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Individual autonomy in antenatal screening is internationally recognized and supported. Policy and practice guidelines in various countries place emphasis on the woman's right to make her own decision and are related to concepts such as self-determination, independence, and self-sufficiency. In contrast, the dominant perspective in Chinese medical ethics suggests that the family is pivotal in making medical decisions, hence providing support for relational autonomy. This study explored Hong Kong Chinese pregnant women's preferences for individual vs relational autonomy for non-invasive prenatal testing (NIPT) for Down syndrome. A qualitative study was carried out using semi-structured interviews with 36 women who had undertaken NIPT in Hong Kong. The findings show that most Hong Kong Chinese women valued aspects of both relational and individual autonomy in decision-making for NIPT. Women expected support from doctors as experts on the topic and wanted to involve their husband in decision-making while retaining control over the outcome. Somewhat surprisingly, the findings do not provide support for the involvement of family members in decision-making for NIPT. The adequacy of current interpretations of autonomy in prenatal testing policies as an individual approach needs discussion, where policy developers need to find a balance between individual and relational approaches., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Purpose: The purpose of this study was to develop a scale of free nursing home adjustment for the elderly in Korea., Method: The developmental processes were construction of a conceptual framework, development of preliminary items, verification of content validity, twice data gathering, verification of construct validity, and reliability of final items. The first 53 preliminary items were obtained through review of literatures about nursing home adjustment and in depth interviews with 5 staffs of nursing home. These items were reviewed by five specialists for content validity and 39 items were chosen. The first data was collected from 107 elderly residing in 3 nursing homes and the second survey was from 147 residents who were living in five nursing homes. Finally this data was analyzed for construct validity and reliability., Result: There were 23 final items which were sorted into 5 factors. The factors were identified as 'Relocation distress symptom'(8 items), 'Making friends'(4 items), 'Acceptance of new residence' (6 items), 'Difficulty in group life'(3 items), and 'Having self-worth'(2 items). The cumulative percent of variance was 53.466%. The reliability of the scale, Cronbach's alpha was .837., Conclusion: The result of this study could be used for measuring nursing home adjustment of the elderly. However, for further validity and reliability, repeated researches are needed.

Recently, an increasing number of employers have provided employment opportunities for older adults. Yet, few studies pay attention to older employees' perceptions of their employment. Using a Japanese national sample of 995 male employees aged 55 to 64, this study examined whether the existing research on organizational commitment applies to older employees, whether measures that are unique to older employees have significant relationships to their organizational commitment, and whether the effects of these factors differ by retirement status. The results of hierarchical multiple regression analyses showed significant relationships between employee organizational commitment and employment security, personal relationships in workplaces and job characteristics. Negative ageism and employer-sponsored programs for older employees also had significant relationships to organizational commitment. The effects of salary, job autonomy, job demands, and employer-sponsored programs differed by retirement status. While the study was consistent with the existing research, it also suggested the importance of measures that are unique to older employees.

This article explores the meaning and experiences of paid work for older women. Taped, in-person interviews were conducted with 53 ethnically and economically diverse women, 55 to 84 years old. The interview guide contained open-ended questions regarding the meaning of work, reasons for working, and the centrality of work to personal identity. Participants discussed the following topics: independence from men; lost dreams and regrets related to paid work and educational opportunities; being responded to as mother by co-workers and supervisors; and working above and beyond the call of duty.

Substantial evidence indicates that medical mistrust, resulting from experiences with discrimination and marginalisation, is a determinant of health disparities in minority populations. However, this research is largely limited to the US and other industrialised countries. To broaden our understanding of the role of medical mistrust on health-care decision making, we conducted a study on healthcare experiences and perceptions in a rural, underserved indigenous community in northwest Namibia (n = 86). Mixing semi-structured interview questions with the medical mistrust index (MMI), we aim to determine the relevance of the MMI in a non-industrialised population and compare index scores with reports of healthcare experiences. We find that medical mistrust is a salient concept in this community, mapping onto negative healthcare experiences and perceptions of discrimination. Reported healthcare experiences indicate that perceived incompetence, maltreatment and discrimination drive mistrust of medical personnel. However, reporting of recent healthcare experiences are generally positive. Our results indicate that the concept of medical mistrust can be usefully applied to communities in the Global South. These populations, like minority communities in the US, translate experiences of discrimination and marginalisation into medical mistrust. Understanding these processes can help address health disparities and aid in effective public health outreach in underserved populations.

INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) for HIV-1 infection is over 99% effective in protecting against HIV acquisition when used consistently and appropriately. However, PrEP uptake and persistent use remains suboptimal, with a substantial gap in utilization among key populations who could most benefit from PrEP. In Latin America specifically, there is poor understanding of barriers to PrEP uptake and persistence among transgender (trans) women. METHODS: In April-May 2018, we conducted qualitative interviews lasting 25-45 min as part of an end-of-project evaluation of TransPrEP, a pilot RCT that examined the impact of a social network-based peer support intervention on PrEP adherence among trans women in Lima, Peru. Participants in the qualitative evaluation, all adult trans women, included individuals who either (1) screened eligible to participate in the TransPrEP pilot, but opted not to enroll (n = 8), (2) enrolled, but later withdrew (n = 6), (3) were still actively enrolled at the time of interview and/or successfully completed the study (n = 16), or (4) were study staff (n = 4). Interviews were audio recorded and transcribed verbatim. Codebook development followed an immersion/crystallization approach, and coding was completed using Dedoose. RESULTS: Evaluation participants had a mean age of 28.2 years (range 19-47). When describing experiences taking PrEP, participant narratives highlighted side effects that spanned three domains: physical side effects, such as prolonged symptoms of gastrointestinal distress or somnolence; economic challenges, including lost income due to inability to work; and social concerns, including interpersonal conflicts due to HIV-related stigma. Participants described PrEP use within a broader context of social and economic marginalization, with a focus on daily survival, and how PrEP side effects negatively contributed to these stressors. Persistence was, in some cases, supported through the interventions educational workshops. CONCLUSION: This research highlights the ways that physical, economic, and social side effects of PrEP can impact acceptability and persistence among trans women in Peru, amplifying and layering onto existing stressors including economic precarity. Understanding the unique experiences of trans women taking PrEP is crucial to informing tailored interventions to improve uptake and persistence.

BACKGROUND: Over two decades of research about traumatic brain injury (TBI) rehabilitation emphasized the persistence of racial health disparities in functional outcomes that disproportionately impact Black populations without naming or addressing racism as the root problem. Further, the experiences of Black people with TBI have yet to be documented and accounted for in scientific scholarship from the perspectives of Black persons in Canada. PURPOSE: This study intended to examine the rehabilitation narratives of Black TBI survivors, family caregivers, and rehabilitation providers and use critical race theory as a conceptual framework to understand how anti-Black racism manifests in those experiences. METHODS: Through critical narrative inquiry informed by a critical constructivist paradigm and a critical race theory lens, in-depth narrative interviewing were conducted with seven survivors, three family caregivers, and four rehabilitation providers. Data were analyzed using reflexive thematic analysis within and across groups of participants to conceptualize themes and sub-themes. FINDINGS: Themes captured how racism becomes institutionalized in TBI rehabilitation: (1) the institutional construction of deficient Black bodies, (2) the institutional construction of rehabilitation access, (3) the institutional investment in resisting and approximating whiteness in rehabilitation practice, and (4) the institutional construction of deficient Black futures. CONCLUSION: Study findings point to the dire need to ensure rehabilitation programs, services, and the delivery of care are not determined based on inequitable practices, racial biases and assumptions about Black people, which determine who deserves to get into rehabilitation and have opportunities to be supported in working towards living a full and meaningful life.

BACKGROUND: Safer conception services are needed to minimize HIV transmission among HIV sero-discordant couples desiring pregnancy. Few studies have evaluated the choices couples make when they are offered multiple safer conception methods or real-world method acceptability. This paper addresses an important knowledge gap regarding factors that influence the choice of safer conception methods, couples actual experiences using safer conception methods, and why some couples switch safer conception methods. METHODS: Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples who exited the SAFER study-a pilot safer conception study for HIV sero-discordant couples in Zimbabwe that offered couples a choice of ART with monthly viral load monitoring (ART/VL), oral PrEP, vaginal insemination, and semen washing. All couples in SAFER had used at least two safer conception methods. RESULTS: We found that safer conception method choice often centered around a desire for intimacy, condomless sex, and certainty in the conception process, particularly for men. Method-related attributes such as familiarity, perceived ease of use, side effects, and perceived level of effectiveness in preventing HIV and achieving pregnancy influenced method choice, switching, and satisfaction. Concerns were expressed about each safer conception method and couples were willing to try different methods until they found method(s) that worked for them. The majority of participants reported having positive experiences using safer conception, especially those using ART/VL + PrEP, citing that they were able to attempt pregnancy for the first time with peace of mind and experienced joy and satisfaction from being able to achieve pregnancy safely. CONCLUSIONS: The differences in method preferences and experiences voiced by participants in this study and in other studies from the region point to the importance of having a variety of safer conception options in the service delivery package and addressing concerns about paternity, intimacy, and method-related attributes to enable HIV sero-discordant couples to safely achieve their reproductive goals.

IntroductionIdentifying the optimal approaches to offering HIV prevention to meet the needs of those at risk is a high priority, particularly given the expanding toolkit of biomedical HIV prevention options. An ongoing study in rural East African communities evaluated the uptake of choices in product, testing mode and location of care delivery through a structured patient-centred HIV prevention delivery model. In this qualitative study, we sought to understand clients' experiences of this "dynamic choice prevention model" (DCP) and highlight pathways of action to inform HIV prevention delivery models.MethodsIn-depth semi-structured interviews were conducted from November 2021 through March 2022 with a purposively selected sample of n = 56 participants in DCP trials (across outpatient departments, antenatal clinics and community settings), and n = 21 healthcare providers (total n = 77). A seven-person multi-regional team translated and inductively coded transcript data. We used a framework analysis approach to identify emergent themes.ResultsIndividuals taking up HIV pre-exposure prophylaxis (PrEP) reported feelings of relief, liberation from fears of acquiring HIV and satisfaction with being able to take action despite partners' behaviours. Couples used a range of approaches afforded by the study to persuade partners to get tested and opt for PrEP. Post-exposure prophylaxis (PEP) use was less common, although women welcomed it in the event of sexual coercion or assault. Participants discussed switching from PEP to PrEP after familiarizing themselves with usage and ascertaining ongoing risk. Participants felt respected by providers, trusted them and appreciated being able to contact them directly for telephone support. Prevention uptake was hindered by stigma, limited experience with and knowledge of prevention methods, gendered and generational power dynamics within intimate partnerships and families, and negative perceptions of methods due to the products themselves. Participants anticipated long-acting injectable PrEP could solve their challenges regarding pill size, daily pill burden and the likelihood of unwanted disclosure.ConclusionsDiverse preferences and barriers to uptake of prevention require a choice of HIV prevention options, locations and delivery modalities-but in addition, flexible, competent and friendly care provision is crucial to promote uptake. Helping clients feel valued, and addressing their unique needs and challenges, enables their agency to prioritize their health.

BACKGROUND: Urinary tract infections (UTI) affect almost two-thirds of all women during their lives and many experience recurrent infections. There are evidence-based guidelines from multiple international societies for evaluation and treatment; however, recent claims-based analyses have demonstrated that adherence to these guidelines is poor. This study seeks to understand the barriers experienced by U.S. primary care providers (PCPs) to providing guideline-based care for UTI and recurrent UTI (rUTI). METHODS: Semi-structured interviews of 18 PCPs, recruited from the greater Los Angeles area, examined real-world clinical management of UTI/rUTI episodes, decisions to refer to subspecialty care, and resources guiding counseling and management. Grounded theory methodology served to analyze interview transcripts and identify preliminary and major themes. RESULTS: Participants expressed the desire to obtain urine cultures for each cystitis episode, but felt pressured to make compromises by patient demands or barriers to care. PCPs had lower thresholds to empirical treatment if patients had a history of rUTIs, were elderly, or declined evaluation. Laboratory data was minimally utilized in clinical decision-making: urinalyses were infrequently considered when interpreting culture data. PCPs treated a broad set of urologic and non-urologic symptoms as UTI, even with negative cultures. PCPs did not feel comfortable initiating UTI prophylaxis, instead seeking specialist evaluation for anatomic causes. They were unaware of management guidelines, typically utilizing UpToDate® as their primary resource. Few evidence-based UTI prevention interventions were recommended by providers. CONCLUSIONS: Low availability of succinct and clear professional guidelines are substantial barriers to appropriate UTI/rUTI care. Poor useability of clinical guidance documents results in substantial confusion about the role of preventative measures and additional diagnostic testing. Difficulties in patient access to care providers lead to expectations for presumptive treatment. Future studies are needed to determine if improved educational materials for providers and/or management algorithms can improve guideline concordance of UTI management.

Understanding the acceptability of long-acting injectable antiretroviral therapy (LAI-ART) among people with HIV (PWH), especially priority populations, is essential for effective implementation. We conducted semi-structured interviews with patients in three Ryan White-funded HIV clinics in San Francisco, Chicago, and Atlanta. We employed maximal variation sampling across age, gender, race, ethnicity, and time living with HIV and oversampled for individuals with suboptimal clinical engagement. An 8-step hybrid deductive and inductive thematic analysis approach guided data analysis. Between August 2020 and July 2021, we conducted 72 interviews. Median age was 46 years; 28% were ciswomen, 7% transwomen, 44% Black/African-American and 35% Latinx, 43% endorsed a psychiatric diagnosis, 35% were experiencing homelessness/unstable housing, and 10% had recent substance use. Approximately 24% were sub-optimally engaged in care. We observed a spectrum of LAI-ART acceptability, ranging from enthusiasm to hesitancy to rejection. We also characterized four emergent orientations towards LAI-ART: innovator, pragmatist, deliberator, and skeptic. Overall, the majority of participants expressed favorable initial reactions towards LAI-ART. Most approached LAI-ART pragmatically, but acceptability was not static, often increasing over the course of the interview. Participants considered their HIV providers as essential for affirming personal relevance. HIV stigma, privacy concerns, and medical mistrust had varied impacts, sometimes facilitating and other times hindering personal relevance. These findings held across priority populations, specifically young adults, cis/trans women, racial/ethnic minorities, and individuals with suboptimal clinical engagement. Further research is needed to explore the transition from hypothetical acceptance to uptake and to confirm the actual benefits and drawbacks of this treatment.

Introduction: The purpose of this study was to characterize how family influences diabetes self-management in Mexican American adults. Methods: Data were analyzed from previously collected data that included 34 semi-structured interviews with Hispanic adults with diabetes and six focus groups with 37 adults with diabetes and family members. Themes related to family and diabetes management were identified and analyzed using a modified template approach. Results: Family-related facilitators to T2DM self-management were (1) provides support, (2) provides motivation, and (3) desire to protect family from diabetes. Family-related challenges were (1) lack of support, (2) family responsibilities, and (3) stress related to family. Diabetes education was shared with family members. Family member perspectives on T2DM included (1) not knowing how to help, (2) effect on emotional wellbeing, (3) diabetes affects the whole family, and (4) family provides support. Conclusion: Most participants with T2DM felt supported by family, but many desired more social support and support surrounding dietary changes from family. Many felt family did not understand what living with diabetes meant for them. Most family members wished to learn more about how to help. Future interventions should include family members and teach them supportive strategies to support beneficial diabetes self-management behaviors.

IntroductionHPTN 083 demonstrated the superiority of long-acting cabotegravir (CAB-LA) versus daily oral emtricitabine/tenofovir disoproxil fumarate (TDF/FTC) as pre-exposure prophylaxis (PrEP) among cisgender men and transgender women who have sex with men (MSM/TGW). HPTN 083 provided the first opportunity to understand experiences with injectable PrEP in a clinical trial.MethodsParticipants from two US sites (Chicago, IL and Atlanta, GA) and one international site (Rio de Janeiro, Brazil) were purposively sampled for individual qualitative interviews (N = 40), between November 2019 and March 2020, to explore trial experiences, barriers to adherence and other factors that may have impacted study implementation or outcomes. The blinded phase ended early due to efficacy; this analysis includes interviews conducted prior to unblinding with three groups defined by adherence (i.e. injection visit attendance): adherent (n = 27), non-adherent (n = 12) and early discontinuers (n = 1). Data were organized using NVivo software and analysed using content analysis.ResultsParticipants (mean age: 27) were primarily cisgender MSM (90%) and Black/African American (60%). Reasons for trial enrolment and PrEP use included a preference for using HIV prevention medication versus treatment in the event of HIV acquisition; the ability to enhance health via study-related education and services; access to a novel, convenient HIV prevention product at no cost; and contributing to MSM/TGW communities through research. Participants contrasted positive experiences with study staff with their routine clinical care, and emphasized increased scheduling flexibility, thorough communication, non-judgemental counselling and open, affirming environments (e.g. compassion, less stigma) as adherence facilitators. Injection experiences were positive overall; some described early injection-related anxiety, which abated with time and when given some measure of control (e.g. pre-injection countdown), and minimal injection site discomfort. Some concerns and misperceptions about injectable PrEP were reported. Barriers to adherence, across all adherence categories, included structural factors (e.g. financial constraints, travel) and competing demands (e.g. work schedules).ConclusionsRespondents viewed injectable PrEP trial participation as a positive experience and a means of enhancing wellbeing. Study site flexibility and affirming clinic environments, inclusive of non-judgemental counselling, were key facilitators of adherence. To support injection persistence, interventions that address structural barriers and promote flexible means of injection delivery may be most effective.

BACKGROUND: COVID-19 impacted the mental health of healthcare workers, who endured pressures as they provided care during a prolonged crisis. We aimed to explore whether and how a Trauma-Informed Care (TIC) approach was reflected in qualitative perspectives from healthcare leaders of their experience during COVID-19 (2020-2021). METHODS: Semi-structured interviews with healthcare leaders from four institutions were conducted. Data analysis consisted of four stages informed by interpretative phenomenological analysis: 1) deductive coding using TIC assumptions, 2) inductive thematic analysis of coded excerpts, 3) keyword-in-context coding of full transcripts for 6 TIC principles with integration into prior inductive themes, and 4) interpretation of themes through 6 TIC principles (safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and awareness of cultural, historical, and gender issues). RESULTS: The actions of leaders (n = 28) that were reported as successful and supportive responses to the COVID-19 pandemic or else missed opportunities reflected core principles of Trauma-Informed Care. To promote safety, leaders reported affirmative efforts to protect staff by providing appropriate physical protection, and enhanced psychological safety by providing channels for communication about emotional well-being. To promote trustworthiness and transparency, leaders listened to their staff, shared current COVID-19 information, and increased frequency of meetings to disseminate accurate information. To promote mutual support, strategies included wellness check-ins, sharing uplifting stories, affirming common goals, articulating fears, and leading by example. Examples of empowerment included: making time and adjusting modalities for flexible communication; naming challenges outside of the hospital; and functioning as a channel for complaints. Reported missed opportunities included needing more dedicated time and space for healthcare employees to process emotions, failures in leadership managing their own anxiety, and needing better support for middle managers. Awareness of the TIC principle of cultural, historical, and gender issues was largely absent. Results informed the nascent Trauma-Informed Healthcare Leadership (TIHL) framework. CONCLUSIONS: We propose the Trauma-Informed Healthcare Leadership framework as a useful schema for action and analysis. This approach yields recommendations for healthcare leaders including creating designated spaces for emotional processing, and establishing consistent check-ins that reference personal and professional well-being.

BackgroundA longer duration of untreated psychosis (DUP) is associated with poorer treatment outcomes. Screening for psychosis spectrum disorders in the primary care setting could help support the earlier detection and treatment of individuals in need. However, the acceptability of screening for psychosis in this setting as part of routine care is currently unknown.MethodsWe conducted a qualitative interview study with providers and service users who participated in an early psychosis screening program conducted in an integrated behavioral health primary care (IBH-PC) setting. Interviews were recruited from one of eight WellSpace Federally Qualified Health Center IBH-PC clinics in the Sacramento, CA area. Transcripts of the recorded interviews were analyzed using thematic analysis.ResultsIn total, 12 providers and eight service users participated in the interviews. Most service user and provider participants were supportive of psychosis screening in an IBH-PC setting, but not as part of the general practitioner consultation due to the brief, non-behavioral health nature of many of the appointments, and the expected low prevalence of psychosis in this population. The support of leadership, adequate training and support, staff turnover, and organizational changes were all seen to impact the successful implementation of the program. Different barriers and facilitators were considered important at each stage of the process from introducing the screening procedures to service users; to determining when, where, and how to screen; and how to effectively manage the referral and post-referral stages.ConclusionsDespite the additional challenges of screening in an IBH-PC setting relative to secondary mental health services, the process was considered acceptable and feasible to providers and service users. Services that plan to conduct psychosis screening in their clinics need to consider the challenges and their potential solutions to implementation at each stage of the screening process.

INTRODUCTION: Community-based health interventions often demonstrate efficacy in clinical trial settings but fail to be implemented in the real-world. We sought to identify the key operational and contextual elements of the Los Angeles Barbershop Blood Pressure Study (LABBPS), an objectively successful community-based health intervention primed for real-world implementation. LABBPS was a cluster randomized control trial that paired the barbers of Black-owned barbershops with clinical pharmacists to manage uncontrolled hypertension in Black male patrons, demonstrating a substantial 21.6 mmHg reduction in systolic blood pressure. Despite this success, the LABBPS intervention has not expanded beyond the original clinical trial setting. The aim of this study was to determine the facilitating and limiting factors to expansion of the LABBPS intervention. METHODS: We undertook a qualitative assessment of semi-structured interviews with study participants performed after trial completion. Interviews included a total of 31 participants including 20 (6%) of the 319 LABBPS program participants (patrons), 10 (19%) barbers, and one (50%) clinical pharmacist. The semi-structured interviews were focused on perceptions of the medical system, study intervention, and influence of social factors on health. RESULTS: Several common themes emerged from thematic analysis of interview responses including: importance of care provided in a convenient and safe environment, individual responsibility for health and health-related behaviors, and engagement of trusted community members. In particular, patrons reported that receiving the intervention from their barber in a familiar environment positively influenced the formation of relationships with clinical pharmacists around shared efforts to improve medication adherence and healthy habits. All interviewee groups identified the trust diad, comprising the familiar environment and respected community member, as instrumental in increasing health-related behaviors to a degree not usually achieved by traditional healthcare providers. DISCUSSION: In conclusion, participants of an objectively successful community-based intervention trial consistently identified key features that could facilitate wider implementation and efficacy: social trust relationships, soliciting insights of trust bearers, and consistent engagement in a familiar community setting. These findings can help to inform the design and operations of future community-based studies and programs aiming to achieve a broad and sustainable impact.

Polygamy is the practice of marriage to multiple partners. Approximately 6-11% of households in Uganda and 4-11% of households in Kenya are polygamous. The complex families produced by polygamous marriage customs give rise to additional considerations for healthcare providers and public health messaging around HIV care. Using 27 in-depth, semi-structured qualitative interviews with participants in two studies in rural Kenya and Uganda, we analysed challenges and opportunities that polygamous families presented in the diagnosis, treatment and prevention of HIV, and provider roles in improving HIV outcomes in these families. Overall, prevention methods seemed more justifiable to families where co-wives live far apart than when all members live in the same household. In treatment, diagnosis of one member did not always lead to disclosure to other members, creating an adverse home environment; but sometimes diagnosis of one wife led not only to diagnosis of the other, but also to greater household support.

BackgroundWith the goal for malaria elimination in Thailand set for 2024, increased coverage and utilization of bed net, especially insecticide-treated net (ITN) or long-lasting insecticidal net (LLIN) is a key strategy. This study aims to provide the necessary information about bed net ownership and utilization among the population at risk of malaria living along the Thai-Myanmar border in Tak province.MethodsA cross-sectional study was conducted using a mixed-method approach in 331 households from 5 hamlets in the villages of the Thai-Myanmar border. The research tools included a questionnaire, bed net inspection, and semi-structured interviews. Logistic regression was used to explore the sociodemographic factors associated with bed net utilization. The qualitative analysis employed a thematic analysis approach.ResultsThis survey found that 98.5% of households had at least one bed net per household, and 74.3% had at least one ITN/LLIN. However, only 30.8% of households reached the standard policy set by the Minister of Public Health of one ITN/LLINs per two persons. Most residents used bed net (92.1% used in the previous night and 80.9% used every day). For those using bed nets, however, 61.9% used ITNs or LLINs the night before and 53.1% used them every day. Nonetheless, the usage rates of bed nets (any type) in the previous night among children and pregnant women were high, reaching 95.3% and 90.0%, respectively. Seven explanatory variables showed statistically significant associations with bed net use every day, including: "not staying overnight in the forest or the field", "sleeping pattern based on gender", "sufficient numbers of bed nets to cover all sleeping spaces", "preference for free bed nets", "age", "gender", and "SES score" showed statistically significant association with bed net use every day. The major reasons for the regular use of bed nets in both household and the forest were to prevent mosquito biting. The reasons for not using bednets in the household were discomfort feelings from heat, perception of unnecessity due to low mosquito density, whereas the reason for not using bed nets in the forest was inconvenience.ConclusionDespite that overall coverage and usage of bed nets was high, only one third reached the standard level specified by the policy. Overnight in the forest, the dissatisfaction with the quality of free bed nets, insufficient number of bed nets, sleeping alone, male gender, age more than 10 years, low socioeconomic status, discomfort from heat, perception of no benefits of bed nets due to low mosquito density, and inconvenience were factors influencing bed net use. Maintaining high coverage and utility rate of bed nets should be a priority for the malaria high-risk population.

BackgroundKenya continues to have a high maternal mortality rate that is showing slow progress in improving. Peri-urban settings in Kenya have been reported to exhibit higher rates of maternal death during labor and childbirth as compared to the general Kenyan population. Although research indicates that women in Kenya have increased access to facility-based birth in recent years, a small percentage still give birth outside of the health facility due to access challenges and poor maternal health service quality. Most studies assessing facility-based births have focused on the sociodemographic determinants of birthing location. Few studies have assessed women's user experiences and perceptions of quality of care during childbirth. Understanding women's experiences can provide different stakeholders with strategies to structure the provision of maternity care to be person-centered and to contribute to improvements in women's satisfaction with health services and maternal health outcomes.MethodsA qualitative study was conducted, whereby 70 women from the peri-urban area of Embakasi in the East side of Nairobi City in Kenya were interviewed. Respondents were aged 18 to 49 years and had delivered in a health facility in the preceding six weeks. We conducted in-depth interviews with women who gave birth at both public and private health facilities. The interviews were recorded, transcribed, and translated for analysis. Braune and Clarke's guidelines for thematic analysis were used to generate themes from the interview data.ResultsFour main themes emerged from the analysis. Women had positive experiences when care was person-centered-i.e. responsive, dignified, supportive, and with respectful communication. They had negative experiences when they were mistreated, which was manifested as non-responsive care (including poor reception and long wait times), non-dignified care (including verbal and physical abuse lack of privacy and confidentiality), lack of respectful communication, and lack of supportive care (including being denied companions, neglect and abandonment, and poor facility environment).ConclusionTo sustain the gains in increased access to facility-based births, there is a need to improve person-centered care to ensure women have positive facility-based childbirth experiences.

ObjectiveTo explore US provider perspectives about self-sourced medication abortion and how their attitudes and clinic practices changed in the context of the COVID-19 pandemic.Study designWe conducted a multi-method study of survey and interview data. We performed 40 baseline interviews and surveys in spring 2019 and 36 follow-up surveys and ten interviews one year later. We compared pre- and post-Likert scale responses of provider views on the importance of different aspects of standard medication abortion assessment and evaluation (e.g., related to ultrasounds and blood-typing). We performed content analysis of the follow-up interviews using deductive-inductive analysis.ResultsSurvey results revealed that clinics substantially changed their medication abortion protocols in response to COVID-19, with more than half increasing their gestational age limits and introducing telemedicine for follow-up of a medication abortion. Interview analysis suggested that physicians were more supportive of self-sourced medication abortion in response to changing clinic protocols that decreased in-clinic assessment and evaluation for medication abortion, and as a result of physicians' altered assessments of risk in the context of COVID-19. Having evidence already in place that supported these practice changes made the implementation of new protocols more efficient, while working in a state with restrictive abortion policies thwarted the flexibility of clinics to adapt to changes in standards of care.ConclusionThis exploratory study reveals that the COVID-19 pandemic has altered clinical assessment of risk and has shifted practice towards a less medicalized model. Further work to facilitate person-centered abortion information and care can build on initial modifications in response to the pandemic.ImplicationsCOVID-19 has shifted clinician perception of risk and has catalyzed a change in clinical protocols for medication abortion. However, state laws and policies that regulate medication abortion limit physician ability to respond to changes in risk assessment.

BackgroundSocioeconomic disadvantages and potential immunocompromise raise particular concerns for people living with HIV (PLWH) and other marginalized communities during the COVID-19 pandemic. In this study, we explored COVID-19 testing and the impact of the pandemic among participants from the Miami Adult Studies on HIV cohort, predominantly composed of low-income minorities living with and without HIV.MethodsBetween July and August 2020, a telephone survey was administered to 299 Miami Adult Studies on HIV participants to assess COVID-19 testing, prevention behaviors, and psychosocial stressors. Health care utilization, antiretroviral adherence, food insecurity, and substance use during the pandemic were compared with those of their last cohort visit (7.8 ± 2.9 months earlier).ResultsHalf of surveyed participants had been tested for COVID-19, 8 had tested positive and 2 had been hospitalized. PLWH (n = 183) were 42% times less likely than HIV-uninfected participants to have been tested. However, after adjustment for age, employment, COVID-19 symptoms, mental health care, and substance use, the effect of HIV status was no longer significant. PLWH were more likely to have seen a health care provider, use face coverings, and avoid public transportation and less likely to be food insecure and drink hazardously. There were significant changes in substance use patterns during the pandemic when compared with those before.ConclusionPLWH, compared with their HIV-uninfected peers, were more likely to engage in preventive measures and health care during the pandemic, potentially reducing their exposure to COVID-19. There were no reported changes in antiretroviral adherence or health care utilization, but there were changes in substance use; these need to be monitored as this crisis progresses.

PurposeWe describe the item development and cognitive evaluation process used in creating the Prevention of Lower Urinary Tract Symptoms Bladder Health Instrument (PLUS-BHI).Materials and methodsQuestions assessing bladder health were developed using reviews of published items, expert opinion, and focus groups' transcript review. Candidate items were tested through cognitive interviews with community-dwelling women and an online panel survey. Items were assessed for comprehension, language, and response categories and modified iteratively to create the PLUS-BHI.ResultsExisting measures of bladder function (storage, emptying, sensation components) and bladder health impact required modification of time frame and response categories to capture a full range of bladder health. Of the women 167 (18-80 years old) completed individual interviews and 791 women (18-88 years) completed the online panel survey. The term "bladder health" was unfamiliar for most and was conceptualized primarily as absence of severe urinary symptoms, infection, or cancer. Coping mechanisms and self-management strategies were central to bladder health perceptions. The inclusion of prompts and response categories that captured infrequent symptoms increased endorsement of symptoms across bladder function components.ConclusionsBladder health measurement is challenged by a lack of awareness of normal function, use of self-management strategies to mitigate impact on activities, and a common tendency to overlook infrequent lower urinary tract symptoms. The PLUS-BHI is designed to characterize the full spectrum of bladder health in women and will be validated for research use.

IntroductionThe COVID-19 pandemic may present special challenges for residential substance use disorder (SUD) treatment facilities, which may lack infrastructure and support to implement infection control protocols while maintaining on-site treatment services. However, little is known about how residential SUD treatment programs are impacted by the COVID-19 pandemic.MethodsThe research team conducted semi-structured interviews with 17 directors of 20 residential SUD treatment programs across California during the state's shelter-in-place order. The researchers then analyzed qualitative interview data thematically and coded them using ATLAS.ti software.FindingsThematic analyses identified six major themes: program-level impacts, staff impacts, client impacts, use of telehealth, program needs, and positive effects. "Program-level impacts" were decreased revenue from diminished client censuses and insufficient resources to implement infection control measures. "Staff impacts" included layoffs, furloughs, and increased physical and emotional fatigue. "Client impacts" were delayed treatment initiation; receipt of fewer services while in treatment; lower retention; and economic and psychosocial barriers to community re-entry. "Use of telehealth" included technical and interpersonal challenges associated with telehealth visits. "Program needs" were personal protective equipment (PPE), stimulus funding, hazard pay, and consistent public health guidance. "Positive effects" of the pandemic response included increased attention to hygiene and health, telehealth expansion, operational improvements, and official recognition of SUD treatment as an essential health care service.ConclusionStudy findings highlight COVID-related threats to the survival of residential SUD treatment programs; retention of the SUD treatment workforce; and clients' SUD treatment outcomes. These findings also identify opportunities to improve SUD service delivery and suggest avenues of support for residential SUD treatment facilities during and after the COVID-19 pandemic.

In HIV-endemic areas, traditional healers are frequently used with, or instead of, biomedical resources for health care needs. Studies show healers are interested in and capable of supporting patients in the HIV care cascade. However, adults who receive care from healers have low engagement with HIV services. To achieve epidemic control, we must understand gaps between the needs of HIV-endemic communities and the potential for healers to improve HIV service uptake. This study's objective was to characterize stakeholder perspectives on barriers to HIV testing and approaches to mitigate barriers in a medically pluralistic, HIV-endemic region. This study was conducted in Mbarara District, a rural area of southwestern Uganda with high HIV prevalence. Participants included HIV clinical staff, traditional healers, and adults receiving care from healers. Fifty-six participants [N = 30 females (52%), median age 40 years (interquartile range, 32-51.5)] were recruited across three stakeholder groups for minimally structured interviews. Themes were identified using an inductive, grounded theory approach and linked together to create a framework explaining stakeholder perspectives on HIV testing. Stakeholders described the "road" to HIV testing as time-consuming, expensive, and stigmatizing. All agreed healers could mitigate barriers by delivering HIV testing at their practices. Collaborations between biomedical and traditional providers were considered essential to a successful healer-delivered HIV testing program. This work describes a novel approach to "shorten the road" to HIV testing, suggesting that traditional healer-delivered HIV testing holds promise to expand uptake of testing among communities with limited access to existing programs.

HIV-related stigma is a frequently cited barrier to HIV testing and care engagement. A nuanced understanding of HIV-related stigma is critical for developing stigma-reduction interventions to optimize HIV-related outcomes. This qualitative study documented HIV-related stigma across eight communities in east Africa during the baseline year of a large HIV test-and-treat trial (SEARCH, NCT: 01864603), prior to implementation of widespread community HIV testing campaigns and efforts to link individuals with HIV to care and treatment. Findings revealed experiences of enacted, internalized and anticipated stigma that were highly gendered, and more pronounced in communities with lower HIV prevalence; women, overwhelmingly, both held and were targets of stigmatizing attitudes about HIV. Past experiences with enacted stigma included acts of segregation, verbal discrimination, physical violence, humiliation and rejection. Narratives among women, in particular, revealed acute internalized stigma including feelings of worthlessness, shame, embarrassment, and these resulted in anxiety and depression, including suicidality among a small number of women. Anticipated stigma included fears of marital dissolution, verbal and physical abuse, gossip and public ridicule. Anticipated stigma was especially salient for women who held internalized stigma and who had experienced enacted stigma from their partners. Anticipated stigma led to care avoidance, care-seeking at remote facilities, and hiding of HIV medications. Interventions aimed at reducing individual and community-level forms of stigma may be needed to improve the lives of PLHIV and fully realize the promise of test-and-treat strategies.

BackgroundThe United Kingdom is experiencing an increase in drug-related deaths and serious bacterial infections among its most vulnerable citizens. Cuts to essential services, coupled with a growing homeless population, create a challenging environment to tackle this public health crisis. In this paper, we highlight an underexplored environmental constraint faced by people living and injecting drugs on the streets. Access to water for injection is restricted in the UK, due to legislative and financial barriers. Austerity measures, such as public toilet closures, further restrict the ability of people made homeless to access clean water and protect themselves from health harms.MethodsWe generated questionnaire (n = 455) and in-depth qualitative interview (n = 32) data with people who inject drugs in London for the Care and Prevent study. Participants provided detail on their life history; drug use, injecting and living environments; health conditions and care seeking practices.FindingsA high proportion of the survey sample reported lifetime history of street homelessness (78%), bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts highlight unsafe, potentially dangerous, injection practices in semi-public spaces. Multiple constraints to sourcing sterile water for injection preparation were reported. Alternatives to sterile water included puddle water, toilet cistern water, whisky, cola soda and saliva. Participants who injected heroin and crack cocaine together unanimously reported adding water at two stages during injection preparation: first, adding water as a vehicle for heroin (which was then heated); second, adding cold water to the heroin mixture prior to adding the crack cocaine. This new finding of a stage addition of solvent may represent an additional risk of infection.ConclusionCurrently, harm reduction equipment and resources for safe injecting are not meeting the needs of people who inject drugs who are street homeless or unstably housed. Preparation of injections with non-sterile water sources could precipitate bacterial and fungal infections, particularly when used without the application of heat. It is crucial that water for injection, also skin cleaning, is made available for the unstably housed and that harm reduction messaging is tailored to speak to the everyday realities of people who prepare and inject drugs in public spaces.

BackgroundLaw enforcement officers (LEOs) come into frequent contact with people who inject drugs (PWID). Through service referrals, LEOs may facilitate PWID engagement in harm reduction, substance use treatment, and other health and supportive services. Little is known about PWID and LEO attitudes and concerns about service referrals, however. The objective of this mixed-methods study was to examine the alignment of service referral preferences and acceptability among PWID and LEOs in Tijuana, Mexico.MethodsWe assessed service referral preferences and perceived likelihood of participation in health and social services, integrating data from structured questionnaires with 280 PWID and 306 LEOs, contextualized by semi-structured interviews and focus groups with 15 PWID and 17 LEOs enrolled in two parallel longitudinal cohorts in Tijuana, Mexico.ResultsAmong potential service referral options, both PWID (78%) and LEOs (88%) most frequently cited assistance with drug- and alcohol-use disorders. Over half of PWID and LEOs supported including harm reduction services such as syringe service programs, overdose prevention, and HIV testing. The majority of PWID supported LEO referrals to programs that addressed basic structural needs (e.g. personal care [62%], food assistance [61%], housing assistance [58%]). However, the proportion of LEOs (30-45%) who endorsed these service referrals was significantly lower (p

BackgroundSelf-monitoring of blood glucose (SMBG) is a crucial tool for maintaining glycemic control in women with gestational diabetes mellitus (GDM). However, to date, little is known about the current status of SMBG engagement among women with GDM in China.ObjectiveTo describe the current status of SMBG engagement among women with GDM in China and identify its barriers and facilitators.Design and settingA mixed-methods design was conducted, comprising a cross-sectional survey and semi-structured interviews. The research data were collected in two tertiary hospitals in Hunan province, China.ParticipantsA total of 323 women with GDM completed the survey from March 2018 to October 2018, and 11 of them participated in the interviews.FindingIn total, 35.6% of the participants actively engaged in SMBG. The participants who had an advanced maternal age (95% CI 0.253-0.947), did not own glucose meters (95% CI 0.054-0.364), did not receive SMBG-related information from health professionals (95% CI 0.232-.987), or received less SMBG information in general (95% CI 0.137-0.52) were less likely to engage in SMBG. Insufficient SMBG information and low awareness of SMBG were also summarized as the main barriers in the interview findings. Facilitators of SMBG engagement included SMBG-related social support (95% CI 1.573-6.135) and health concerns related to themselves and the unborn infant.ConclusionAbout one-third of Chinese women with GDM engaged in SMBG. An accurate and complete description of how SMBG should be performed is needed from health professionals. Strategies to obtain more SMBG-related social support and a greater emphasis on health concerns are recommended to increase SMBG engagement among women with GDM in China.

PrEP persistence, or PrEP use over time, has been shown to be short, with most PrEP users stopping within 6-12 months. Furthermore, those most vulnerable to HIV often use PrEP for shorter periods. This qualitative study explores patient, provider, and contextual factors that influence PrEP persistence. In interviews with 25 PrEP users and 18 PrEP providers in San Francisco's safety net clinics, we analyze the perceived benefits and difficulties of taking PrEP, including structural barriers. We identify different steps in receipt of PrEP care (clinic visits and lab tests, pharmacy interactions, and medication adherence), and describe barriers and facilitators for providers and patients at each step. Our findings suggest that drop-in visits, streamlined testing, standing orders for labs, and 90-day PrEP prescriptions are highly desirable for many PrEP users. Also important are the proactive provision of adherence support and counseling, and referrals for housing, substance use, and mental health services.

Transgender women share more in common with cisgender women, with respect to sociocultural context and factors influencing HIV risk and outcomes, than they do with "men who have sex with men", a behavioral risk category in which they often are included. However, it is not yet clear whether both transgender and cisgender women would find integrated, all-women HIV programs and services desirable and beneficial. We Are All Women was a qualitative study conducted in the San Francisco Bay Area from April 2016 to January 2017, using a conceptual framework based on gender affirmation and trauma-informed care, to explore barriers and facilitators to inclusion of transgender women in HIV treatment and support services traditionally focused on cisgender women. Thirty-eight women (10 trans, 25 cis, and 3 "other" gender) participated in six semistructured, facilitated focus groups. In addition, five HIV care providers participated in semistructured, in-depth interviews. Both trans and cis women identified the desire for gender affirmation, a feeling of safety (specifically space without men), and potential community building within a care and healing context as powerful facilitators of an inclusive all-women care environment. At the same time, they recognized that tensions do exist between idealized visions of such an environment, deep-seated sentiments and behaviors among some cis women toward trans women, and the practical realities of creating the optimal spaces for all women. Opportunities for dialog between trans and cis women to mitigate gender-associated phobias and misperceptions are a valuable first step in creating HIV care environments that serve all women.

Marriage is a point of change in young people's lives, especially in parts of the world that place high value on it, such as in South Asian countries including Nepal. However, marriage practices are changing, with a move towards more love marriage; this is likely to have important implications on women's status and agency, household and couple dynamics, and mental and physical health. The aim of this paper is to describe how changing marriage formation patterns and traditional practices such as co-residence and dowry are intersecting and impacting relationships post-marriage. In-depth qualitative interviews took place with 20 intact triads of newly married women, their husbands and their mothers-in-law, in one district of Nepal in 2017. Many marriages remain arranged; however, couples often talk or meet before marriage and feel that they are able to build a foundation of love before marrying. Access to technology facilitates this practice, although some couples are reluctant to admit their communication, suggesting stigma about this practice. Husbands have growing ambivalence about dowry, leading to confusion and negatively impacting on relationships post-marriage. A clash of traditional and modern ideas and practices is occurring in Nepal, influencing newly married women's household status and relationship quality, and potentially impacting women's health.

Prediabetes affects one-third of U.S. adults. Lifestyle change interventions, such as the Diabetes Prevention Program (DPP), can significantly lower type 2 diabetes risk, but little is known about how the DPP could be best adapted for women. This mixed-methods study assessed the impact of gender-tailoring and modality choice on DPP engagement among women Veterans with prediabetes. Participants were offered women-only groups and either in-person/peer-led or online modalities. Implementation outcomes were assessed using attendance logs, recruitment calls, and semi-structured interviews about patient preferences. Between June 2016 and March 2017, 119 women Veterans enrolled in the DPP (n = 51 in-person, n = 68 online). We conducted 22 interviews between August and September 2016 (n = 10 early-implementation) and March and July 2017 (n = 12 follow-up). Most interviewees preferred women-only groups, citing increased comfort, camaraderie, and mutual understanding of gender-specific barriers to lifestyle change. More women preferred online DPP, and those using this modality participated at higher rates. Most endorsed the importance of modality choice and were satisfied with their selection; however, selection was frequently based on participants' personal circumstances and access barriers and not on a "preferred choice" of two equally accessible options. Patient engagement and program reach can be expanded by tailoring the DPP for population-specific needs.

Understanding why clients stop taking pre-exposure prophylaxis (PrEP) is critical to improve PrEP delivery and ultimately reduce HIV incidence. We analyzed data from a programmatic evaluation conducted at the Los Angeles LGBT Center from February to May 2018. Of 180 respondents to the emailed survey, 91 had stopped taking PrEP and 11 never started. Among former PrEP users, most common reasons for stopping were entering a monogamous relationship (43%) and side effects (40%). Ten of 11 who never started PrEP reported access barriers (e.g., cost, insurance problems). A quarter of inactive clients re-engaged with PrEP services following the survey and 15% restarted PrEP by October 2018. Improving PrEP retention may require multifaceted interventions-e.g., tailored discussions about stopping and restarting PrEP safely as HIV risk changes, ensuring consistent access to affordable PrEP, and alternative dosing strategies. An emailed survey may be a simple, effective strategy to reengage some PrEP clients.

ObjectiveLike any therapy, acupuncture is effective for some patients, while not helpful for others. Understanding from a patients' perspective what makes one respond or not to acupuncture can help guide further intervention development. This study aimed to identify factors that influence the perception of acupuncture's therapeutic effect among cancer survivors with insomnia.MethodWe conducted post-treatment semi-structured interviews with cancer survivors who were randomized to the acupuncture group in a clinical trial for the treatment of insomnia. Survivors were categorized into Responders and Non-Responders to acupuncture treatment based on the change in the Insomnia Severity Index with a reduction of eight points or greater as the cut-off for the response. An integrated approach to data analysis was utilized by merging an a priori set of codes derived from the key ideas and a set of codes that emerged from the data through a grounded theory approach. Codes were examined for themes and patterns.ResultsAmong 28 cancer survivors interviewed, 18 (64%) were classified as Responders. Participants perceived the ability to respond to acupuncture as dependent on treatment that effectively: (1) alleviated co-morbidities contributing to insomnia, (2) supported sleep hygiene practices, and (3) provided a durable therapeutic effect. Acupuncture treatment that did not address one of these themes often detracted from positive treatment outcomes and diminished perceived benefit from acupuncture.Significance of resultsWe identified patient-perceived contributors to response to acupuncture, such as co-morbid medical conditions, adequate support for sleep hygiene practices, and temporary therapeutic relief. Addressing these factors may improve the overall effectiveness of acupuncture for insomnia.

Alcohol use among HIV-positive individuals in sub-Saharan Africa directly impacts adherence to antiretroviral therapy and HIV outcomes. Few studies have examined approaches to reduce alcohol use among HIV-affected couples, despite evidence that alcohol use is a couple-level concern. We conducted a qualitative study with 23 alcohol-using couples to identify multilevel barriers and facilitators of alcohol use, and potential intervention options with couples. Data were analyzed at individual and dyadic levels using framework analysis. All couples were married and had at least one partner on ART. Men were the primary alcohol drinkers with few women reporting alcohol use. Most women tried to persuade their partners to reduce their alcohol intake and when unsuccessful, enlisted help from relatives and HIV care providers. Effective couple negotiation around men's alcohol use was constrained by negative peer influence and men's desire for friendship to cope with life stressors. Women were primarily concerned about the expense of alcohol and described how alcohol prevented the family from meeting basic needs and investing in the future. Alcohol use was described as a major barrier to ART adherence, but was also viewed as the cause of couple and family violence, extramarital partnerships, food insecurity, and poverty. We conclude that multilevel interventions based on couples' needs and preferences are urgently needed. Couple-based intervention approaches could include provider-led alcohol counseling with couples, alcohol reduction support groups for couples, couples' counseling to bolster couple communication and problem-solving around alcohol, and economic-strengthening interventions for couples.

HIV seropositive adherence-challenged women, who reported being on ART for at least four months were interviewed. Data on healthcare history, anti-retroviral therapy, clinic visits, doctor communication, disclosure and fear of stigma were collected. Better engagement in care was significantly more likely among older women, ≥ 10 years of education, higher income, HIV status disclosure to family, with higher community stigma fears and fewer healthcare access barriers. To promote retention, women may be encouraged to consider disclosing their HIV serostatus to supportive household members. A variety of possible interventions to overcome the prevalent barriers to care are provided.

Aim: To address the unmet needs of patients interested in regenerative medicine, Mayo Clinic created a Regenerative Medicine Consult Service (RMCS). We describe the service and patient satisfaction. Materials & methods: We analyzed RMCS databases through retrospective chart analysis and performed qualitative interviews with patients. Results: The average patient was older to elderly and seeking information about regenerative options for their condition. Patients reported various conditions with osteoarthritis being most common. Over a third of consults included discussions about unproven interventions. About a third of patients received a clinical or research referral. Patients reported the RMCS as useful and the consultant as knowledgeable. Conclusion: An institutional RMCS can meet patients' informational needs and support the responsible translation of regenerative medicine.

BACKGROUND:mHealth technologies are proliferating globally to address quality and timeliness of health care delivery by Community Health Workers (CHWs). This study aimed to examine CHW and beneficiaries' perceptions of a new mHealth intervention (Common Application Software [CAS] for CHWs in India. The objectives of the study were to seek perspectives of CHWs and beneficiaries on the uptake of CAS, changes in CHW-beneficiary interactions since the introduction of CAS and potential barriers faced by CHWs in use of CAS. Further, important contextual factors related to CHW-beneficiary interface and dynamics that may have a bearing on CAS have been described. METHODS:A qualitative study was conducted in two states of India (Bihar and Madhya Pradesh) from March-April 2018 with CHWs (n = 32) and beneficiaries (n = 55). All interviews were conducted and recorded in Hindi, transcribed and translated into English, and coded and thematically analysed using Dedoose. FINDINGS:The mHealth intervention was acceptable to the CHWs who felt that CAS improved their status in the communities where they worked. Beneficiaries' views were a mix of positive and negative perceptions. The divergent views between CHWs and beneficiaries surrounding the use and impact of CAS highlight an underlying mistrust, socio-cultural barriers in engagement, and technological barriers in implementation. All these contextual factors can influence the perception and uptake of CAS. CONCLUSIONS:mHealth interventions targeting CHWs and beneficiaries have the potential to improve performance of CHWs, reduce barriers to information and potentially change the behaviors of beneficiaries. While technology is an enabler for CHWs to improve their service delivery, it does not necessarily help overcome social and cultural barriers that impede CHW-beneficiary interactions to bring about improvements in knowledge and health behaviors. Future interventions for CHWs including mHealth interventions should examine contextual factors along with the acceptability, accessibility, and usability by beneficiaries and community members.

Low-income communities of color experience significant political, economic, and health inequities and, not unrelatedly, are disproportionately exposed to violent crime than are residents of higher income communities. In an effort to mitigate concentrations of poverty and crime, governmental agencies have partnered with affordable housing developers to redevelop public housing "projects" into mixed-income communities and to do so within a "trauma-informed" framework. The current study analyzes how residents have historically and contemporaneously negotiated, endured, and resisted structural and interpersonal violence in 2 long-standing, predominately African American, public housing communities undergoing a public-private housing redevelopment initiative. Interviews with 44 adult public housing residents (age range = 18-75 years; 82% African American/Black) were conducted during a 2-year period while residents' homes were being demolished and rebuilt into mixed-income communities. Analysis of in-depth interviews used constructivist grounded theory principles to reveal a common theme and basic social process of the ongoing formation of homeplace, with subthemes focusing on the ways homeplace emerges through shared lineage, knowing and caring practices; how homeplace is maintained through networks of protection in unsafe contexts; how homeplace is disrupted as a result of redevelopment activities; and the reclamation of homeplace during redevelopment in the service of hope and healing. These findings offer a nuanced view of resident's lived experiences of place-based trauma and collective resistance and resilience, while also highlighting the place-specific ways in which redevelopment unsettles deeply rooted sociocultural configurations of home and community. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

BackgroundSterile syringe access reduces injection-related health harms, yet access in the U.S. remains grossly inadequate. In California, syringe services programs (SSPs) are authorized mainly at the local level, and many communities remain underserved. State law also allows, but does not require, non-prescription syringe sales at pharmacies, but participation is low. We draw on the theoretical concept of "landscapes of antagonism" to examine how discordance between state and local decision-making contributes to uneven syringe access and health harms in California's Central Valley, where injection rates are high.MethodsOur study took place in Fresno and Kern counties. We draw on participant observation and qualitative interviews with individuals who inject drugs and key informants to examine issues around syringe access.ResultsOverall, 8 key informants represented harm reduction, medical, and faith-based organizations. Among 46 people who inject drugs, mean age was 39 (range: 20-65), 37% were female, and 37% self-identified as Latino. About half of individuals at each site had ever successfully purchased from pharmacies, but limited locations and perceived judgement from pharmacy staff posed common barriers. There was no SSP in Kern County due to political opposition; Fresno's SSP has been run by volunteers for more than 20 years despite opposition, and recently gained authorization. Reflecting this disparity, all but two individuals in Fresno accessed syringes from the SSP, whereas only one person in Kern had ever been to an SSP. To fill gaps in access in both sites, individuals obtained syringes that were often already used from diabetics, friends, and people on the street, sharing and reusing syringes at dangerously high rates.ConclusionLandscapes of antagonism create syringe access inequities that threaten to exacerbate disease transmission and other health harms. Our study raises questions about accountability for the health of people who use drugs and suggests a need for political action.

ContextIt is accepted as the norm that couples in South Asia begin childbearing immediately after marriage and that, even if they would like to delay, they are pressured to have children by household members. Little research, however, has explored the desire to delay childbearing among newly married couples and their household members in Nepal-a setting with changing marriage formation patterns, increasing women's education and falling fertility.MethodsTo explore the dynamics of current childbearing desires, in-depth interviews of 20 intact triads of newly married women, their husbands and their mothers-in-law were conducted in one district of Nepal in February-March 2017. Using thematic analysis, interviews were read and coded separately by type (wives, husbands, mothers-in-law), and then the triads were read together and coded to determine household-level patterns and themes.ResultsMost newly married women and men want to delay their first birth, but have not communicated with each other about this. Even though couples are often in agreement about delaying, they feel pressured by in-laws and society to bear children early. Contrary to expectations, some mothers-in-law support delaying childbearing to allow their daughter-in-law to mature, continue her education or earn wages; however, they too perceive societal pressure. Male migration for work also contributes to early childbearing pressure.ConclusionsHelping couples to sort through conflicting fertility norms and desires may be important to delay childbearing when desired. Programs should engage all household members, and work to increase couples' and household communication to address misperceptions about fertility desires.

BackgroundAfter a COVID-19 diagnosis, vulnerable populations face considerable logistical and financial challenges to isolate and quarantine. We developed and evaluated a novel, community-based approach ('Test-to-Care' Model) designed to address these barriers for socioeconomically vulnerable Latinx individuals with newly diagnosed COVID-19 and their households.MethodsThis three-week demonstration project was nested within an epidemiologic surveillance study in a primarily Latinx neighborhood in the Mission district of San Francisco, California. The Test-to-Care model was developed with input from community members and public health leaders. Key components included: (1) provision of COVID-19-related education and information about available community resources, (2) home deliveries of material goods to facilitate safe isolation and quarantine (groceries, personal protective equipment and cleaning supplies), and (3) longitudinal clinical and social support. Newly SARS-CoV-2 PCR-positive participants were eligible to participate. Components of the model were delivered by the Test-to-Care team, which was comprised of healthcare providers and community health workers (CHWs) who provided longitudinal clinic- and community-based support for the duration of the isolation period to augment existing services from the Department of Public Health (DPH). We evaluated the Test-to-Care Model using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework and drew upon multiple data sources including: programmatic data, informal interviews with participants and providers/CHWs and structured surveys among providers/CHWs.ResultsOverall, 83 participants in the surveillance study were diagnosed with COVID-19, of whom 95% (79/83) were Latinx and 88% (65/74) had an annual household income

BackgroundFood insecurity, limited access to adequate food, in adulthood is associated with poor health outcomes that suggest a pattern of accelerated aging. However, little is known about factors that impact food insecurity in midlife which in turn could help to identify potential pathways of accelerated aging.MethodsLow-income adults (n = 17,866; 2014 National Health Interview Survey), ages 18 to 84, completed a 10-item food security module and answered questions regarding health challenges (chronic conditions and functional limitations) and financial worry. We used multinomial logistic regression for complex samples to assess the association of health challenges and financial worry with food insecurity status and determine whether these associations differed by age group, while adjusting for poverty, sex, race/ethnicity, education, family structure, social security, and food assistance.ResultsFood insecurity rates were highest in late- (37.5%) and early- (36.0%) midlife, relative to younger (33.7%) and older (20.2%) age groups and, furthermore, age moderated the relationship between food insecurity and both risk factors (interaction p-values < .05, for both). The effects of poor health were stronger in midlife relative to younger and older ages. Unlike younger and older adults, however, adults in midlife showed high levels of food insecurity regardless of financial worry.ConclusionsFindings suggest that food insecurity in midlife may be more severe than previously thought. Greater efforts are needed to identify those at greatest risk and intervene early to slow premature aging.

BackgroundWell-tolerated, highly effective HCV treatment, known as direct-acting antivirals (DAAs), is now recommended for all people living with HCV, providing the tools for HCV elimination. We sought to understand treatment barriers among low-income HIV/HCV coinfected patients and providers with the goal of increasing uptake.MethodsIn 2014, we conducted 26 interviews with HIV/HCV co-infected patients and providers from a San Francisco clinic serving underinsured and publically-insured persons to explore barriers impacting treatment engagement and completion. Interview transcripts were coded, and a thematic analysis was conducted to identify emerging patterns.ResultsConditions of poverty-specifically, meeting basic needs for food, shelter, and safety-undermined patient perceptions of self-efficacy to successfully complete HCV treatment programs. While patient participants expressed interest in HCV treatment, the perceived burden of taking daily medications without strong social support was an added challenge. This need for support contradicted provider assumptions that, due to the shorter-course regimens, support is unnecessary in the DAA era.ConclusionsInterferon-free treatments alone are not sufficient to overcome social-structural barriers to HCV treatment and care among low-income HIV/HCV co-infected patients. Support for patients with unmet social needs may facilitate treatment initiation and completion, particularly among those in challenging socioeconomic situations.

IntroductionThis study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings.MethodsAs part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes.ResultsFifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks.ConclusionsDespite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams.Supplement informationThis article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

BackgroundIndividual child-level risk factors for Early Childhood Caries (ECC) have been studied, but broader family- and community-level influences on child oral hygiene behaviors are less well understood. This study explored multiple levels of influence on oral hygiene behaviors for young children in Early Head Start (EHS) to inform a future behavioral intervention targeting children from low-income families.MethodsTwenty-four semi-structured interviews were conducted with mothers of children under 4 years old, enrolled in the home visitor (HV) component of one EHS program in Los Angeles, CA, who participated in the BEhavioral EConomics for Oral health iNnovation pilot study (BEECON) in 2016-7. Audio-recordings of interviews were translated if needed, and transcribed in English, and coding and analysis was facilitated by Dedoose qualitative software. This investigation used general thematic analysis guided by the Fisher-Owens child oral health conceptual framework to identify influences on oral hygiene behaviors for the young children.ResultsMany mothers reported brushing their children's teeth twice/day, and concern that most children frequently resisted brushing. They identified children being sick or tired/asleep after outings as times when brushing was skipped. Several child-, family-, and community-level themes were identified as influences on child oral hygiene behaviors. At the child-level, the child's developmental stage and desire for independence was perceived as a negative influence. Family-level influences included the mother's own oral hygiene behaviors, other family role models, the mother's knowledge and attitudes about child oral health, and mothers' coping skills and strategies for overcoming challenges with brushing her child's teeth. Overall, mothers in the EHS-HV program were highly knowledgeable about ECC risk factors, including the roles of bacteria and sugar consumption, which motivated regular hygiene behavior. At the community-level, mothers discussed opportunities to connect with other EHS-HV families during parent meetings and playgroups that HV coordinated. A few mothers noted that EHS-HV playgroups included brushing children's teeth after snacking, which can be a potential positive influence on children's hygiene practices.ConclusionChild-, family- and community-level factors are important to consider to inform the development of tailored oral health preventive care programs for families in EHS-HV programs.

Fishing communities in Uganda have high rates of excessive alcohol consumption and negative health outcomes related to alcohol consumption, such as HIV acquisition and transmission and intimate partner violence victimization and perpetration. Research lacks understanding of alcohol use in Ugandan fishing communities, underlying reasons for excessive drinking among fishermen or how their community perceives negative health outcomes linked to excessive alcohol consumption. This qualitative study was conducted among Ugandan fisherfolk to determine why excessive alcohol consumption has overtaken their communities. Through analyzing in-depth interviews and focus group discussions, reasons for drinking and community perceptions of drinking were explored using the Socio Ecological Model and the Time Perspective Theory. Interviews were coded into two content themes: social influences on drinking and using alcohol to cope with stress. Participants acknowledged links between excessive alcohol consumption and negative health outcomes within their families and communities. These findings highlight the need for alcohol-related reduction interventions that are sensitive to contextual factors and self-identified contributors to problematic alcohol use within individuals and their communities. Such interventions must consider the social, ecological and economic conditions within fishing sites, focusing not only on individual-level behavioral change but also challenging the underlying structures that foster excessive alcohol consumption.

Cancer genetic counseling (CGC) combines psychosocial counseling and genetic education provided by genetic counselors to patients and families who have a history of cancer and are considering or have undergone genetic testing for hereditary cancer syndromes. The quantity and complexity of information provided can be challenging for any patient, but is even more so for those with limited English proficiency (LEP). This exploratory study investigated healthcare interpreters' and genetic counselors' perspectives on the role of interpreters in providing care to LEP patients during CGC. Through a survey of 18 interpreters and conventional content analysis of semi-structured interviews with 11 interpreters and 10 GCs at two California public hospitals, we found that: 1) interpreters viewed their role as patient advocate, cultural broker, and emotional support, not simply a conduit; 2) interpreters were challenged by remote interpretation, lack of genetic knowledge, and the emotional content of encounters; 3) interpreters and GCs held conflicting views of the value of counselors' limited Spanish knowledge; and 4) trust, the foundation of the interpreter-provider dyad, was often lacking. The challenges identified here may result in poor healthcare experiences and outcomes for LEP patients. As genomics becomes more widespread and more LEP patients encounter CGC, the role of healthcare interpreters in facilitating effective communication must be further defined in order to facilitate better working relationships between interpreters and genetic counselors, and optimal communication experiences for patients.

The study assessed the HIV treatment cascade of people living with HIV (PLWH) in Iran and the reasons for gaps in HIV services in 2014. We did the cascade analysis using the WHO HIV test-treat-retain cascade analysis tool (2014). To measure the gaps, we check the records for all PLWH reported to the national HIV surveillance till September 2014 to define how many were alive, linked to HIV care, assessed for CD4 count, started antiretroviral therapy (ART), and reported to be alive up to five years after ART. To assess the reasons for gaps in the cascade, we ran desk review, four focus group discussions (FGD) and fifty one in-depth interviews with key informants including PLWH. Spectrum model estimated 75,700 PLWH in Iran, of whom, only 22,647 people (%30) were diagnosed. Of those who were diagnosed with HIV, 16,266 people (%72) enrolled in HIV care. About 13% of all PLWH retained in HIV care and only 9% (6,745 people) had ever tested for CD4 count. Only 8% (6,018 people) of all PLWH received ART by September 2014. We found the biggest gap in the HIV treatment cascade to be HIV diagnosis as only 30% of PLWH have been diagnosed. Innovative strategies to improve HIV testing, particularly those work best for key populations, is critical to reach the 90–90-90 targets.