Evaluating the implementation and use of the regional cancer plan in Western Sweden through concept mapping.

QUALITY PROBLEM OR ISSUE: Within healthcare, policy documents are often used to strategically standardize, streamline or change how general health issues are managed for a specific patient group or treatment. Despite significant effort in developing policy and strategic planning documents, these may not have the intended impact and their value has long been questioned by practitioners. CHOICE OF SOLUTION: To identify barriers and affordances for the implementation and use of a strategic plan for cancer care in the Western Sweden Healthcare Region, we used Concept Mapping; a participatory mixed method approach to inquiry consisting of both qualitative and quantitative tasks intended to elicit and integrate the diverse perspectives of multiple stakeholders. IMPLEMENTATION: The study was carried out between April and October 2017 and consisted of several sequential data collection steps: idea generation, sorting and rating ideas for importance and feasibility. Stakeholders from different levels and professions in cancercare participated, but the number varied in the separate steps of data collection: idea generation (n = 112), sorting (n = 16) and rating (n = 38). EVALUATION: A concept map visualized seven areas that stakeholders throughout the cancer-care process considered necessary to address in order to enable the implementation of the plan. Skills provision was considered the most important cluster but also rated as least feasible. A consistent theme emerged that information, or lack thereof, might be a barrier for the plan being put into action to a greater extent in the cancer-care units. Nine actionable ideas rated highly on both importance and feasibility were presented as a go-zone. LESSONS LEARNED: Our results suggest that efforts might be better spent on ensuring information about and accessibility to strategic documents throughout the organization, rather than frequently updating them or producing new ones. Having sufficient skills provision seems to be the prerequisite for successful implementation.

Resident perspectives on communication training that utilizes immersive virtual reality.

BACKGROUND: Communication skills can be difficult to teach and assess in busy outpatient settings. These skills are important for effective counseling such as in cases of influenza vaccine hesitancy. It is critical to consider novel educational methods to supplement current strategies aimed at teaching relational skills. METHODS: An immersive virtual reality (VR) curriculum on addressing influenza vaccine hesitancy was developed using Kern's six-step approach to curriculum design. The curriculum was meant to teach best-practice communication skills in cases of influenza vaccine hesitancy. Eligible participants included postgraduate level (PL) 2 and PL-3 pediatric residents (n = 24). Immediately following the curriculum, a survey was administered to assess residents' attitudes toward the VR curriculum and perceptions regarding the effectiveness of VR in comparison to other educational modalities. A survey was administered 1 month following the VR curriculum to assess trainee-perceived impact of the curriculum on clinical practice. RESULTS: All eligible residents (n = 24) completed the curriculum. Ninety-two percent (n = 22) agreed or strongly agreed that VR simulations were like real-life patient encounters. Seventy-five percent (n = 18) felt that VR was equally effective to standardized patient (SP) encounters and less effective than bedside teaching (P < 0.001). At 1-month follow-up, 67% of residents (n = 16) agreed or strongly agreed that the VR experience improved how they counseled families in cases of influenza vaccine hesitancy. DISCUSSION: An immersive VR curriculum at our institution was well-received by learners, and residents rated VR as equally effective as SP encounters. As such, immersive VR may be a promising modality for communication training.

The use of concept mapping to identify community-driven intervention strategies for physical and mental health.

Research that partners with youth and community stakeholders increases contextual relevance and community buy-in and therefore maximizes the chance for intervention success. Concept mapping is a mixed-method participatory research process that accesses the input of the community in a collaborative manner. After a school-wide health needs assessment at a low-income, minority/immigrant K-8 school identified bullying and obesity as the most important health issues, concept mapping was used to identify and prioritize specific strategies to address these two areas. Stakeholders including 160 K-8 students, 33 college students working in the school, 35 parents, 20 academic partners, and 22 teachers/staff brainstormed strategies to reduce and prevent obesity and bullying. A smaller group of stakeholders worked individually to complete an unstructured sorting of these strategies into groups of similar ideas, once for obesity and again for bullying. Multidimensional scaling and cluster analysis was applied to the sorting data to produce a series of maps that illustrated the stakeholders' conceptual thinking about obesity and bullying prevention strategies. The maps for both obesity and bullying organized specific strategies into themes that included education, parental role, teacher/school supervision, youth role, expert/professional role, and school structure/support.

Using Concept Mapping Methods to Define "Healthy Aging" in Anchorage, Alaska.

This exploratory research project captured a multidimensional model of healthy aging in Anchorage, Alaska, by utilizing the Concept Mapping (CM) methodology with a sample of 53 older adults (aged 55+), aging advocates, public health professionals, and senior service providers. Multidimensional scaling and cluster analyses were conducted to map the relationship between 100 aspects of healthy aging, resulting in 12 distinct concepts of healthy aging. Study participants identified both lifestyle factors and aspects of their environment, providing results that can inform future research and policy development. The perspectives of older adults are scarce in the literature, but how they conceptualize the factors that contribute to healthy aging can have profound influence on behaviors and health outcomes. In addition, CM is a little-used methodology in gerontology that fosters community capacity building, meaningful contributions, and trusting research partnerships. We also provide recommendations for using these methods with older adults.

Image gently: a web-based practice quality improvement program in CT safety for children.

OBJECTIVE: Radiologists want to improve quality and safety to benefit their pediatric patients and to comply with new requirements of the American Board of Radiology for maintenance of certification. The purpose for this article is to describe the development, construction, and content of a free, Web-based practice quality improvement (PQI) module in CT safety for children. CONCLUSION: We describe an online tutorial accessible on the Image Gently Website that enables radiologists nationwide to perform PQI in CT safety for pediatric patients.

The Learning Exchange, a Community Knowledge Commons for Learning Networks: Qualitative Evaluation to Test Acceptability, Feasibility, and Utility.

BACKGROUND: Learning Networks are distributed learning health systems that enable collaboration at scale to improve health and health care. A key requirement for such networks is having a way to create and share information and knowledge in furtherance of the work of the community. OBJECTIVE: We describe a Learning Exchange-a bespoke, scalable knowledge management and exchange platform initially built and tested for improving pediatric inflammatory bowel disease outcomes in the ImproveCareNow (ICN) Network-and assess evidence of its acceptability, feasibility, and utility in facilitating creation and sharing of information in furtherance of the work of the community and as a model for other communities. METHODS: Acceptability was assessed via growth in active users and activity. Feasibility was measured in terms of the percentage of users with a log-in who became active users as well as user surveys and a case study. Utility was measured in terms of the type of work that the Learning Exchange facilitated for the community. RESULTS: The ICNExchange has over 1000 users and supported sharing of resources across all care centers in ICN. Users reported that the Learning Exchange has facilitated their work and resulted in increased ability to find resources relevant to local information needs. CONCLUSIONS: The ICNExchange is acceptable, feasible, and useful as a knowledge management and exchange platform in service of the work of ICN. Experience with the ICNExchange suggests that the design principles are extensible to other chronic care Learning Networks.

And then the internet happened: Thoughts on the future of concept mapping.

Over 25 years ago, in the late twentieth century, concept mapping emerged as a mixed method approach to inquiry that enables a group of people to conceptualize their thinking about a specific topic. Since then, the application of concept mapping has spread widely and an easy prediction for the future is that this trend is likely to continue; a more important and greater challenge is to think about the ways in which concept mapping may and should evolve. Discussed here are thoughts about the future of concept mapping including some predictions of likely directions and suggestions for new possibilities. Thoughts on the future are grounded in concept mapping applications that have emerged and gained ground in recent years; these include exploring wicked problems in communities and integrating concept mapping with other methods of inquiry. Thoughts on the future are also grounded in the social and cultural milieu in which we find ourselves at this time. The influence of social media and internet technologies has led to the emergence peer production and crowdsourcing as approaches to co-create information, knowledge, products and services. These tactics may create fertile ground for the further spread of concept mapping. This same collaborative milieu has produced the open software movement which in turn, offers opportunities to enhancing the methodology of concept mapping.

Introduction to a special issue on concept mapping.

Concept mapping was developed in the 1980s as a unique integration of qualitative (group process, brainstorming, unstructured sorting, interpretation) and quantitative (multidimensional scaling, hierarchical cluster analysis) methods designed to enable a group of people to articulate and depict graphically a coherent conceptual framework or model of any topic or issue of interest. This introduction provides the basic definition and description of the methodology for the newcomer and describes the steps typically followed in its most standard canonical form (preparation, generation, structuring, representation, interpretation and utilization). It also introduces this special issue which reviews the history of the methodology, describes its use in a variety of contexts, shows the latest ways it can be integrated with other methodologies, considers methodological advances and developments, and sketches a vision of the future of the method's evolution.

A Virtual Reality Curriculum for Pediatric Residents Decreases Rates of Influenza Vaccine Refusal.

OBJECTIVE: Influenza vaccine hesitancy is common in the primary care setting. Though physicians can affect caregivers' attitudes toward vaccination, physicians report uneasiness discussing vaccine hesitancy. Few studies have targeted physician-patient communication training as a means to decrease vaccination refusal. METHODS: An immersive virtual reality (VR) curriculum was created to teach pediatric residents communication skills when discussing influenza vaccine hesitancy. This pilot curriculum consisted of 3 VR simulations during which residents counseled graphical character representatives (avatars) who expressed vaccine hesitancy. Participants were randomized to the intervention (n = 24) or control (n = 21) group. Only residents in the intervention group underwent the VR curriculum. Impact of the curriculum was assessed through difference in influenza vaccine refusal rates between the intervention and control groups in the 3 months after the VR curriculum. RESULTS: Participants included postgraduate level (PL) 2 and PL3 pediatric residents. All eligible residents (n = 45) participated; the survey response rate was 100%. In patients aged 6 to 59 months, residents in the intervention group had a decreased rate of influenza vaccination refusal in the postcurriculum period compared to the control group (27.8% vs 37.1%; P = .03). CONCLUSIONS: Immersive VR may be an effective modality to teach communication skills to medical trainees. Next steps include evaluation of the curriculum in a larger, multisite trial.

See what we say: using concept mapping to visualize Latino immigrant's strategies for health interventions.

OBJECTIVES: Researchers need specific tools to engage community members in health intervention development to ensure that efforts are contextually appropriate for immigrant populations. The purpose of the study was to generate and prioritize strategies to address obesity, stress and coping, and healthcare navigation that are contextually appropriate and applicable to the Latino immigrant community in Cincinnati, Ohio, and then use the results to develop specific interventions to improve Latino health in our area. METHODS: A community-academic research team used concept mapping methodology with over 200 Latino immigrants and Latino-serving providers. A community intervention planning session was held to share the final concept maps and vote on strategies. RESULTS: The concept maps and results from the intervention planning session emphasized a community lay health worker model to connect the Latino immigrant community with resources to address obesity, stress and coping, and healthcare navigation. CONCLUSIONS: Concept maps allowed for the visualization of health intervention strategies prioritized by the larger Latino immigrant community. Concept maps revealed the appropriate content for health interventions as well as the process community members preferred for intervention delivery.

Mapping the Views of Adolescent Health Stakeholders.

PURPOSE: Health research that includes youth and family stakeholders increases the contextual relevance of findings, which can benefit both the researchers and stakeholders involved. The goal of this study was to identify youth and family adolescent health priorities and to explore strategies to address these concerns. METHODS: Stakeholders identified important adolescent health concerns, perceptions of which were then explored using concept mapping. Concept mapping is a mixed-method participatory research approach that invites input from various stakeholders. In response to prompts, stakeholders suggested ways to address the identified health conditions. Adolescent participants then sorted the statements into groups based on content similarity and rated the statements for importance and feasibility. Multidimensional scaling and cluster analysis were then applied to create the concept maps. RESULTS: Stakeholders identified sexually transmitted infections (STIs) and obesity as the health conditions they considered most important. The concept map for STIs identified 7 clusters: General sex education, support and empowerment, testing and treatment, community involvement and awareness, prevention and protection, parental involvement in sex education, and media. The obesity concept map portrayed 8 clusters: Healthy food choices, obesity education, support systems, clinical and community involvement, community support for exercise, physical activity, nutrition support, and nutrition education. Ratings were generally higher for importance than for feasibility. CONCLUSIONS: The concept maps demonstrate stakeholder-driven ideas about approaches to target STIs and obesity in this context. Strategies at multiple social ecological levels were emphasized. The concept maps can be used to generate discussion regarding these topics and to identify interventions.

Using concept mapping to mobilize a Black faith community to address HIV.

Research that partners with community stakeholders increases contextual relevance and community buy-in and maximizes the chance for intervention success. Within a framework of an academic-community partnership, this project assessed a Black faith-community's needs and opportunities to address HIV. We used concept mapping to identify/prioritize specific HIV-related strategies that would be acceptable to congregations. Ninety stakeholders brainstormed strategies to address HIV; 21 sorted strategies into groups and rated their importance and feasibility. Multidimensional scaling and cluster analysis were applied to the sorting to produce maps that illustrated the stakeholders' conceptual thinking about HIV interventions. Of 278 responses, 93 were used in the sorting task. The visual maps represented eight clusters: church acceptance of people living with HIV; education (most feasible); mobilization and communication; church/leaders' empowerment; church involvement/collaboration; safety/HIV prevention; media outreach; and, stigma (most important). Concept mapping clarified multifaceted issues of HIV in the Black faith community. The results will guide HIV programming in congregations.

A Pilot Study of the Creation and Implementation of a Teaching Development Assessment Tool.

BACKGROUND: The importance of effective clinical teaching skills is well established in the literature. However, reliable tools with validity evidence that are able to measure the development of these skills and can effectively be used by nonphysician raters do not exist. OBJECTIVE: Our initiative had 2 aims: (1) to develop a teaching development assessment tool (TDAT) that allows skill assessment along a continuum, and (2) to determine if trained nonphysicians can assess clinical teachers with this tool. METHODS: We describe the development of the TDAT, including identification of 6 global teaching domains and observable teaching behaviors along a 3-level continuum (novice/beginner, competent/proficient, expert) and an iterative revision process involving local and national content experts. The TDAT was studied with attending physicians during inpatient rounds with trained physician and nonphysician observers over 6 months. RESULTS: The TDAT showed emerging evidence of content, construct, and viable validity (the degree to which an assessment tool is practical, affordable, suitable, evaluable, and helpful in the real world) for the evaluation of attending physicians on inpatient rounds. Moderate to near perfect interrater reliability was seen between physician and nonphysician raters for the domains of promotion of clinical reasoning, control of the learning environment, ability to teach to multiple levels of learners, and provision of feedback. CONCLUSIONS: The TDAT holds potential as a valid and reliable assessment tool for clinical teachers to track the development of each individual's teaching skills along the continuum from early development to mastery.

Allergen sensitization profiles in a population-based cohort of children hospitalized for asthma.

RATIONALE: Allergen sensitization is associated with asthma morbidity. A better understanding of allergen sensitization patterns among children hospitalized for asthma could help clinicians tailor care more effectively. To our knowledge, however, sensitization profiles among children hospitalized for asthma are unknown. OBJECTIVES: We sought to describe allergen sensitization profiles and the distribution of self-reported in-home exposures among children hospitalized for asthma. We also sought to assess how sensitization profiles varied by sociodemographic and clinical factors. METHODS: This population-based cohort study includes data for 478 children, aged 4-16 years, hospitalized for an asthma exacerbation. Predictors included child age, race, sex, insurance status, reported income, salivary cotinine, exposure to traffic-related air pollution, asthma and atopic history, and season of admission. Outcomes included serum IgE specific to Alternaria alternata/A. tenuis, Aspergillus fumigatus, American cockroach, mouse epithelium, dust mite (Dermatophagoides pteronyssinus and farinae), cat dander, and dog dander (deemed sensitive if IgE ≥ 0.35). Self-reported adverse exposures included mold/mildew, water leaks, cockroaches, rodents, and cracks or holes in the walls or ceiling. Presence of carpeting and furry pets was also assessed. MEASUREMENTS AND MAIN RESULTS: More than 50% of included patients were sensitized to each of Alternaria, Aspergillus, dust mite, cat dander, and dog dander; 28% were sensitized to cockroach and 18% to mouse. Roughly 68% were sensitized to three or more allergens with evidence of clustering. African American children, compared with white children, were more likely to be sensitized to Alternaria, Aspergillus, cockroach, and dust mite (all P<0.01). White children were more likely to be sensitized to mouse, cat, and dog (all P<0.01). Lower income was associated with cockroach sensitization whereas higher income was associated with dog and cat sensitization (all P<0.01). Atopic history was associated with sensitization to three or more allergens (P<0.01). Although 42% reported exposure to at least one adverse in-home exposure (and 72% to carpet, 51% to furry pets), only weak relationships were seen between reported exposures and sensitizations. CONCLUSIONS: Most children admitted to the hospital for asthma exacerbations are sensitized to multiple indoor allergens. Atopy on the inpatient unit serves as a potential target for improvement in chronic asthma management.

Can a video curriculum on the social determinants of health affect residents' practice and families' perceptions of care?

INTRODUCTION: Screening and management of the social determinants of health (SDH) are critical for child health promotion. We sought to evaluate the impact of a facilitated video curriculum on resident SDH screening competence, parental perceptions of resident practice, resident-initiated referrals to a medical-legal partnership (MLP), and formula distribution to food-insecure families. METHODS: This was a pre-post study with concurrent control performed at a large pediatric residency program. Second- and third-year residents were assigned to control and intervention groups on the basis of their continuity clinic day. The curriculum included videotaped vignettes of screening for SDH and a "day in the life" series of families describing the impact of intervention on their lives. Residents completed self-assessments on screening competence and resource knowledge. After a well-child encounter, families (3 per resident) assessed their level of trust and respect for the resident and the number of SDHs screened for. MLP referral rates and formula distribution were compared. RESULTS: The intervention group's self-assessed competence in screening for housing, benefits, and educational concerns was significantly higher compared to controls (each P ≤ .05). Parents' rating of trust and respect was high and did not differ between groups. Screening for each SDH was higher in the intervention group with domestic violence (odds ratio 2.16, 95% confidence interval 1.01-4.63) and depression (odds ratio 2.63, 95% confidence interval 1.15-5.99), reaching statistical significance. MLP referral rates increased (P = .06), and formula distribution (P = .02) reached statistical significance in the intervention group. CONCLUSIONS: This SDH video curriculum improved resident self-assessed screening competence, parental perception of screening, and both MLP referrals and formula distribution.

Concept maps as network data: analysis of a concept map using the methods of social network analysis.

Concept mapping is a method that creates a visual representation that illustrates the thoughts, ideas, or planned actions that arise from a group of stakeholders on a particular issue. Social network analysis is a method that likewise creates a visual representation of data; a network map typically represents people and the connections, or lack thereof, between these people regarding a particular issue. While the goals of these two methods differ, the underlying data structures are similar; a network of relationships between data elements. Social network analysis is explored here as a supplement to concept mapping. A secondary analysis of a concept map to define to leadership needs was conducted using social network analysis. The methods and the implications for supplementing the analysis of concept maps and debriefing results with stakeholders are discussed.

Parental Health Attributions of Childhood Health and Illness: Development of the Pediatric Cultural Health Attributions Questionnaire (Pedi-CHAQ).

The causes attributed to childhood health and illness across cultures (cultural health attributions) are key factors that are now more frequently identified as affecting the health outcomes of children. Research suggests that the causes attributed to an event such as illness are thought to affect subsequent motivation, emotional response, decision making, and behavior. To date, there is no measure of health attributions appropriate for use with parents of pediatric patients. Using the Many-Facets approach to Rasch analysis, this study assesses the psychometrics of a newly developed instrument, the Pediatric Health Attributions Questionnaire (Pedi-CHAQ), a measure designed to assess the cultural health attributions of parents in diverse communities. Results suggest acceptable Rasch model statistics of fit and reliability for the Pedi-CHAQ. A shortened version of the questionnaire was developed as a result of this study and next steps are discussed.

Understanding the social networks of parents of children with sickle cell disease.

Although there is substantial literature documenting the challenges of pediatric sickle cell disease (SCD) for children and their parents, there is limited research identifying how parents prioritize their needs and use their social networks to manage information regarding their child's SCD in terms of physical and mental health. We examined parents' perceived needs regarding child health issues as they relate to SCD; who and what sources of information are utilized by parents regarding SCD; the frequency with which they consult these resources; and the level at which they trust them. Parents in this study reported that mothers, physicians, the Internet, and books were key sources of support, guidance, and counsel regarding the health needs of children with SCD. These three sources were rated high in importance, trust, frequency of contact, and perceived supportiveness toward mental and physical health needs.