Sarah Wiehe

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https://hdl.handle.net/1805/6823

Engaging the Community to Inform Patient-Centered Outcomes Research

Despite well-known associations between where a person lives and his/her health, few patient-centered approaches have been used to develop and implement place-based health interventions. For the first time in the United States, Avondale Meadows, a Purpose Built Community in Indianapolis, is incorporating health as part of its community development strategy.

Avondale Meadows is an 800-unit, mixed income housing development with a key emphasis on housing, education, and health. Now, nearly all units leased and health-related amenities, including a Health and Wellness Center, are about to be implemented. Dr. Wiehe, with a team of academic and community partners, have engaged all stakeholders, including current and future residents, to discuss how to improve the community’s health. Through mixed-methods and participatory design, the team has elicited and engaged residents to develop health-promoting interventions in their community. These ideas were presented back to the larger community for validation and further resident engagement. Now, as the community members are incorporated into the ‘research team,’ they will work together to translate their ideas into action.

Dr. Wiehe’s work to engage the community in ways to improve their health is another example of how IUPUI’s faculty members are TRANSLATING their RESEARCH INTO PRACTICE.

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Adolescent Health-Risk Behavior and Community Disorder
(2013-11) Wiehe, Sarah E.; Kwan, Mei-Po; Wilson, Jeffrey S.; Fortenberry, J. Dennis
Background Various forms of community disorder are associated with health outcomes but little is known about how dynamic context where an adolescent spends time relates to her health-related behaviors. Objective Assess whether exposure to contexts associated with crime (as a marker of community disorder) correlates with self-reported health-related behaviors among adolescent girls. Methods Girls (N = 52), aged 14–17, were recruited from a single geographic urban area and monitored for 1 week using a GPS-enabled cell phone. Adolescents completed an audio computer-assisted self-administered interview survey on substance use (cigarette, alcohol, or marijuana use) and sexual intercourse in the last 30 days. In addition to recorded home and school address, phones transmitted location data every 5 minutes (path points). Using ArcGIS, we defined community disorder as aggregated point-level Unified Crime Report data within a 200-meter Euclidian buffer from home, school and each path point. Using Stata, we analyzed how exposures to areas of higher crime prevalence differed among girls who reported each behavior or not. Results Participants lived and spent time in areas with variable crime prevalence within 200 meters of their home, school and path points. Significant differences in exposure occurred based on home location among girls who reported any substance use or not (p 0.04) and sexual intercourse or not (p 0.01). Differences in exposure by school and path points were only significant among girls reporting any substance use or not (p 0.03 and 0.02, respectively). Exposure also varied by school/non-school day as well as time of day. Conclusions Adolescent travel patterns are not random. Furthermore, the crime context where an adolescent spends time relates to her health-related behavior. These data may guide policy relating to crime control and inform time- and space-specific interventions to improve adolescent health.
Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya
(2009-04) Vreeman, Rachel C.; Nyandiko, Winstone M.; Sang, Edwin; Musick, Beverly S.; Braitstein, Paula; Wiehe, Sarah E.
Background: Kenya experienced a political and humanitarian crisis following presidential elections on 27 December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods: We conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and 25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre- and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort. ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue from was analyzed using constant comparison, progressive coding and triangulation. Results: Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642 on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence, a significant drop from 98% pre-election (p < 0.001). Children on ART were significantly more likely to return to clinic than those not on ART. Members of tribes targeted by violence and members of minority tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging priorities, and hopelessness. Conclusion: During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique program strengths may have minimized these disruptions.
Acceptance of HIV Testing for Children Ages 18 Months to 13 Years Identified Through Voluntary, Home-Based HIV Counseling and Testing in Western Kenya
(2010-10) Vreeman, Rachel C.; Nyandiko, Winstone M.; Braitstein, Paula; Were, Martin C.; Ayaya, Samwel O.; Ndege, Samson K.; Wiehe, Sarah E.
Background Home-based, voluntary counseling and testing (HCT) presents a novel approach to early diagnosis. We sought to describe uptake of pediatric HIV testing, associated factors, and HIV prevalence among children offered HCT in Kenya. Methods The USAID-AMPATH Partnership conducted HCT in western Kenya in 2008. Children 18 months to 13 years were offered HCT if their mother was known to be dead, her living status was unknown, mother was HIV-infected or of unknown HIV status. This retrospective analysis describes the cohort of children encountered and tested. Results HCT was offered to 2,289 children and accepted for 1,294 (57%). Children were more likely to be tested if more information was available about a suspected or confirmed maternal HIV-infection (for HIV-infected, living mothers OR=3.20, 95% CI: 1.64–6.23), if parents were not in household (OR=1.50, 95% CI: 1.40–1.63), if they were grandchildren of head of household (OR=4.02, 95% CI: 3.06–5.28), or if their father was not in household (OR=1.41, 95% CI: 1.24–1.56). Of the eligible children tested, 60 (4.6%) were HIV-infected. Conclusions HCT provides an opportunity to identify HIV among high-risk children; however, acceptance of HCT for children was limited. Further investigation is needed to identify and overcome barriers to testing uptake.
Listening to Patients and Talking to Doctors: A Case for Design in Medicine, & A Call to Action
(2014-03) Sanematsu, Helen; Wiehe, Sarah E.
This paper describes how design can work at a fundamental level to improve health in the United States. It argues for a design application that levels the playing field between the doctor and the patient in a way that re-establishes the person as the center of medical advancement. It uses the inclusion of a design research oriented Patient Engagement Core within a current study at the Indiana University School of Medicine as a way to demonstrate the relevance of design to health research. We touch upon the research environment established by the National Institutes of Health as a driver for the relevance of design in medicine, and finally, we suggest that designers use their visual communication and design research skills within health research to increase its relevancy to patients and the population, and ‘make the science stick’ through better understanding of patient perspectives. We assert that by entering discourse in health at this foundational stage we contribute to a new understanding of what health is, who might contribute to its improvement, who determines the relevancy of research, and how such research is used.
Center for Urban Health: Enhancing the health of cities by focusing on communities and the environment
(Office of the Vice Chancellor for Research, 2014-04-11) Filippelli, Gabriel; Johnson, Daniel P.; Wiehe, Sarah E.; Watson, Dennis P.
Urban sustainability is a new philosophy of developing healthy, productive communities that (1) promote and use locally-produced foods and products, (2) ensure safe access to natural spaces, and (3) establish low-carbon transportation systems. Urban living is arguably the most sustainable form of community given the concentration of resources, protection of arable land, and vertical structure of housing. In fact, urbanization is becoming the global norm; the percentage of global population living in urban settings has increased from less than 30% in 1950 to 47% in 2000; the percentage of urban dwellers is expected to increase to 60% by 2025. The promise of a healthy and sustainable urban future is clouded, however, by the reality of environmental insults, economic disparities, and behavioral pressures that exist in modern cities. The challenge is not how to build a shiny carbon-neutral city from scratch, but rather how to transition our current urban state toward one that is healthier, has less environmental impact, and is more prepared to respond and adjust to variety of environmental, social, and health changes in the future. Several groups at IUPUI and in the community are collaborating to explore connections between environment, behavior, health, and climate as related to urban environments. These translational efforts are inter- and trans-disciplinary, as evidenced by earth scientists publishing with pediatricians, and geographers publishing with epidemiologists. These efforts are largely undertaken with a geospatial and geotemporal research template. This template allows environmental, health, and behavioral data to be collected individually but with reference to space and time, which become important metadata components for analysis. The Center for Urban Health promotes discovery by building research collaborations among Center Investigators, conducting workshops on cutting-edge developments in urban health, and bridging campus and community efforts in public health, including the Reconnecting to Our Waterways (RWO) initiative.
Time From First Intercourse to First Sexually Transmitted Infection Diagnosis Among Adolescent Women
(2009-12) Tu, Wanzhu; Batteiger, Byron E.; Wiehe, Sarah E.; Ofner, Susan; Van Der Pol, Barbara; Katz, Barry P.; Orr, Donald P.; Fortenberry, J. Dennis
Objective To determine the time between first intercourse and first sexually transmitted infection (STI) with Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis and time between repeated infections. Design Observational study. Setting Three adolescent medicine clinics. Participants A cohort of 386 urban young women aged 14 to 17 years at enrollment. Main Outcome Measures Age at first intercourse; organism-specific interval between first intercourse and first STI diagnosis; interval between repeated infections; and age at first STI test prior to study participation. Results Participants had first intercourse at a young age (first, second, and third quartiles were 13, 14, and 15 years of age, respectively). By age 15 years, 25% of the women acquired their first STI, most often C trachomatis. Median interval between first intercourse and first STI diagnosis was 2 years. Within 1 year of first intercourse, 25% had their first C trachomatis infection. Repeated infections were common; within 3.6, 6, and 4.8 months, 25% of the women with prior C trachomatis, N gonorrhoeae, and T vaginalis infection were reinfected with the respective organisms. Considerable delay in STI testing was found for those who began sex at a younger age. The median interval between first sex and first test were 4.9, 3.5, 2.1, 1.8, and 1.2 years for those who had first sex at ages 10, 11, 12, 13, and 14 years, respectively. Conclusions Timely screening and treatment are important for prevention of STI sequelae. For urban adolescent women, STI screening (especially for C trachomatis) should begin within a year after first intercourse and infected individuals should be retested every 3 to 4 months.
Using GPS-enabled cell phones to track the travel patterns of adolescents
(2009-05) Wiehe, Sarah E.; Carroll, Aaron E.; Liu, Gilbert C.; Haberkorn, Kelly L.; Hoch, Shawn C.; Wilson, Jeffrey S.; Fortenberry, J. Dennis
Background Few tools exist to directly measure the microsocial and physical environments of adolescents in circumstances where participatory observation is not practical or ethical. Yet measuring these environments is important as they are significantly associated with adolescent health-risk. For example, health-related behaviors such as cigarette smoking often occur in specific places where smoking may be relatively surreptitious. Results We assessed the feasibility of using GPS-enabled cell phones to track adolescent travel patterns and gather daily diary data. We enrolled 15 adolescent women from a clinic-based setting and asked them to carry the phones for 1 week. We found that these phones can accurately and reliably track participant locations, as well as record diary information on adolescent behaviors. Participants had variable paths extending beyond their immediate neighborhoods, and denied that GPS-tracking influenced their activity. Conclusion GPS-enabled cell phones offer a feasible and, in many ways, ideal modality of monitoring the location and travel patterns of adolescents. In addition, cell phones allow space- and time-specific interaction, probing, and intervention which significantly extends both research and health promotion beyond a clinical setting. Future studies can employ GPS-enabled cell phones to better understand adolescent environments, how they are associated with health-risk behaviors, and perhaps intervene to change health behavior.
Flexibility in Faculty Work-Life Policies at Medical Schools in the Big Ten Conference
(2011-05) Welch, Julie L.; Wiehe, Sarah E.; Palmer-Smith, Victoria; Dankoski, Mary E.
Purpose: Women lag behind men in several key academic indicators, such as advancement, retention, and securing leadership positions. Although reasons for these disparities are multifactorial, policies that do not support work-life integration contribute to the problem. The objective of this descriptive study was to compare the faculty work-life policies among medical schools in the Big Ten conference. Methods: Each institution's website was accessed in order to assess its work-life policies in the following areas: maternity leave, paternity leave, adoption leave, extension of probationary period, part-time appointments, part-time benefits (specifically health insurance), child care options, and lactation policy. Institutions were sent requests to validate the online data and supply additional information if needed. Results: Each institution received an overall score and subscale scores for family leave policies and part-time issues. Data were verified by the human resources office at 8 of the 10 schools. Work-life policies varied among Big Ten schools, with total scores between 9.25 and 13.5 (possible score: 0–21; higher scores indicate greater flexibility). Subscores were not consistently high or low within schools. Conclusions: Comparing the flexibility of faculty work-life policies in relation to other schools will help raise awareness of these issues and promote more progressive policies among less progressive schools. Ultimately, flexible policies will lead to greater equity and institutional cultures that are conducive to recruiting, retaining, and advancing diverse faculty.
Photo-Elicitation as an Adjunct to Structured Interviews When Assessing Ideal Romantic and Sexual Relationships
(2013-02) Best, Candace; Fortenberry, J. Dennis; Wiehe, Sarah E.
Structured interviews have been used as an assessment tool in clinical and research settings for many years. However, such interviews have limitations, especially when questions are abstract from the daily life experiences of adolescents and young adults (e.g., “What are all the qualities you desire in a romantic partner?”). Accordingly, photo-elicitation was incorporated as a tool into how young women perceive ideal romantic and sexual relationships.
Use of Cell Phone Diaries to Understand Risk Contexts of Sexual Events Among Female Sex Workers
(2013-07) Roth, Alexis M.; Hensel, Devon J.; Gunn, Jayleen K.L.; Fortenberry, J. Dennis; Garfein, R; Arno, Janet N.; Wiehe, Sarah E.
Background Data collection using mobile technologies, such as cell phones, allows more frequent and real-time data collection and is less prone to recall bias. We describe the feasibility of using twice daily cell phone diaries to capture contextual features of STI/HIV-risk that could impact disease acquisition among female sex workers (FSW). Methods Women engaging in transactional sex in the prior 90 days were recruited utilising incentivized snowball sampling. Participants completed STI testing and baseline/exit surveys. Over 4-weeks, they completed twice-daily electronic diaries assessing event-level sexual behaviour, condom use, and drug use. Weekly in-person interviews used open-ended questions to explore geographical characteristics of sexual encounter locations as well as acceptability of event-level monitoring. Results 25/26 participants (median age 43.5 years) completed the 4-week study. At baseline, 27% tested positive for a STI. Participants completed 84.5% of 1,518 expected surveys and 95% of 106 expected interviews. Patterns of diary compliance were stable over time. Partnered sexual activity was captured in 21.4% of diaries. At the participant-level, most reported giving oral sex (84.7%) or vaginal sex (96.1%); fewer (19.2%) reported engaging in anal sex. Among women reporting partnered sexual behaviour with any partner type (i.e., new/regular customers, romantic partners), using condoms was reported 39.2%, 45.5% and 83.3% of the time for giving oral sex, vaginal sex, and anal sex respectively. At the event-level, the frequency of giving oral sex, vaginal sex or anal sex did not significantly change over time. Conclusions It is feasible to engage and retain FSW in a technologically-advanced study to characterise risk contexts of sexual events. Adherence to study protocol was high indicating event-level monitoring using cell phone based diaries is acceptable. These data can be utilised to improve our understanding of the individual, relational and environmental factors that influence STI/HIV acquisition among FSW.

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