Practical Guidance for Studies Using Freelisting Interviews.

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

Study Protocol: Type III hybrid Effectiveness-Implementation Study Implementing Age-Friendly Evidence-Based Practices in the VA to Improve Outcomes in Older Adults

Background Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an “Age-Friendly Health System” to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on “4Ms” that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person’s goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an “Age-Friendly Health System,” leading to reduced harm and improved outcomes in older adults. Methods We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place – Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while “facility-free days” is our primary effectiveness outcome across evidence-based practice interventions. Discussion To our knowledge, this is the first large-scale randomized effort to implement “Age-Friendly” aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities. Trial registration Registered 05 May 2021, at ISRCTN #60,657,985

Application of the Social-Ecological Framework to Understand Breastfeeding Outcomes in Women Veterans

Introduction: While breastfeeding is a major public health priority and provides numerous benefits to mother and child, women veterans encounter many barriers to initiating and sustaining breastfeeding. For women veterans, barriers to breastfeeding may be compounded by their military experiences or, conversely, may be decreased by the sources of support that are uniquely available to them by Veterans Health Administration (VHA). Methods: This investigation utilized a survey of a cohort of 363 women veterans, interviewed before and after delivery, who were enrolled in care at a national sample of VA facilities. Using the Social Ecological Model, regression analyses were used to explore the relationship between breastfeeding at 4 weeks postpartum and maternal/infant characteristics, interpersonal dynamics, community influences, and system factors. An additional analysis was conducted to determine the extent to which military sexual trauma (MST) moderated the relationship between a set of individual, interpersonal, community, and system factors and breastfeeding at 4 weeks postpartum. Results: Eighty percent of women Veterans in this study were breastfeeding at 4 weeks postpartum. Employment, deployment history, traumatic brain injury (TBI) and geographic region were significantly related to breastfeeding at 4 weeks in the multivariate model. Self-employed mothers were 3.5 times more likely to breastfeed than those who were employed outside the home. Women Veterans with TBI were significantly less likely to breastfeed at 4 weeks. Mothers who had been deployed at any point in their military career were 2.2 times more likely to be breastfeeding than those who never deployed. This analysis also found significant variation in odds of breastfeeding by geographic region, with southern Veteran service areas having significantly lower rates than all other regions. MST was not a significant predictor of breastfeeding at 4 weeks but was a significant moderator of the relationship between mother’s age and breastfeeding. Conclusion: In this population of women Veterans, breastfeeding rates were comparable to those in the general population at 4 weeks postpartum. More research is needed to examine rates at 6 months and 1 year postpartum. Support for breastfeeding Veterans should account for their military experience and any related injuries incurred during military service

Increasing the Acceptability of Lethal Means Safety Counseling for Firearms: Tips and Scripts for Clinicians, Health System Leaders, and Researchers

In lethal means safety counseling (LMSC), clinicians encourage patients to limit their access to common and lethal means of suicide, especially firearms. However, clinicians may hesitate to deliver this evidence-based intervention. By conducting a systematic review of the growing number of qualitative studies examining stakeholder perspectives on LMSC, we identified stakeholder-recommended strategies for clinicians, health system leaders, and researchers to increase LMSC acceptability. We conducted a pre-registered, comprehensive search for studies up to February 2021 using PubMed and PsycInfo. Thematic synthesis, with an inductive and iterative approach, was used to analyze findings. Eighteen studies examined the perspectives of a various stakeholders across multiple clinical settings on LMSC for firearms. Using relevant themes, we describe strategies and present scripts, rationales, and resources that may increase LMSC acceptability. Clinicians may approach LMSC in a nonjudgmental manner with awareness of their own biases, demonstrate cultural competency by acknowledging the role of firearms in patient’s lives, and adapt LMSC to patients’ previous experiences with firearms, safety, and injury. Clinicians can contextualize and provide a rationale for LMSC, decide whether or not to ask about access to firearms, and recommend a range of storage options tailored to the patient. Free locking devices or coupons for purchasing devices may be distributed. These strategies for potentially increasing the acceptability of LMSC for firearms are the first to be based on a comprehensive set of studies generated by diverse stakeholders. Future efforts should focus on testing them empirically and considering them alongside other relevant outcomes (e.g., feasibility, efficacy)

Disparities in Breastfeeding Among Military Veterans

BACKGROUND: Although breastfeeding is a major public health priority and provides numerous benefits, women veterans encounter many barriers to initiating and sustaining breastfeeding. Women veterans are a growing population with unique health care needs related to exposures and injuries experienced during military service. These military experiences are linked to health diagnoses known to impact postpartum health behaviors, such as breastfeeding. RESEARCH AIM: The aim of this study was to identify factors associated with breastfeeding at 4 weeks postpartum among women veterans. METHODS: We used 2016-to-2018 survey data from women veterans (N = 420), interviewed before and after delivery, who were enrolled in maternity care coordination at a national sample of Veterans Health Administration facilities. Using the social ecological model, logistic regression was employed to explore the relationship between breastfeeding at least 4 weeks and postpartum and maternal/infant characteristics, interpersonal dynamics, community influences, and system factors. RESULTS: The rate of breastfeeding at 4 weeks postpartum was 78.6% among this sample of veterans. Self-employed participants were 2.8 times more likely to breastfeed than those who were employed outside the home. Participants who had been deployed at any point in their military career were twice as likely to breastfeed compared with those who never deployed. In this study sample, race independently predicted lower rates of breastfeeding, with African American participants being 48% less likely to breastfeed as compared with white participants. CONCLUSION: Our analysis suggests significant racial disparities in breastfeeding within veteran populations utilizing Veterans Health Administration, despite access to multiple sources of support from both the Veterans Health Administration and the community

Characterizing Twitter Content About HIV Pre-exposure Prophylaxis (PrEP) for Women: Qualitative Content Analysis

BackgroundHIV remains a persistent health problem in the United States, especially among women. Approved in 2012, HIV pre-exposure prophylaxis (PrEP) is a daily pill or bimonthly injection that can be taken by individuals at increased risk of contracting HIV to reduce their risk of new infection. Women who are at risk of HIV face numerous barriers to HIV services and information, underscoring the critical need for strategies to increase awareness of evidence-based HIV prevention methods, such as HIV PrEP, among women. ObjectiveWe aimed to identify historical trends in the use of Twitter hashtags specific to women and HIV PrEP and explore content about women and PrEP shared through Twitter. MethodsThis was a qualitative descriptive study using a purposive sample of tweets containing hashtags related to women and HIV PrEP from 2009 to 2022. Tweets were collected via Twitter’s API. Each Twitter user profile, tweet, and related links were coded using content analysis, guided by the framework of the Health Belief Model (HBM) to generate results. We used a factor analysis to identify salient clusters of tweets. ResultsA total of 1256 tweets from 396 unique users were relevant to our study focus of content about PrEP specifically for women (1256/2908, 43.2% of eligible tweets). We found that this sample of tweets was posted mostly by organizations. The 2 largest groups of individual users were activists and advocates (61/396, 15.4%) and personal users (54/396, 13.6%). Among individual users, most were female (100/166, 60%) and American (256/396, 64.6%). The earliest relevant tweet in our sample was posted in mid-2014 and the number of tweets significantly decreased after 2018. We found that 61% (496/820) of relevant tweets contained links to informational websites intended to provide guidance and resources or promote access to PrEP. Most tweets specifically targeted people of color, including through the use of imagery and symbolism. In addition to inclusive imagery, our factor analysis indicated that more than a third of tweets were intended to share information and promote PrEP to people of color. Less than half of tweets contained any HBM concepts, and only a few contained cues to action. Lastly, while our sample included only tweets relevant to women, we found that the tweets directed to lesbian, gay, bisexual, transgender, queer (LGBTQ) audiences received the highest levels of audience engagement. ConclusionsThese findings point to several areas for improvement in future social media campaigns directed at women about PrEP. First, future posts would benefit from including more theoretical constructs, such as self-efficacy and cues to action. Second, organizations posting on Twitter should continue to broaden their audience and followers to reach more people. Lastly, tweets should leverage the momentum and strategies used by the LGBTQ community to reach broader audiences and destigmatize PrEP use across all communities

The Moderating Effects of HIV-relevant Factors on the Relationship between Intimate Partner Violence and Intention to Start HIV Pre-Exposure Prophylaxis (PrEP) among Cisgender Women

Background: Intimate partner violence (IPV) and HIV are serious and related public health problems that detrimentally impact women’s health. Because women who experience IPV are more likely to acquire HIV, it is critical to promote HIV prevention strategies, such as HIV pre-exposure prophylaxis (PrEP), that increase autonomy. Setting: This study of cis-gender women eligible for HIV PrEP took place between 2017 and 2019 in Philadelphia and New York City. Methods: This study aimed to examine the relationship between four types of IPV (control, psychological, psychological, physical, sexual) and intention to start PrEP among PrEP-eligible cisgender women; and assess the extent to which HIV relevant factors moderate the association between IPV experience and intention to start PrEP. Results: In this sample (n=214) of PrEP-eligible women, 68.7% indicated intention to start PrEP in the next 3 months. Ethnicity was strongly associated with intention to start PrEP, with Hispanic women having the highest odds of intending to start PrEP in the next 3 months. Having a controlling partner significantly predicted intention to start PrEP. Women with more than one sex partner, any IPV in the past 12 months, past 12-month sexual IPV, or a controlling partner had higher odds of intending to start PrEP as compared with those who had one or no partners and had no IPV. Conclusion: These findings point to a need for patient-centered interventions that address the need for safety and autonomy among cisgender, PrEP-eligible women

Cancer Survivors with Unmet Needs were More Likely to use Complementary and Alternative Medicine

PURPOSE: Despite advancements in cancer care, cancer survivors continue to experience a substantial level of physical and emotional unmet needs (UMN). This study aims to determine the relationship between patients\u27 perceived UMN and their use of complementary and alternative medicine (CAM) to help with cancer problems during and after treatment. METHODS: A mailed, cross-sectional survey was completed by 614 cancer survivors identified through the Pennsylvania Cancer Registry 3.5 to 4 years from initial diagnosis. Relationships among UMN and CAM use along with clinical and socio-demographic factors were examined. RESULTS: Respondents who identified any UMN were 63% more likely to report CAM use than those without UMN (58% vs. 36%), p \u3c 0.001. UMN remained the only independent predictor (adjusted odds ratio = 2.30, 95% confidence interval = 1.57-3.36, p \u3c 0.001) of CAM use in a multivariate logistic regression model that included age, sex, marital status, education, previous chemotherapy and radiotherapy. Adjusted for covariates, UMN in domains of emotional, physical, nutritional, financial, informational, treatment-related, employment-related, and daily living activities were all related to CAM use, whereas UMN in transportation, home care, medical staff, family and spirituality were not related to CAM use. Patients who experienced multiple types of unmet needs were also more likely to use multiple types of CAM (p \u3c 0.001 for model). CONCLUSIONS: Cancer survivors who experienced unmet needs within the existing cancer treatment and support system were more likely to use CAM to help with cancer problems. Research is needed to determine if appropriate CAM use decreases unmet needs among cancer survivors

Cancer Survivors with Unmet Needs were More Likely to use Complementary and Alternative Medicine

PURPOSE: Despite advancements in cancer care, cancer survivors continue to experience a substantial level of physical and emotional unmet needs (UMN). This study aims to determine the relationship between patients\u27 perceived UMN and their use of complementary and alternative medicine (CAM) to help with cancer problems during and after treatment. METHODS: A mailed, cross-sectional survey was completed by 614 cancer survivors identified through the Pennsylvania Cancer Registry 3.5 to 4 years from initial diagnosis. Relationships among UMN and CAM use along with clinical and socio-demographic factors were examined. RESULTS: Respondents who identified any UMN were 63% more likely to report CAM use than those without UMN (58% vs. 36%), p \u3c 0.001. UMN remained the only independent predictor (adjusted odds ratio = 2.30, 95% confidence interval = 1.57-3.36, p \u3c 0.001) of CAM use in a multivariate logistic regression model that included age, sex, marital status, education, previous chemotherapy and radiotherapy. Adjusted for covariates, UMN in domains of emotional, physical, nutritional, financial, informational, treatment-related, employment-related, and daily living activities were all related to CAM use, whereas UMN in transportation, home care, medical staff, family and spirituality were not related to CAM use. Patients who experienced multiple types of unmet needs were also more likely to use multiple types of CAM (p \u3c 0.001 for model). CONCLUSIONS: Cancer survivors who experienced unmet needs within the existing cancer treatment and support system were more likely to use CAM to help with cancer problems. Research is needed to determine if appropriate CAM use decreases unmet needs among cancer survivors