lots which affected community well-being, physical health, and mental health. Vacant land was thought to affect community well-being by overshadowing positive aspects of the community, contributing to fractures between neighbors, attracting crime, and making residents fearful. Vacant land was described as impacting physical health through injury, the buildup of trash, and attraction of rodents, as well as mental health through anxiety and stigma. Participants had several ideas for solutions to vacant land in their community, including transformation of vacant lots into small park spaces for the elderly and playgrounds for youth, and the use of abandoned homes for subsidized housing and homeless shelters. A few participants took pride in maintaining vacant lots on their block, and others expressed interest in performing maintenance but lacked the resources to do so. Public health researchers and practitioners, and urban planners should engage local residents in the design and implementation of vacant land strategies. Furthermore, municipalities should ensure that the health and safety impact of vacant land helps drive policy decisions around vacant land.

Seen Through Their Eyes: Residents’ Reflections on the Cognitive and Contextual Components of Diagnostic Errors in Medicine

Purpose Diagnostic errors in medicine are common and costly. Cognitive bias causes are increasingly recognized contributors to diagnostic error but remain difficult targets for medical educators and patient safety experts. The authors explored the cognitive and contextual components of diagnostic errors described by internal medicine resident physicians through the use of an educational intervention. Method Forty-one internal medicine residents at University of Pennsylvania participated in an educational intervention in 2010 that comprised reflective writing and facilitated small-group discussion about experiences with diagnostic error from cognitive bias. Narratives and discussion were transcribed and analyzed iteratively to identify types of cognitive bias and contextual factors present. Results All residents described a personal experience with a case of diagnostic error that contained at least one cognitive bias and one contextual factor that may have influenced the outcome. The most common cognitive biases identified by the residents were anchoring bias (36; 88%), availability bias (31; 76%), and framing effect (23; 56%). Prominent contextual factors included caring for patients on a subspecialty service (31; 76%), complex illness (26; 63%), and time pressures (22; 54%). Eighty-five percent of residents described at least one strategy to avoid a similar error in the future. Conclusions Residents can easily recall diagnostic errors, analyze the errors for cognitive bias, and richly describe their context. The use of reflective writing and narrative discussion is an educational strategy to teach recognition, analysis, and cognitive-bias-avoidance strategies for diagnostic error in residency education.

Asking the Patient About Patient-Centered Medical Homes: A Qualitative Analysis

BackgroundWhat patients perceive and experience within a patient-centered medical home (PCMH) is an understudied area, and to date, the patient perspective has not been an integral component of existing PCMH measurement standards. However, upcoming guidelines necessitate the use of patient-reported experiences and satisfaction in evaluations of practice and provider performance.ObjectiveTo characterize patients’ experiences with care after PCMH adoption and their understanding and perceptions of the PCMH model and its key components, and to compare responses by degree of practice-level PCMH adoption and patient race/ethnicity.DesignQualitative study.ParticipantsAdult patients with diabetes and/or hypertension (n = 48).ApproachWe surveyed and ranked all PCMH adult primary care practices affiliated with one academic medical center with at least three providers (n = 23), using an instrument quantifying the degree of PCMH adoption. We purposively sampled minority and non-minority patients from the four highest-ranked and four lowest-ranked PCMH-adopting practices to determine whether responses varied by degree of PCMH adoption or patient race/ethnicity. We conducted semi-structured telephone interviews with patients about their experiences with care and their perceptions and understanding of key PCMH domains. Interviews were recorded, transcribed, and imported into NVivo 10 for coding and analysis, using a modified grounded theory approach.Key ResultsWe found that patients uniformly lacked awareness of the PCMH concept, and the vast majority perceived no PCMH-related structural changes, regardless of the degree of practice-reported PCMH adoption or the patients race/ethnicity. Despite this lack of awareness, patients overwhelmingly reported positive relationships with their provider and positive overall experiences.ConclusionsAs we continue to redesign primary care delivery with an emphasis on patient experience measures as performance metrics, we need to better understand what, if any, aspects of practice structure relate to patient experience and satisfaction with care.

Teen perceptions of good drivers and safe drivers: implications for reaching adolescents

Objective: To understand definitions of the phrases “good driver” and “safe driver” among teen pre-drivers and early drivers in order to appropriately tailor messages about driving safety. Design: Qualitative study using freelisting, an anthropological research technique, to explore nuances in the ways that teens define a good driver and a safe driver Setting: Classes in six high schools each in a different state in the USA. Subjects: 193 adolescent pre-drivers and early drivers, aged 15–17. Main outcome measures: Meaning of the phrase good driver and safe driver was identified for subgroups of adolescents. Results: Teen pre-drivers and early drivers define a good driver and a safe driver as one who is cautious, alert, responsible, does not speed, obeys the law, uses seatbelts, and concentrates. There are subtle and potentially important differences in the way that subgroups define a good driver and a safe driver. Conclusions: Injury prevention experts need to attend closely to the implicit meanings that teens attach to everyday terms. Freelisting is a method that identifies perceptions about the meaning of health communication messages and suggests differences in meaning among subgroups.

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.

An Anthropology of Caregiving

Anthropology is a lens through which we might understand the diversity of issues inherent in the ways that contemporary humans care for one another. The anthropology of caregiving provides an understanding of the range of behaviors, perceptions, and feelings associated with providing care for another person. Culture, a concept central to anthropology, comprises the implicit and explicit set of assumptions, behavioral guidelines, and interconnected beliefs that are shared by members of a society (Helman, Culture, health and illness, 2001). Culture shapes both the experience of illness and that of giving care, and informs the ways that these roles are perceived by others. Illness behaviors are often linked to social factors, gender norms, ethnic factors, and politics, as well as differences in philosophies, cultures, and in socioeconomic status (Brown and Barrett Understanding and applying medical anthropology, 2009). This chapter will explore fundamental concepts from medical anthropology and describe their contributions to our understanding of caregiving.

Creating a Toolkit to Reduce Disparities in Patient Engagement

Background: Patient engagement has become a major focus of health care improvement efforts nationally. Although evidence suggests patient engagement can be beneficial to patients, it has not been consistently defined, operationalized, or translated into practice. Objectives: Our objective was to develop a toolkit to help providers increase patient engagement and reduce disparities in patient engagement. Research Design: We used qualitative interviews and observations with staff at primary care sites nationally to identify patient engagement practices and resources used to engage patients. We then used a modified Delphi process, that included a series of conference calls and surveys, where stakeholders reduced lists of engagement practices based on perceived feasibility and importance to develop a toolkit for patient engagement. Sampling: Sites were selected for interviews and site visits based on the concentration of minority patients served and performance on a measure of patient engagement, with the goal of highlighting practices at sites that successfully serve minority patients. Results: We created a toolkit consisting of patient engagement practices and resources. No identified practice or resource specifically targeted patient engagement of minorities or addressed disparities. However, high-performing, high–minority-serving sites tended to describe more staff training opportunities and staff feedback mechanisms. In addition, low-performing and high–minority-serving sites more often reported barriers to implementation of patient engagement practices. Conclusions: Stakeholders agreed on feasible and important engagement practices. Implementation of this toolkit will be tracked to better understand patient engagement and its effect on patient-centered care and related disparities in care.

Qualitative Methods: Tools for Understanding and Engaging Communities

Understanding community needs and establishing research priorities must occur through respectful and effective collaborations between communities, local organizations, and researchers. Qualitative inquiry can serve as a bridge between researchers and communities, allowing for group goal identification and priority setting. Qualitative techniques can transform the traditional participant-researcher relationship into a rich partnership steered by empowered representatives of a community. These approaches can also inform program planning through formative process evaluation and ongoing community engagement. Additionally, qualitative methods serve as a foundation for Community Based Participatory Research (CBPR) or Action Research. Qualitative data collection methods vary widely but frequently involve interviews, observations, or focus groups. Less common, but more interactive and creative approaches, such as intercept interviews, freelisting, walking interviews, photo elicitation interviews, photovoice, and nominal group technique can enhance a researcher’s ability to collaborate with a community and create lasting and effective partnerships. Each approach presents unique implementation, recruitment, and ethical challenges, all of which will be discussed in this chapter. Since the advent of the internet, communities are no longer necessarily defined by geographically proximate group members, so this chapter will briefly discuss in-person, telephone, and online approaches to community identification, partnership building, and data collection. This chapter will also discuss the researcher’s responsibility to the community in all phases of the research process. We will address data collection, organization, and analysis, including effective ways to work with community members to plan a dissemination strategy. Such strategies may include traditional reports, presentations, exhibits, or websites. Timely reporting of research findings back to the community and the role and value of traditional academic dissemination approaches will also be addressed.

Perceptions of caregivers and adolescents of the use of telemedicine for the child sexual abuse examination

BACKGROUND Childhood sexual abuse is a common cause of morbidity and mortality. All victims should receive a timely comprehensive medical exam. Currently there is a critical shortage of child abuse pediatricians who can complete the comprehensive child sexual abuse examination. Telemedicine has emerged as an innovative way to provide subspecialty care to this population. Despite the growing popularity of telemedicine, no literature exists describing patient and caregiver perceptions of telemedicine for this sensitive exam. OBJECTIVE To explore caregiver and adolescent perspectives of the use of telemedicine for the child sexual abuse examination and discover factors that drive satisfaction with the technology. PARTICIPANTS AND SETTING Caregivers and adolescents who presented for a child sexual abuse medical evaluation at our countys child advocacy center. METHODS We completed semi structured interviews of 17 caregivers and 10 adolescents. Guided by the Technology Acceptance Model interviews assessed perceptions about: general feelings with the exam, prior use of technology, feelings about telemedicine, and role of the medical team. Interviews were audio-recorded, transcribed, coded and analyzed using content analysis with constant comparative coding. Recruitment ended when thematic saturation was reached. RESULTS There was an overwhelming positive response to telemedicine. Participants reported having a good experience with telemedicine regardless of severity of sexual abuse or prior experience with technology. Behaviors that helped patients and caregivers feel comfortable included a clear explanation from the medical team and professionalism demonstrated by those using the telemedicine system. CONCLUSION Telemedicine was widely accepted by adolescents and caregivers when used for the child sexual abuse examination.