Why do Stayers Stay? Perceptions of White and Black Long-Term Employees in a Community Mental Health Center.

Previous research has focused on factors influencing turnover of employees in the mental health workforce, yet little research has explored reasons why employees stay. To facilitate retaining a diverse mental health workforce, the current study aimed to elucidate factors that contributed to employees' tenure at a community mental health center (CHMC) as well as compare these perceptions between Black and White employees. Long-term employees (7 years or more) from one urban CMHC (n = 22) completed semi-structured stayer interviews. Using emergent thematic analysis, stayer interviews revealed four major themes for why they have stayed at the organization for 7 years or more: (1) work as a calling, (2) supportive relationships, (3) opportunities for growth or meaningful contribution, and (4) organization mission's alignment with personal attributes or values. Comparison between Black and White stayer narratives revealed differences in their perceptions with work as a calling and opportunities for growth and meaningful contribution. Guided by themes derived from stayer interviews, the current study discusses theoretical (e.g., job embeddedness theory, theory of racialized organizations, self-determination theory) and practical implications (e.g., supporting job autonomy, Black voices in leadership) in an effort to improve employee retention and address structural racism within a mental health organization.

Identity recognition from faces and bodies in schizophrenia spectrum disorders.

Deficits in facial identity recognition and its association with poor social functioning are well documented in schizophrenia, but none of these studies have assessed the role of the body in these processes. Recent research in healthy populations shows that the body is also an important source of information in identity recognition, and the current study aimed to thoroughly examine identity recognition from both faces and bodies in schizophrenia. Sixty-five individuals with schizophrenia and forty-nine healthy controls completed three conditions of an identity matching task in which they attempted to match unidentified persons in unedited photos of faces and bodies, edited photos showing faces only, or edited photos showing bodies only. Results revealed global deficits in identity recognition in individuals with schizophrenia (ηp2 = 0.068), but both groups showed better recognition from bodies alone as compared to faces alone (ηp2 = 0.573), suggesting that the ability to extract useful information from bodies when identifying persons may remain partially preserved in schizophrenia. Further research is necessary to understand the relationship between face/body processing, identity recognition, and functional outcomes in individuals with schizophrenia-spectrum disorders.

Machine Learning with Human Resources Data: Predicting Turnover among Community Mental Health Center Employees.

BACKGROUND: Human resources (HR) departments collect extensive employee data that can be useful for predicting turnover. Yet, these data are not often used to address turnover due to the complex nature of recorded data forms. AIMS OF THE STUDY: The goal of the current study was to predict community mental health center employees' turnover by applying machine learning (ML) methods to HR data and to evaluate the feasibility of the ML approaches. METHODS: Historical HR data were obtained from two community mental health centers, and ML approaches with random forest and lasso regression as training models were applied. RESULTS: The results suggested a good level of predictive accuracy for turnover, particularly with the random forest model (e.g., Area Under the Curve was above .8) compared to the lasso regression model overall. The study also found that the ML methods could identify several important predictors (e.g., past work years, wage, work hours, age, job position, training hours, and marital status) for turnover using historical HR data. The HR data extraction processes for ML applications were also evaluated as feasible. DISCUSSION: The current study confirmed the feasibility of ML approaches for predicting individual employees' turnover probabilities by using HR data the organizations had already collected in their routine organizational management practice. The developed approaches can be used to identify employees who are at high risk for turnover. Because our primary purpose was to apply ML methods to estimate an individual employee's turnover probability given their available HR data (rather than determining generalizable predictors at the wider population level), our findings are limited or restricted to the specific organizations under the study. As ML applications are accumulated across organizations, it may be expected that some findings might be more generalizable across different organizations while others may be more organization-specific (idiographic). IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The organization-specific findings can be useful for the organization's HR and leadership to evaluate and address turnover in their specific organizational contexts. Preventing extensive turnover has been a significant priority for many mental health organizations to maintain the quality of services for clients. IMPLICATIONS FOR HEALTH POLICIES: The generalizable findings may contribute to broader policy and workforce development efforts. IMPLICATIONS FOR FURTHER RESEARCH: As our continuing research effort, it is important to study how the ML methods and outputs can be meaningfully utilized in routine management and leadership practice settings in mental health (including how to develop organization-tailored intervention strategies to support and retain employees) beyond identifying high turnover risk individuals. Such organization-based intervention strategies with ML applications can be accumulated and shared by organizations, which will facilitate the evidence-based learning communities to address turnover. This, in turn, may enhance the quality of care we can offer to clients. The continuing efforts will provide new insights and avenues to address data-driven, evidence-based turnover prediction and prevention strategies using HR data that are often under-utilized.

eHealth Use on Acute Inpatient Mental Health Units: Implementation Processes, Common Practices, and Barriers to Use.

Information technology to promote health (eHealth) is an important and growing area of mental healthcare, yet little is known about the use of patient-facing eHealth in psychiatric inpatient settings. This quality improvement project examined the current practices, barriers, implementation processes, and contextual factors affecting eHealth use across multiple Veteran Health Administration (VHA) acute mental health inpatient units. Staff from units serving both voluntary and involuntary patients (n = 49 from 37 unique sites) completed surveys regarding current, desired, and barriers to use of Veteran-facing eHealth technologies. Two subsets of respondents were then interviewed (high success sites in eHealth use, n = 6; low success sites, n = 4) to better understand the context of their eHealth use. Survey responses indicated that 20% or less of Veterans were using any type of eHealth technology while inpatient. Tablets and video chat were the most desired overall and most successfully used eHealth technologies. However, many sites noted difficulty implementing these technologies (e.g., limited Wi-Fi access). Qualitative analysis of interviews revealed differences in risk/benefit analysis and implementation support between high and low success eHealth sites. Despite desired use, patient-facing eHealth technology is not regularly implemented on inpatient units due to multiple barriers (e.g., limited staffing, infrastructure needs). Successful implementation of patient-facing eHealth may require an internal champion, guidance from external supports with experience in successful eHealth use, workload balance for staff, and an overall perspective shift in the benefits to eHealth technology versus the risks.

A preliminary investigation of paranoia variability and its association with social functioning.

Background: Paranoid ideation is a core feature of psychosis and is associated with impaired social functioning. Severity of paranoia can fluctuate across time as symptoms wax and wane; however, no study has systematically investigated how this intra-individual variability in paranoia may relate to social impairments and social functioning. Methods: Fifty-five patients with DSM-5 diagnoses and recent paranoia were followed for up to one year and completed the suspiciousness/persecution section (P6) of the Positive and Negative Symptom Scale (PANSS) on a monthly basis to monitor fluctuations in paranoia. Categorical changes between paranoid and non-paranoid status were monitored and tallied. Participants self-reported current paranoia and anxiety levels as well as social functioning when demonstrating paranoia changes. Results: Most patients showed changes between paranoid categories (60%). Individuals with no paranoia change showed higher current paranoia and lower independence-competence subscores of the Birchwood Social Functioning Scale (SFS) compared with those with one change. Current paranoia and state anxiety explained significant variance in the prosocial activities subscore of SFS, and importantly, paranoia changes accounted for variance above and beyond these effects. Individuals with higher current paranoia participated less in prosocial activities, however those with higher paranoia variability were more involved in social activities. Similarly, individuals with more paranoia variability demonstrated better overall social functioning as measured by the averaged SFS total score. Conclusion: Paranoia fluctuation is prevalent across time, and both paranoia severity and variability impact social functioning, in that lower levels of paranoia severity and higher levels of paranoia variability are associated with better interpersonal functioning.

Implementation and staff understanding of shared decision-making in the context of recovery-oriented care across US Veterans Health Administration (VHA) inpatient mental healthcare units: a mixed-methods evaluation.

OBJECTIVES: To examine the understanding and practice of shared decision-making (SDM) within the context of recovery-oriented care across Veterans Health Administration (VHA) inpatient mental healthcare units. DESIGN: VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient Scale (RAIN). Scores on the RAIN item for medication SDM were used to rank each site from lowest to highest. The top 7 and bottom 8 sites (n=15) were selected for additional analyses using a mixed-methods approach, involving qualitative interviews, observation notes and quantitative data. SETTING: 34 VHA inpatient mental health units located in every geographical region of the USA. PARTICIPANTS: 55 treatment team members. RESULTS: Our results identified an overarching theme of 'power-sharing' that describes participants' conceptualisation and practice of medication decision-making. Three levels of power sharing emerged from both interview and observational data: (1) No power sharing: patients are excluded from treatment decisions; (2) Limited power sharing: patients are informed of treatment decisions but have limited influence on the decision-making process; and (3) Shared-power: patients and providers work collaboratively and contribute to medication decisions. Comparing interview to observational data, only observational data indicating those themes differentiate top from bottom scoring sites on the RAIN SDM item scores. All but one top scoring sites indicated shared power medication decision processes, whereas bottom sites reflected mostly no power sharing. Additionally, our findings highlight three key factors that facilitate the implementation of SDM: inclusion of veteran in treatment teams, patient education and respect for patient autonomy. CONCLUSIONS: Implementation of SDM appears feasible in acute inpatient mental health units. Although most participants were well informed about SDM, that knowledge did not always translate into practice, which supports the need for ongoing implementation support for SDM. Additional contextual factors underscore the value of patients' self-determination as a guiding principle for SDM, highlighting the role of a supporting, empowering and autonomy-generating environment.

Variation in State Education Regulations for RNs.

BACKGROUND: There is variation in nursing education quality, measured as first-time NCLEX (National Council Licensure Examination)-RN pass rates (FTPR), both across and within the United States. Current research examines program-level characteristics associated with performance. METHOD: This study examines state-level policies and their relationship to FTPR (both associate and baccalaureate nursing degrees) to identify policies that enhance nursing program quality. Ordinary least squares regression analyses were conducted for state and program levels, and tests for interactions of variables were conducted between the two levels. RESULTS: Accredited for-profit programs were associated with a 24% higher FTPR than nonaccredited for-profit programs. In addition, for-profit programs in more business-friendly states were associated with an 11.8% lower FTPR. CONCLUSION: National standards for licensure pass rates, a mandate that all programs be accredited, and better enforcement could help improve the quality of RN programs nationwide. States with pro-business policies should be aware of the effect of their policies on the proliferation of for-profit schools. [J Nurs Educ. 2022;61(5):242-249.].

Inpatient Mental Healthcare before and during the COVID-19 Pandemic.

Prior studies have demonstrated disruption to outpatient mental health services after the onset of the COVID-19 pandemic. Inpatient mental health services have received less attention. The current study utilized an existing cohort of 33 Veterans Health Affairs (VHA) acute inpatient mental health units to examine disruptions to inpatient services. It further explored the association between patient demographic, clinical, and services variables on relapse rates. Inpatient admissions and therapeutic services (group and individual therapy and peer support) were lower amongst the COVID-19 sample than prior to the onset of COVID-19 while lengths of stay were longer. Relapse rates did not differ between cohorts. Patients with prior emergent services use as well as substance abuse or personality disorder diagnoses were at higher risk for relapse. Receiving group therapy while admitted was associated with lower risk of relapse. Inpatient mental health services saw substantial disruptions across the cohort. Inpatient mental health services, including group therapy, may be an important tool to prevent subsequent relapse.

Amygdala hyperconnectivity in the paranoid state: A transdiagnostic study.

BACKGROUND: Paranoia significantly contributes to social impairments across clinical diagnoses, and amygdala dysfunction has been identified as a neurobiological marker of paranoia among individuals with schizophrenia. Therefore, we aimed to investigate amygdala functional connectivity (FC) in paranoia across diagnoses. METHODS: Forty-five patients with recent history of clinically significant paranoid ideation and a current DSM-5 diagnosis of any disorder underwent resting-state functional magnetic resonance imaging either in a paranoid (N = 23) or non-paranoid (N = 22) state. Amygdala FC were compared between paranoid and non-paranoid patients. Supplemental correlation analyses between amygdala FC and paranoia score were performed separately in patients and a non-equivalent healthy control (HC; N = 60) group. RESULTS: Increased FC was found between right amygdala and the prefrontal cortex (PFC) [bilateral medial superior frontal gyrus, anterior cingulate, medial frontal gyrus, the triangular part and the opercular part of the inferior frontal gyrus (IFG); right orbital part of IFG], the frontal cortex (bilateral median cingulate, left precentral gyrus), and subcortical areas (right insula) in the paranoid group compared with the non-paranoid group. No significant between-group differences were observed in left amygdala FC. FC between right amygdala and PFC and frontal cortex was positively correlated with paranoia in patient and HC groups. CONCLUSION: Paranoia is associated with right amygdala hyperconnectivity with PFC, frontal cortex, and insula. This hyperconnectivity was evident regardless of diagnosis and therefore identify a likely transdiagnostic neural mechanism, which may help to identify treatment targets that could potentially improve the social functioning of individuals with clinical diagnoses.

Preliminary evidence for the efficacy of single-session transcranial direct current stimulation to the ventrolateral prefrontal cortex for reducing subclinical paranoia in healthy individuals.

OBJECTIVES: Paranoia manifests similarly in subclinical and clinical populations and is related to distress and impairment. Previous work links paranoia to amygdala hyperactivity and reduced activation of the ventrolateral prefrontal cortex (VLPFC), a region thought to regulate amygdala activity. METHODS: This study aimed to reduce subclinical paranoia in 40 undergraduates by increasing activity of the VLPFC via single-session transcranial Direct Current Stimulation (tDCS). A double-blind, crossover (active vs. sham stimulation) design was used. RESULTS: Paranoia significantly decreased after active stimulation (dz  = 0.51) but not sham (dz  = 0.19), suggesting that tDCS of VLPFC was associated with mean-level reductions in paranoia. CONCLUSION: These findings demonstrate preliminary support for the role of single-session active stimulation to the VLPFC for reducing subclinical paranoia in healthy individuals. PRACTITIONER POINTS: In both clinical and subclinical populations, paranoia is related to distress and poorer functional outcomes. Paranoia has been linked to overactivation of the amygdala, a brain region responsible for detecting salience and threat, and reduced activation of the ventrolateral prefrontal cortex (VLPFC), a region thought to modulate and regulate amygdala activity. In this study, transcranial direct current stimulation (tDCS) of the VLPFC reduced self-reported paranoia in healthy undergraduate students. tDCS may be a promising intervention for reducing paranoia in subclinical and clinical populations. Effects were relatively small and require replication with larger subclinical samples and with clinical samples.

Understanding Why Nurse Practitioner (NP) and Physician Assistant (PA) Productivity Varies Across Community Health Centers (CHCs): A Comparative Qualitative Analysis.

This study asks how much and why the productivity of advanced practice clinicians (APCs; nurse practitioners and physician assistants) varies across community health centers (CHCs), as measured in their marginal contribution to overall patient visits. We found APCs in the 90th percentile CHCs provide about 1,840 adjusted-visits per year, whereas APCs in the 10th percentile CHCs provide about 978 adjusted-visits per year. We interviewed leadership at 14 high APC and 16 low APC productivity CHCs to elicit organizational conditions that could explain the difference. Using content analysis and then qualitative comparative analysis, we found several important conditions were more common among high productivity CHCs, including scheduling APCs and physicians for the same number of visits, parity in terms of any financial incentives, and formal education programs for new APCs during onboarding/transition to practice.

Measuring mentalizing: A comparison of scoring methods for the hinting task.

OBJECTIVE: The Social Cognition Psychometric Evaluation (SCOPE) study supported the utility and practicality of the Hinting task as a measure of social cognition/mentalizing in clinical trials, specifically with the SCOPE authors' stringent scoring system. However, it remains unclear whether the SCOPE scoring system is necessary for the task to be judged as psychometrically sound. METHOD: Independent raters rescored data from the three phases of SCOPE using the Hinting task's original scoring criteria. Psychometric properties of the task when scored with the original criteria versus more stringent SCOPE criteria were compared in a large sample of individuals with chronic schizophrenia (n = 397) and matched controls (n = 300) as well as a smaller sample of individuals with early psychosis (n = 38) and controls (n = 39). RESULTS: In both samples, SCOPE criteria resulted in lowered average scores and reduced ceiling effects. Further, revised scoring resulted in strengthened relationships between the hinting task and outcome measures in the chronic sample, and better differentiated early psychosis patients from controls. Conversely, test-retest reliability and internal consistency estimates were not improved using revised scoring and remained suboptimal, particularly for healthy controls. CONCLUSION: Overall, SCOPE scoring criteria improved some psychometric properties and clinical utility, suggesting that these criteria should be considered for implementation.

Implicit and explicit processing of bodily emotions in schizophrenia.

INTRODUCTION: Disturbed emotion processing is well documented in schizophrenia, but the majority of studies evaluate processing of emotion only from facial expressions. Social cues are also communicated via body posture, and they are similarly relevant for successful social interactions. The aim of the current study was to thoroughly examine body perception abilities in individuals with schizophrenia. METHODS: Fifty-nine patients with schizophrenia and 37 healthy controls completed two tasks of body processing. The first, which was based on the Affect Misattribution Procedure, evaluated implicit processing of bodily emotions, and the second utilised a traditional emotion identification paradigm to assess explicit emotion recognition. RESULTS: Results revealed aberrant implicit processing, but more normative explicit processing, in individuals with schizophrenia. Moderate associations were found between processing of bodies and symptoms of paranoia. Performance on the tasks was not related to cognitive functioning but was associated with clinician-rated social functioning. CONCLUSIONS: Collectively, these results provide information about disturbed processing of bodily emotions in schizophrenia and suggest that these disturbances are associated with the severity of positive symptoms and predict difficulties in everyday social activities and interpersonal relationships.

Assessment of a high-SNR chemical-shift-encoded MRI with complex reconstruction for proton density fat fraction (PDFF) estimation overall and in the low-fat range.

BACKGROUND: Improving the signal-to-noise ratio (SNR) of chemical-shift-encoded MRI acquisition with complex reconstruction (MRI-C) may improve the accuracy and precision of noninvasive proton density fat fraction (PDFF) quantification in patients with hepatic steatosis. PURPOSE: To assess the accuracy of high SNR (Hi-SNR) MRI-C versus standard MRI-C acquisition to estimate hepatic PDFF in adult and pediatric nonalcoholic fatty liver disease (NAFLD) using an MR spectroscopy (MRS) sequence as the reference standard. STUDY TYPE: Prospective. POPULATION/SUBJECTS: In all, 231 adult and pediatric patients with known or suspected NAFLD. FIELD STRENGTH/SEQUENCE: PDFF estimated at 3T by three MR techniques: standard MRI-C; a Hi-SNR MRI-C variant with increased slice thickness, decreased matrix size, and no parallel imaging; and MRS (reference standard). ASSESSMENT: MRI-PDFF was measured by image analysts using a region of interest coregistered with the MRS-PDFF voxel. STATISTICAL TESTS: Linear regression analyses were used to assess accuracy and precision of MRI-estimated PDFF for MRS-PDFF as a function of MRI-PDFF using the standard and Hi-SNR MRI-C for all patients and for patients with MRS-PDFF <10%. RESULTS: In all, 271 exams from 231 patients were included (mean MRS-PDFF: 12.6% [SD: 10.4]; range: 0.9-41.9). High agreement between MRI-PDFF and MRS-PDFF was demonstrated across the overall range of PDFF, with a regression slope of 1.035 for the standard MRI-C and 1.008 for Hi-SNR MRI-C. Hi-SNR MRI-C, compared to standard MRI-C, provided small but statistically significant improvements in the slope (respectively, 1.008 vs. 1.035, P = 0.004) and mean bias (0.412 vs. 0.673, P < 0.0001) overall. In the low-fat patients only, Hi-SNR MRI-C provided improvements in the slope (1.058 vs. 1.190, P = 0.002), mean bias (0.168 vs. 0.368, P = 0.007), intercept (-0.153 vs. -0.796, P < 0.0001), and borderline improvement in the R2 (0.888 vs. 0.813, P = 0.01). DATA CONCLUSION: Compared to standard MRI-C, Hi-SNR MRI-C provides slightly higher MRI-PDFF estimation accuracy across the overall range of PDFF and improves both accuracy and precision in the low PDFF range. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:229-238.

Automated CT and MRI Liver Segmentation and Biometry Using a Generalized Convolutional Neural Network.

PURPOSE: To assess feasibility of training a convolutional neural network (CNN) to automate liver segmentation across different imaging modalities and techniques used in clinical practice and apply this to enable automation of liver biometry. METHODS: We trained a 2D U-Net CNN for liver segmentation in two stages using 330 abdominal MRI and CT exams acquired at our institution. First, we trained the neural network with non-contrast multi-echo spoiled-gradient-echo (SGPR)images with 300 MRI exams to provide multiple signal-weightings. Then, we used transfer learning to generalize the CNN with additional images from 30 contrast-enhanced MRI and CT exams.We assessed the performance of the CNN using a distinct multi-institutional data set curated from multiple sources (n = 498 subjects). Segmentation accuracy was evaluated by computing Dice scores. Utilizing these segmentations, we computed liver volume from CT and T1-weighted (T1w) MRI exams, and estimated hepatic proton- density-fat-fraction (PDFF) from multi-echo T2*w MRI exams. We compared quantitative volumetry and PDFF estimates between automated and manual segmentation using Pearson correlation and Bland-Altman statistics. RESULTS: Dice scores were 0.94 ± 0.06 for CT (n = 230), 0.95 ± 0.03 (n = 100) for T1w MR, and 0.92 ± 0.05 for T2*w MR (n = 169). Liver volume measured by manual and automated segmentation agreed closely for CT (95% limit-of-agreement (LoA) = [-298 mL, 180 mL]) and T1w MR (LoA = [-358 mL, 180 mL]). Hepatic PDFF measured by the two segmentations also agreed closely (LoA = [-0.62%, 0.80%]). CONCLUSIONS: Utilizing a transfer-learning strategy, we have demonstrated the feasibility of a CNN to be generalized to perform liver segmentations across different imaging techniques and modalities. With further refinement and validation, CNNs may have broad applicability for multimodal liver volumetry and hepatic tissue characterization.

Demand creation for primary biomedical prevention: identifying lessons across interventions to inform daily oral preexposure prophylaxis programs.

PURPOSE OF REVIEW: At a moment when UNAIDS (Joint United Nations Programme on HIV/AIDS) has acknowledged a 'prevention crisis,' and multiple countries and implementers are emphasizing 'user-centered' and/or differentiated models of delivering HIV treatment and prevention, it is essential to understand and act on best practices from all relevant interventions to create effective oral preexposure prophylaxis (PrEP) programs. RECENT FINDINGS: It is possible to adapt private sector approaches to understanding and segmenting the preferences and mindsets of potential consumers to primary HIV prevention programs, as demonstrated by a voluntary medical male circumcision (VMMC)-focused intervention that successfully trained and supported counselors to identify and deliver tailored messages to men potentially undergoing VMMC. Literature on PrEP and demand creation is less extensive and suggests uneven application of user-centered design and demand-side thinking; a recent analysis of condom programing demonstrates that failure to maintain resources for social marketing can drive a collapse in use and an increase in HIV incidence. SUMMARY: Approaches to demand creation for primary prevention are dynamic and evolving. However, the lag between implementation and publication means that there is a paucity of PrEP-specific information. Insights from VMMC and other strategies can and must be considered as part of a more holistic approach to increasing demand for primary prevention interventions.

Client predictors of the therapeutic alliance in individual resiliency training for first episode psychosis.

Individuals experiencing their first episode of psychosis (FEP) are often reluctant to seek treatment, and are difficult to engage and retain in mental health services. The therapeutic alliance (TA), or the affective and collaborative bond between therapist and client, is predictive of better treatment outcomes for clients with FEP; thus, it is important to understand the predictors of the TA in order to determine how best to foster a positive alliance with these individuals. The primary aim of the present study was to examine whether baseline client characteristics, including severity of symptoms, social functioning, and insight, were associated with the TA. The exploratory aim was to examine associations between demographic variables (age, race, and gender) and the TA. The present study included a subsample of participants (n = 134) who received Individual Resiliency Training (IRT) as part of the NAVIGATE treatment in the Recovery After An Initial Schizophrenia Episode Early Treatment Program study. Four trained research assistants rated the TA from early audiotaped sessions of IRT. Multilevel modeling was utilized given the nested data structure. Results indicated that more severe positive and less severe negative symptoms were significantly and uniquely associated with a better therapeutic alliance, as was female gender. The findings suggest that client symptom profiles should be considered when developing a TA with FEP clients.

In Women's Eyes: Key Barriers to Women's Access to HIV Treatment and a Rights-Based Approach to their Sustained Well-Being.

There is rightly a huge global effort to enable women living with HIV to have long productive lives, through treatment access. However, many women living with HIV experience violence against women (VAW), in both domestic and health care settings. The ways in which VAW might prevent treatment access and adherence for women has not to date been reviewed coherently at the global level, from women's own perspectives. Meanwhile, funding for global health care, including HIV treatment, is shrinking. To optimize women's health and know how best to optimize facilitators and minimize barriers to access and adherence, especially in this shrinking funding context, we need to understand more about these issues from women's own perspectives. In response, we conducted a three-phase review: (1) a literature review (phase one); (2) focus group discussions and interviews with nearly 200 women living with HIV from 17 countries (phase two); and (3) three country case studies (phase three). The results presented here are based predominantly on women's own experiences and are coherent across all three phases. Recommendations are proposed regarding laws, policies, and programs which are rights-based, gendered, and embrace diversity, to maximize women's voluntary, informed, confidential, and safe access to and adherence to medication, and optimize their long-term sexual and reproductive health.