Disclaimer

Michael A. Mitchell, M.A., Advanced Fellow
VAPHS Interdisciplinary Addiction Program for Education and Research
&
James Conley, B.A., Research Health Science Specialist
VA Pittsburgh Healthcare System, Pittsburgh, PA
Disclaimer
•
The opinions expressed herein are those of the authors
and do not necessarily reflect those of the U.S.
Government, or any of its agencies.
Acknowledgments
•
Co-Authors
• Lauren Matukaitis Broyles, Gala True, Keri Rodriguez, Daniel
Hedayati, Adam Gordon
•
Consultants/Advisors
• David Mancuso, VA Pittsburgh’s H-PACT
• Salva Balbale, Center for Evaluation of Practices and Experiences of Patient-Centered
Care, Hines VA Medical Center
•
This material is based upon work supported in part by
• Office of Academic Affiliations
• Health Services Research and Development Service
• VISN4 Mental Illness Research, Education and Clinical Center
• Resources and use of facilities at VA Pittsburgh Healthcare System
Objectives
1. Describe 2 major areas in homeless Veteran research
2. Identify 2 different approaches to visual-based data
collection
3. Describe implementation strategies for using visualbased qualitative data collection methods
4. Establish a discussion about potential use of visualbased methods at your local facilities
Photo credits:
Veteran: http://www.thepeoplesvoice.org/
Developing Patient-Centered Care
• Patient preferences
• Needs
• Values
• Experience of illness
• Experience with
healthcare
Institute of Medicine (2001).
System for the 21st Century
Crossing the Quality Chasm: A New Health
. Washington, D.C.: National Academy Press.
Implementing Patient-Centered
Care
Personalized
• Pro-active
• Patient-driven
•
Patient-Centered Medical Homes for
Homeless Veterans
Primary
Care
Specific
Needs
PACT
Access
Partnerships
Vetera
n
Homeles
s
Services
TeamTeambased
Addictio
n
Services
Coordination
Mental
Health
Services
10
Gabrielian, S. et al. (2014). Primary Care Medical Services for Homeless Veterans. Federal Practitioner.
H-PACT Preliminary Findings
25%
28%
System
Reduction ED
use
Hospitalizations
Provider
Patient
http://www.endveteranhomelessness.org/sites/default/files/H-PACT_Newsletter_April2014_Final.pdf
How are we assessing health care
experiences?
Explain
Understand
Engage
Addiction Researchers and Call to
Action
(2005)
(2008)
(2014)
De Silva DM (2013) Measuring Patient
Experience. Evidence Scan. London: the Health
Foundation
Asking
Inquiring
Kertesz, S. G., Pollio, D. E., Jones, R. N., Steward, J., Stringfellow, E. J., Gordon, A. J., ... & Holt, C. L. (2014).
Development of the Primary Care Quality-Homeless (PCQ-H) Instrument: A Practical Survey of Homeless
Patients’ Experiences in Primary Care. Medical care, 52(8), 734-742
Engaging
Using Pictures: An Innovative
Approach
PhotoVoice
Methodology Community-based
Procedures
•
•
•
•
•
•
Purpose
Participants create photo
prompts
Participant-produced
photos
Community needs
assessment
Group interviews with
pictures
Collaborative analysis
Photo/art exhibit
Advocacy, call to action and
change in the community
PhotoPhoto-Elicitation Interviews
Participatory-based
•
•
•
•
Researcher creates photo
prompts
Research or participantproduced photos
Individual interviews to
discuss pictures
Photos accompany research
dissemination (e.g.,
manuscripts)
Enhance qualitative research
methods
Exemplars of PhotoVoice, PhotoElicitation
Pictures are platforms for patients to
communicate their perception
Photographer: “Keith H”
Project: From War to Home (PI: True)
Photographer: “MDK”
Project: From War to Home (PI: True)
Positive Feedback on Using Participatory
Photography as Data Collection Method
Investigator
• Greater detail
• New information
• Rapport
“The most common experience
conducting PEIs was that
photographs spurred meaning that
otherwise might have remained
dormant in a face-to-face interview”
(Clark-Ibanez, 2007)
Participant
‘A photograph is worth a thousand
words, and it’s easier for me to
• Thoughtful/insightful discussion at interviewexplain it by showing you a
photograph than just say what I like
what the VA has to offer’ (qtd In
• Freedom, creative control
Balbale et al., 2014)
Padgett, D. K., Smith, B. T., Derejko, K. S., Henwood, B. F., & Tiderington, E. (2013). A Picture Is Worth...? Photo Elicitation
Interviewing With Formerly Homeless Adults. Qualitative health research, 23(11), 1435-1444.
Clark-Ibanez, M. (2004). Framing the social world with photo-elicitation interviews. American behavioral scientist, 47(12), 15071527.
Balbale, S. N., Morris, M. A., & LaVela, S. L. (2014). Using Photovoice to Explore Patient Perceptions of Patient-Centered Care in
the Veterans Affairs Health Care System. The Patient-Patient-Centered Outcomes Research, 7(2), 187-195.
Visual-based methods to amplify
patient voices
National Archives and Records Administration
www.archives.gov
Homeless Veterans’ Opinions of
Integrated Care Environments (“HVOICE”)
•
Purpose
• To explore attitudes about health and health care experiences
among Veterans who are homeless/at-risk to become homeless
using innovative qualitative methods
•
Implications
• Inform researchers, clinical providers, and hospital administrators
Design and Methods
•
•
•
•
•
Exploratory design
n~25 Veterans receiving care at VAPHS H-PACT
Participant-generated photographs
Photo-elicitation, qualitative interviews
Exit survey evaluating patient acceptability
28
Study Flow
• Research Visit 1
• Demographics, health baseline survey
• Photography orientation session
• Instructions for photo journaling session #1 (“Health”)
• Research Visit 2
• Interview with pictures
• Instructions for photo journaling session #2 (“Quality,
Access”)
• Research Visit 3
• Interview with pictures
• Exit survey
• New memory card
Photo-elicitation Prompts
Session 2: Quality and Access
(1) What is good healthcare?
(2) What has helped you get to your VA primary care
appointments and other healthcare services?
(3) What kind of barriers do you face getting to your VA
primary care appointments and any other healthcare services?
(4) What was your life like before and after you started
receiving services from primary care?
29
Exit Survey
•
Reactions to Research Participation Scale
• 21 item; 5-point Likert Scale (strongly disagree- strongly agree)
• 5 factors (Participation; Personal benefits; Emotional reactions;
Perceived drawbacks; Global evaluation)
• “I found participating in this study personally meaningful”
• “I believe this study’s results will be useful to others”
• “I found participating in this study boring”
Likert-scale items based on qualitative and visual
methods literature
• Open-ended prompts
•
Newman, E., & Kaloupek, D. G. (2004). The risks and benefits of participating in trauma-focused research studies. Journal of
traumatic stress, 17(5), 383-394.
30
Conclusion
“If we are truly to achieve a health care system
that is patientpatient-centered,
centered we must continue
to search for creative
ways to elicit, and
heed, the voice of the patient”
Sofaer, S., & Firminger, K. (2005). Patient perceptions of the quality of health services. Annu. Rev. Public Health, 26, 513-559.
Lessons from Establishing A
Visual Research Methods Study
Four Areas
•Study Conceptualization and Design
•Grant Writing and Funding
•Stakeholders
•Gatekeepers
Research and Quality
Improvement
Study Conceptualization and
Design
…and do it early
Study Conceptualization and
Design
X Qualitative methods
X Homeless veterans
X Veterans Affairs environment
X Visual research methods
…and do it early
Consider your
Patient population
Compounded Complexity
Transportation
Retention
Data security and control
Participant coercion
Consider your
Patient population
Grant Writing
and Reviewers
Grant Writing
and Reviewers
Consider your audience
Defend your method
Speak the language
Notes on budgeting
One: Staff
research assistant(s)
qualitative lead
visual method lead
Notes on budgeting
Two: Materials and Services
cameras and storage
audio capture
transcription
printing considerations
Notes on budgeting
Stakeholders
Stakeholders
Understanding the culture
Participant engagement and
recruitment
Interviewing
Gatekeepers
Start before the gun
Allies not antagonists
Anticipate questions
Taking your time
Gatekeepers
Funding Opportunities
•
“Directory of Funding Sources for Community-Based
Participatory Research”
• http://depts.washington.edu/ccph/pdf_files/directory-062704f.pdf
Additional Resources
•
Homeless Veterans
• VA National Center on Homelessness among Veterans
http://www.va.gov/homeless/nationalcenter.asp
•
Ethical, logistical considerations
• Photovoice organization: http://photovoice.org/
• Wang, C. C., & Redwood-Jones, Y. A. (2001). Photovoice ethics:
Perspectives from Flint photovoice. Health Education & Behavior,
28(5), 560-572.
•
Gala True’s CBPR project with OEF/OIF Veterans
http://www.va.gov/FromWarToHome/
Group Discussion
• How are you assessing patient satisfaction
at your facility?
• Do you think your facility would be open to
visual-based research/evaluation methods?
• Questions? Comments?
Contact Information
Michael A. Mitchell, M.A.
Michael.mitchell10@va.gov
412-360-2139 (office)
James Conley, B.A.
James.Conley@va.gov
(412) 360-2674 (office)
VA Pittsburgh Healthcare System (VAPHS)
University Drive C (151C)
Pittsburgh, PA 15240-1001
Numbers
•
Homeless Individuals and Veterans
• 633,782 homeless people (individuals and families) (2012)
• 62,619 Veterans (2012)
•
H-PACT
• 2012 VHA funded 32 pilot sites
• 10,584 (patients enrolled to date) with 44 sites actively enrolling
(May 2014)
https://www.hudexchange.info/resources/documents/2012AHAR_PITEstimates.pdf
http://www.endveteranhomelessness.org/programs/homeless-pact
Homeless Veterans Sample
Characteristics
•
Survival/
• “Qualitative studies employing longitudinal, ethnographic
methods to investigate the distinct experiences of
homeless Veterans will help researchers to understand
what is unique about Veteran exposure to risk factors
common to the general homeless population. This
remains poorly understood at present but may have
important implications for designing homelessness
prevention programs that will be effective for Veterans”
News headlines/taglines
Jerry Tovo- “They may have been Heroes” project about
photographing/photo-journalism with homeless veterans
across the country
• “Armed with cameras, Anchorage’s homeless document
their world”
•
• http://www.adn.com/slideshow/photos-armed-cameras-
anchorages-homeless-document-their-world
•
Bridge House Humanity Project Launch and Art Show
• http://www.dailycamera.com/news/boulder/ci_25853814/boulder-
photography-project-contrasts-homeless-housed-lives
•
Pictures of Hope (homeless children)
• http://www.mlive.com/news/flint/index.ssf/2014/07/pictures_of_hop
e_helps_give_a.html
De Silva (2013)
CBPR
•
“Collaborative approach to research that equitably
involves all partners in the research process and
recognizes the unique strengths that each brings. CPBR
begins with a research topic of importance to the
community with the aim of combining knowledge and
action for social change to improve community health and
eliminate health disparities”
58
Future Directions
Activity/Exercise
Program or Needs Assessment
• Ask to take pictures about their experiences with the
conference and recommendations for next year
• Set-up email account
• Include 1-2 sentence description (since not doing PEI)
•
•
“Insanity: doing the same thing over and over again and
expecting different results”
• Einstein
•
“Not everything that counts can be counted, and not
everything that can be counted counts”
• Einstein on data collection
If you could re-do one element of the
project, what would that be?
•
Stakeholder engagement from the very beginning and
throughout the research process, adopting more truly a
CBPR/collaborative approach
• Identifying RQ, data collection methods, analysis, dissemination