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Lee NS, Keddem S, Sorrentino AE, Jenkins KA, Long JA. Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex. JAMA Netw Open 2024; 7:e2356600. [PMID: 38373000 PMCID: PMC10877456 DOI: 10.1001/jamanetworkopen.2023.56600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Importance Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups. Objective To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex. Design, Setting, and Participants This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022. Main Outcomes and Measures The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group. Results Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect. Conclusions and Relevance In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.
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Affiliation(s)
- Natalie S. Lee
- Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, The Ohio State University, Columbus
| | - Shimrit Keddem
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Anneliese E. Sorrentino
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Kevin Ahmaad Jenkins
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Judith A. Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Harhay MN, Klassen AC, Gunen B, Hingorany S, Sweeting J, Lee J, HaileSelasse JR, Milliron BJ. Patient and Health Care Professional Perspectives on Addressing Obesity in ESKD. Am J Kidney Dis 2023; 82:419-428. [PMID: 37086964 PMCID: PMC10524159 DOI: 10.1053/j.ajkd.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/28/2023] [Indexed: 04/24/2023]
Abstract
RATIONALE & OBJECTIVE Obesity is common among patients with end-stage kidney disease (ESKD) and is a pervasive barrier to kidney transplantation. Patient perspectives about barriers to weight loss and patient and health care professionals' viewpoints about optimal obesity management in ESKD are needed. STUDY DESIGN Qualitative study using a descriptive phenomenological approach to understand ESKD patients' lived experiences with obesity and weight loss and patients' and health professionals' perceptions about optimal obesity care for ESKD patients. SETTING & PARTICIPANTS Between October 2020 and December 2021, we conducted 90-minute semistructured interviews with 40 ESKD patients with obesity (body mass index [BMI] ≥30kg/m2) and 60-minute interviews with 20 ESKD health care professionals. ANALYTICAL APPROACH Deductive and inductive thematic analysis of interviews. RESULTS Among patients with ESKD, the median age was 55 (IQR, 46-63) years, median BMI was 39.5 (IQR, 35.3-41.6) kg/m2, and median dialysis vintage was 5 (IQR, 3-8) years; 58% were female, and 46% were non-Hispanic White. Among health care professionals, 50% were renal dietitians, 20% were nephrologists, and the remainder were transplant professionals (surgeons, nephrologists, and dietitians). ESKD patients described unique weight loss challenges, including (1) conflicting tenets of "kidney-friendly" versus popular diets, (2) fatigue due to dialysis that affects dietary choices, and (3) perceived pressure and unrealistic expectations from health professionals to lose weight for kidney transplantation. Professionals and patients described a lack of transparent and honest communication about obesity and unclear roles and responsibilities for obesity counseling. LIMITATIONS Lack of caregiver perspectives and potential lack of transferability to overall dialysis population given overrepresentation of patients with severe obesity and previous weight loss surgery. CONCLUSIONS Obesity interventions for ESKD patients should be tailored to meet the unique challenges reported by patients with ESKD. Clarifying ESKD health professionals' roles and responsibilities for obesity care would help to ensure that patients have consistent and effective support to manage obesity. PLAIN-LANGUAGE SUMMARY Adults with coexisting obesity and end-stage kidney disease (ESKD) are often required to lose weight for kidney transplantation. Yet there is little knowledge about barriers to healthy weight loss in this population. In this study, we conducted interviews with 40 ESKD patients with coexisting obesity and 20 ESKD health care professionals to learn about opportunities to improve obesity-related health care in ESKD. Patients reported that fatigue and dialysis affected dietary choices, and fluid and food restrictions hampered weight loss. Professionals described a lack of training, comfort, and time to address obesity. Patients and professionals reported a lack of open communication about obesity management. Improving obesity-related education and clinical communication should be prioritized to improve care for patients with ESKD and obesity.
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Affiliation(s)
- Meera Nair Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania; Department of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, Pennsylvania; Department of Medicine, Penn Transplant Institute, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
| | - Ann C Klassen
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Bengucan Gunen
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Sneha Hingorany
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jasmine Sweeting
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Joanna Lee
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - J Rachael HaileSelasse
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Brandy-Joe Milliron
- Department of Nutrition Sciences, Drexel University College of Nursing and Health Professions, Philadelphia, Pennsylvania
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Keddem S, Barg FK, Frasso R. Practical Guidance for Studies Using Freelisting Interviews. Prev Chronic Dis 2021. [DOI: 10.5888/pcd18.200355] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Shimrit Keddem
- Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Frances K. Barg
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rosemary Frasso
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
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Keddem S, Barg FK, Frasso R. Practical Guidance for Studies Using Freelisting Interviews. Prev Chronic Dis 2021; 18:E04. [PMID: 33444525 PMCID: PMC7845553 DOI: 10.5888/pcd17.200355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Freelisting is a qualitative interviewing technique that has recently grown in popularity. It is an excellent tool for rapidly exploring how groups of people think about and define a particular health-related domain and is well suited for engaging communities and identifying shared priorities. In this article, we outline 7 practical considerations for conducting freelisting studies summarized from 16 articles conducted by the authors at the University of Pennsylvania and Thomas Jefferson University in partnership with community-based organizations and students. Our recommendations can inform study design, data collection, and data analysis for investigators who are interested in using freelisting interviews in their research.
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Affiliation(s)
- Shimrit Keddem
- Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.,Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Frances K Barg
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rosemary Frasso
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania.,College of Population Health, Thomas Jefferson University, 901 Walnut St,10th Floor, Philadelphia, PA 19107.
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Hwang J, Lee C, Mastrolonardo E, Frasso R. Where there's smoke, there's fire: what current and future providers do and do not know about electronic cigarettes. BMC Public Health 2020; 20:1145. [PMID: 32689998 PMCID: PMC7372802 DOI: 10.1186/s12889-020-09265-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 07/14/2020] [Indexed: 02/08/2023] Open
Abstract
Background Health care providers play a pivotal role as educators on health-related matters ranging from vaccination to smoking cessation. With the rising popularity of electronic cigarettes (e-cigarettes), providers face a new challenge. To date, studies have identified a general lack of knowledge among providers regarding e-cigarettes and discomfort with counseling patients on e-cigarette use. This study aims to systematically explore the perspectives of different health care providers on e-cigarettes and their health implications. With a growing availability of research on the health consequences of e-cigarette use, our study also aims to assess the familiarity of our participants with this literature. Methods From July to October 2018, a sample of attendings (n = 15), residents (n = 15), medical students (n = 33), and nursing students (n = 28) from Thomas Jefferson University participated in a freelisting interview and survey. Results Our study found that perceptions of e-cigarettes vary across different participant groups, as evidenced by the range of responses when asked to think about e-cigarettes and their health implications. We identified gaps in knowledge among students regarding FDA regulation of e-cigarettes and found that attending physicians are less aware than junior trainees of the prevalence of use. Familiarity with evidence-based health consequences was variable and low across all groups. Finally, participants most commonly reported learning about e-cigarettes from news outlets and social media rather than professional platforms. Conclusion This study highlights the need for curricular development in nursing and medical schools, residency training, and continuing medical education regarding e-cigarette use and their impact on human health.
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Affiliation(s)
- Josephine Hwang
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Crystal Lee
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric Mastrolonardo
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rosemary Frasso
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA.
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Byrne R, Bird J, Reeve S, Jones W, Shiers D, Morrison A, Pyle M, Peters S. Understanding young peoples' and family members' views of treatment for first episode psychosis in a randomised controlled trial (MAPS). EClinicalMedicine 2020; 24:100417. [PMID: 32775967 PMCID: PMC7393652 DOI: 10.1016/j.eclinm.2020.100417] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND There is limited evidence to inform treatment decision-making in adolescents experiencing first episode psychosis (FEP). In the MAPS trial (Managing Adolescent first Episode Psychosis: a feasibility Study), adolescents with FEP received either antipsychotic medication (AP), psychological intervention (PI), or both. We investigated treatment views of young people and family members across each treatment arm of MAPS. METHODS Thirteen adolescents participating in MAPS and eighteen family members attended in-depth audio-recorded interviews to discuss trial treatments. Interviews were analysed using inductive Thematic Analysis, identifying salient themes across these accounts. FINDINGS Family members in particular reported an urgent need for treatment regardless of type. Both AP and PI were broadly viewed as acceptable treatment approaches, but for differing reasons which participants weighed against a range of concerns. AP were often seen to reduce symptoms of psychosis, though participants expressed concerns about side effects. PI were viewed as interactive treatment approaches that helped improve understanding of psychosis and enhanced coping, although some found PI emotionally and cognitively challenging. Combining treatments was seen to maximise benefits, with a perceived interaction whereby AP facilitated engagement with PI. INTERPRETATION Acceptability of and engagement with treatments for FEP may differ between individual young people and their family/carers. In order to be able to offer fully informed choices, and determine an optimum treatment approach for young people with FEP, definitive trial evidence should be established to determine wanted and unwanted treatment impacts. FUNDING NIHR HTA programme (project number 15/31/04).
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Affiliation(s)
- R.E. Byrne
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich M25 3BL, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
| | - J.C. Bird
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX4 7JX, UK
| | - S. Reeve
- Department of Clinical, Educational, and Health Psychology, University College London, WC1E 6BT, UK
| | - W. Jones
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich M25 3BL, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
| | - D. Shiers
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich M25 3BL, UK
| | - A.P. Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich M25 3BL, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
| | - M. Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich M25 3BL, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
| | - S. Peters
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
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RE B, S R, JC B, W J, D S, AP M, M P, S P. Clinicians' views of treatment types for first episode psychosis delivered in a randomised controlled trial (MAPS). EClinicalMedicine 2020; 24:100421. [PMID: 32775968 PMCID: PMC7393656 DOI: 10.1016/j.eclinm.2020.100421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinicians' treatment beliefs could affect the feasibility of delivering different treatments in a randomised controlled trial (RCT). In MAPS (Managing Adolescent first Episode Psychosis: a feasibility Study), adolescents with first episode psychosis (FEP) were randomly allocated to receive either antipsychotic medication (AP), psychological intervention (cognitive behavioural therapy [CBT] and family intervention [FI]), or both. We conducted a nested qualitative study to investigate clinicians' views of these treatments. METHODS Purposive sampling identified seventeen clinicians from CAMHS and Early Intervention services with prescribing responsibilities for 14-18 year olds at three participating MAPS sites. Individual participants were interviewed to examine their views of treatments in the MAPS trial. Interview transcripts were analysed using inductive Thematic Analysis. FINDINGS Clinicians viewed the decision to refer adolescents to the MAPS trial as requiring careful clinical judgement. Assessment complexity and diagnostic uncertainty had to be balanced against the urgency for treatment to reduce risk and distress. Underlying influences including duty of care and treatment beliefs underpinned decisions. Clinicians consistently valued AP as the primary treatment for FEP, with CBT and/or FI seen as helpful secondary treatment options. Nevertheless, the potential harms of prescribing AP, or not, to such a young population were highlighted as being of concern in treatment decision-making, and fostered reluctance to refer into a RCT. INTERPRETATION The design and delivery of RCTs involving young people experiencing FEP should consider the views of responsible clinicians, recognising that perceived treatment urgency, limitations in diagnostic precision, and existing treatment beliefs may influence trial processes. FUNDING NIHR HTA programme (project number 15/31/04).
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Affiliation(s)
- Byrne RE
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, M25 3BL, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
| | - Reeve S
- Department of Clinical, Educational, and Health Psychology, University College London, WC1E 6BT
| | - Bird JC
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Jones W
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, M25 3BL, UK
| | - Shiers D
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, M25 3BL, UK
| | - Morrison AP
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, M25 3BL, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
| | - Pyle M
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, M25 3BL, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
| | - Peters S
- Division of Psychology and Mental Health, University of Manchester, Manchester, M13 9PL, UK
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