Patient and Caregiver Perspectives on Implementation of ACE Screening in Pediatric Care Settings: A Qualitative Evaluation

INTRODUCTION

This qualitative research study explored the perspectives of adolescents, 12 to 19-years-old, and caregivers of children under 12-years-old on the acceptibility of adverse childhood experiences (ACEs) screenings in five pediatric clinics.

METHOD

A constructivist grounded theory approach was utilized. One-on-one semistructured phone interviews were conducted with 44 adolescents and 95 caregivers of children less than 12 years old. Interviews were analyzed using thematic analysis.

RESULTS

Most participants reported feeling comfortable discussing ACEs with their providers. Some reported that screening helped build trust. Others expressed privacy concerns and did not receive information about the reason for screening. Adolescent patients shared conflicting feelings-of both comfort and discomfort. Caregivers attending to multiple children, foster parents, and monolingual Spanish speakers disclosed unique challenges to ACEs screening. We found no evidence of lasting adverse effects.

DISCUSSION

Participants generally found ACEs screenings acceptable. Some adolescents identified benefits from the experience. However, clinics planning to adopt routine ACEs screening should ensure clear messaging on why screening is occurring, anticipate and address privacy concerns, and adopt workflows to discuss screening results.

Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics

PURPOSE

To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care.

METHODS

We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals.

RESULTS

Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening.

CONCLUSIONS

Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.

"They Just Helped Save My Life:" Client Perspectives on the Los Angeles County Full Service Partnership (FSP) Program for Serious Mental Illness

The purpose of this qualitative study was to elicit client perspectives on the Los Angeles County Full Service Partnership (FSP) program - an adaptation of Assertive Community Treatment (ACT). Semi-structured interviews were conducted with 20 FSP clients. Qualitative data were analyzed using thematic analysis. Two major themes were identified from the interview data: (1) Clients' acknowledgement of the material benefits of the FSP program; and (2) FSP's impact on restoring and stabilizing clients' social and treatment relationships. Interviewees greatly valued the material (i.e., basic needs, housing assistance) and relational (i.e., relationships with providers, restored personal relationships) aspects of the program, but did not ascribe the same degree of value to mental health treatment. Interviewees' emphases on material and relational aspects reflect the status of assertive mental health treatment as an intervention on intermediary determinants of health in the lives of persons diagnosed with serious mental illness.

A Qualitative Investigation of Preparedness for the Launch of 988: Implications for the Continuum of Emergency Mental Health Care

On July 16, 2022, the 988 mental health crisis hotline launched nationwide. In addition to preparing for an increase in call volume, many jurisdictions used the launch of 988 as an opportunity to examine their full continuum of emergency mental health care. Our goal was to understand the characteristics of jurisdictions' existing continuums of care, identify factors that distinguished jurisdictions that were more- versus less-prepared for 988, and explore perceived strengths and limitations of the planning process. We conducted 15 qualitative interviews with state and local mental health program directors representing 10 states based on their preparedness for the 988 rollout. Interviews focused on 988 call centers, mobile crisis response, and crisis stabilization, as well as strengths and limitations of the 988 planning process. Data were analyzed using rapid qualitative analysis, an approach designed to draw insights on evolving processes and extract actionable findings. Interviewees from jurisdictions that reported that they were more-prepared for the launch of 988 tended to have local 988 call centers and already had local access to mobile crisis teams and crisis stabilization units. Interviewees across jurisdictions described challenges to offering a robust continuum of crisis services, including workforce shortages and geographic constraints. Though jurisdictions acknowledged the importance of integrating peer support staff and serving diverse populations, many perceived room for growth in these areas. Though 988 has launched, efforts to bolster the existing continuum will continue and hinge on efforts to expand the behavioral health workforce, engage diverse partners, and collect relevant data.

Correspondence between the RAND-Negative Impact of Asthma on Quality of Life item bank and the Marks Asthma Quality of Life Questionnaire

BACKGROUND

In many research and clinical settings in which patient-reported outcome (PRO) measures are used, it is often desirable to link scores across disparate measures or to use scores from 1 measure to describe scores on a separate measure. However, PRO measures are scored by using a variety of metrics, making such comparisons difficult.

OBJECTIVE

The objective of this article was to provide an example of how to transform scores across disparate measures (the Marks Asthma Quality of Life Questionnaire [AQLQ-Marks] and the newly developed RAND-Negative Impact of Asthma on Quality of Life item bank [RAND-IAQL-Bank]) by using an item response theory (IRT)-based linking method.

METHODS

Our sample of adults with asthma (N = 2032) completed 2 measures of asthma-specific quality of life: the AQLQ-Marks and the RAND-IAQL-Bank. We use IRT-based co-calibration of the 2 measures to provide a linkage, or a common metric, between the 2 measures. Co-calibration refers to the process of using IRT to estimate item parameters that describe the responses to the scales' items according to a common metric; in this case, a normal distribution transformed to a T scale with a mean of 50 and an SD of 10.

RESULTS

Respondents had an average age of 43 (15), were 60% female, and predominantly non-Hispanic White (56%), with 19% African American, 14% Hispanic, and 11% Asian. Most had at least some college education (83%), and 90% had experienced an asthma attack during the last 12 months. Our results indicate that the AQLQ-Marks and RAND-IAQL-Bank scales measured highly similar constructs and were sufficiently unidimensional for IRT co-calibration. Once linked, scores from the 2 measures were invariant across subgroups. A crosswalk is provided that allows researchers and clinicians using AQLQ-Marks to crosswalk to the RAND-IAQL toolkit.

CONCLUSIONS

The ability to translate scores from the RAND-IAQL toolkit to other "legacy" (ie, commonly used) measures increases the value of the new toolkit, aids in interpretation, and will hopefully facilitate adoption by asthma researchers and clinicians. More generally, the techniques we illustrate can be applied to other newly developed or existing measures in the PRO research field to obtain crosswalks with widely used traditional legacy instruments.