"A Friendly Conversation." Developing an eHealth Intervention to Increase COVID-19 Testing and Vaccination Literacy Among Women with Criminal and Legal System Involvement.

Many women leaving jails are ill-prepared to follow recommended COVID-19 mitigation practices, including testing and vaccination. Low COVID-19-related health literacy, exposure to disinformation, and mistrust in authorities put women at increased risk. Research on this population has shown significant use of mobile devices for communication and web access and public Wi-fi for the internet. Using inductive (formative empirical research with the community) and deductive (theory-based) practices, we designed, developed, and pilot-tested a multimedia, culturally tailored web-based electronic health (eHealth) application to increase COVID-19-specific health literacy and promote testing and vaccination among women with criminal and legal system involvement (CLSI). The intervention included a serialized animated multimedia component and a telenovela-style series, complementing each other and addressing knowledge needs identified in the formative research phase of the project. The eHealth intervention was pilot-tested with 13 CLSI women by using online activity logs and semi-structured telephone interviews. Findings confirmed that eHealth interventions employing multimodal information delivery had increased chances of engaging audiences, especially when developed with input from the target population and are culturally tailored. In addition, using a web-based delivery optimized for mobile made the intervention accessible on various devices and decreased the risk of technical problems.

Integrating HPV Vaccination Within PrEP care Delivery for Underserved Populations: A Mixed Methods Feasibility Study.

Human Papillomavirus (HPV) vaccination is effective at preventing anal cancer, which disproportionally impacts gay/bisexual men (GBM) and transgender women (TGW). Vaccine coverage among GBM/TGW is insufficient to reduce anal cancer disparities. Federally qualified health centers (FQHCs) can increase reach and uptake of HPV vaccination by integrating and promoting HPV vaccination in ongoing HIV preventive care (e.g., Pre-exposure Prophylaxis [PrEP]). The purpose of the current study was to assess the feasibility and potential impact of integrating HPV vaccination with PrEP care. We conducted a mixed methods study of PrEP providers and staff (qualitative interviews, N = 9) and PrEP patients (quantitative survey, N = 88) at an FQHC in Philadelphia, Pennsylvania. Qualitative thematic analysis of PrEP provider/staff interviews was informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify and describe barriers and facilitators to HPV vaccination implementation. Quantitative analysis of PrEP patient survey was informed by the Information-Motivation-Behavioral Skills Model. Quantitative interviews resulted in 16 themes related to characteristics of the inner and outer clinic context. Barriers among providers included lack of focus on HPV in PrEP management guidelines, in metrics mandated by funding agencies, and in electronic medical record templates. Lack of anal cancer specific knowledge and motivation was identified in both PrEP patients and providers/staff. Providing HPV vaccination during routine PrEP visits was highly acceptable to both patients and providers. Based on these findings, we recommend several multi-level strategies to increase HPV vaccine uptake among PrEP patients.

The Perfect Storm: Perceptions of Influencing Adults Regarding Latino Teen Pregnancy in Rural Communities.

INTRODUCTION: Recognition of the importance of adolescents' environments in influencing their sexual and reproductive health (SRH) decision-making necessitates a deeper understanding of the role that community stakeholders play in shaping Adolescent and Young Adults (AYA) access to SRH education and care. We describe community stakeholders' knowledge, beliefs, and attitudes about AYA's SRH needs in three rural Latino communities in Kansas. METHODS: Key stakeholders completed a written survey incorporating the theory of Planned Behavior to assess attitudes, norms, and intentions to support AYA's SRH education and access to care. RESULTS: Across three rural immigrant community settings, respondents (N = 55) included 8 community health workers, 9 health care providers, 7 public health officials, 19 school health officials, and 12 community members. More than half self-identified as Latino (55%). Six (11%) participants, half of whom were in the health sector, thought SRH education would increase the likelihood that teens would engage in sexual activities. In contrast, other stakeholders thought that providing condoms (17, 30.9%), contraception other than condoms (14, 25.5%), and providing HPV immunization (5, 9.6%) would increase the likelihood of engaging in sexual activity. Ambivalence regarding support for SRH education and service provision prevailed across sectors, reflected even in the endorsement of the distribution of less effective contraceptive methods. Obstacles to care include immigration status, discrimination, lack of confidential services, and transportation. CONCLUSION: Key stakeholders living in rural communities revealed misconceptions, negative attitudes, and ambivalent beliefs related to the delivery of SRH education and services, potentially creating barriers to AYA's successful access to care.

Little is known about the knowledge, beliefs and attitudes held by key stakeholders in rural immigrant Latino communities regarding their level of support for AYA's SRH needs. Key stakeholders may harbor influential and ambivalent opinions regarding AYA's sexuality considering existing cultural norms, therefore, stigmatizing access to SRH education and care. We examined key community stakeholders' attitudes and norms as measures of intentions to support AYA's SRH education and care. We identify actionable steps needed to eliminate existing barriers to AYA's access to SRH education and care among at-risk immigrant Latino communities in the rural Midwest.

Sex and aging: Perspectives of older adult women with experience of incarceration.

To explore perspectives on sexuality, sexual health, and sexual health care of older adult women with a history of criminal legal system involvement, we conducted phone interviews with women aged 50 years or older who were living in the community but had a history of jail and/or prison incarceration. Interview questions and initial analysis were guided by the sexual health framework for public health and Mitchell's sexual wellness model. Data analysis followed a framework method. Nine women, aged 53-66, participated in phone interviews between December 2020 and December 2021. Slightly over half the participants were Black; none were Hispanic. Most were single. We formulated a sex-in-aging (SAGE) framework comprising three categories and two overarching themes. Women with a history of criminal-legal system involvement have heterogeneous views on sex and sexual health and describe a range of desire and sexual activity as they age, including shifting ideas about what they expect from partners, how they keep themselves safe in sexual and intimate relationships, and how life circumstances that are often associated with criminal legal system involvement (substance use, trauma) impact their interest in sex as they age. The SAGE framework integrates these categories and themes and offers a starting point for further research and intervention development.

Developing a Cancer Prevention Health Education Resource: a Primer of Process and Evaluation.

Limited women's health and cancer prevention materials are available that have been validated for vulnerable populations. Such materials are especially important for groups, which have intermittent and typically low-quality healthcare access and are at greatest risk for missing out on women's health and cancer prevention screening. Health education materials are developed from heterogeneous sources. Clinical and research teams have minimal guidance in terms of sources, timelines, outputs, and evaluation in the development of such materials. The goal of this paper is to share our process in developing and evaluating an up-to-date women's health and cancer prevention learning guide appropriate for a target population of women involved in the criminal justice system. A ten-page learning guide was drafted using the current evidence-based data, with the objective of providing educational material on four topics: cervical cancer, breast cancer, sexually transmitted infection, and unintended pregnancy prevention. The learning guide was then tested on a convenience sample of 33 women at a local county jail. Feedback was organized into three parts in which the participants Responded to open-ended question, "What is missing?" Rated each of the four topics for design and content Completed a usability assessment Common themes were participants' interest in learning about side effects of birth control and wanting more information on testing and treatment, specifically for sexually transmitted infections (STIs). Women were satisfied with the cancer prevention information presented to them. This report provides a framework for cancer prevention researchers who are developing health education materials for vulnerable populations.

Cervical Cancer Screening and Prevention among Survivors of Intimate Partner Violence.

Women who experience intimate partner violence are an underserved population at risk for cervical cancer, precipitated by their heightened risk for human papilloma virus (HPV) and underutilization of gynecological care. This pilot study describes the self-reported behaviors, levels of knowledge, and perceived self-efficacy with cervical cancer screening (i.e., Pap testing) and prevention (i.e., HPV vaccination) among survivors (N = 30) recruited from two domestic violence shelter organizations in the midwestern United States. Survey results indicate a need for increased knowledge and awareness about cervical cancer and prevention strategies among this population; only 23 percent (n = 7) participants reported an up-to-date Pap test and 17 percent (n = 5) participants reported HPV vaccination. Findings also indicate how theoretical constructs from the health belief model, together with feminist understandings of coercive control and empowerment, might explain survivors' proactive cervical health behaviors and offer insights for intervention.

Learning from maternal voices on COVID-19 vaccine uptake: Perspectives from pregnant women living in the Midwest on the COVID-19 pandemic and vaccine.

The aim of this study was to understand COVID-19 vaccine perceptions and decision-making among a racially/ethnically diverse population of pregnant and lactating women in the Midwest. Pregnant female participants (N = 27) at least 18 years. or older living in the Midwest were recruited to participate in a maternal voices survey. A mix-methods approach was used to capture the perceptions of maternal voices concerning the COVID-19 vaccine. Participants completed an online survey on COVID-19 disease burden, vaccine knowledge, and readiness for uptake. A total of 27 participants completed the Birth Equity Network Maternal Voices survey. Most participants were African American (64%). Sixty-three percent intend to get the vaccine. Only 25% felt at-risk for contracting COVID-19, and 74% plan to consult their provider about getting the COVID-19 vaccine. At least 66% had some concerns about the safety of the vaccine. Participants indicated a willingness to receive the COVID-19 vaccine, especially if recommended by their provider. We found little racial/ethnic differences in perceptions of COVID-19 and low vaccine hesitancy.

Perceived healthcare quality and contraception utilization among persons recently incarcerated.

Purpose: Previously incarcerated women have specific gender and physiologic needs that are poorly addressed on community re-entry. The objective of this study is to evaluate the relationship between contraception use and perceived healthcare quality post-incarceration. Additionally, we examine the association between social determinants of health and contraception use post-incarceration. Methods: A secondary analysis of a cross-sectional study of reproductive-aged women with a history of criminal-justice involvement in three cities (n = 383) was performed. Questions related to demographics, social determinants of health, sexual and reproductive health practices, health services use, and healthcare quality were analyzed. Bivariate analysis and logistic regression examined associations between these variables and contraception utilization among persons recently incarcerated. Results: 35% of the participants used a method to prevent pregnancy. There were no significant differences noted between contraceptive users and non-users in perceived healthcare quality. Participants who were not using a contraceptive method were more likely to lack health insurance and experience food insecurity when compared to contraceptive users. Conclusions: Although there was no difference in perceived healthcare quality between contraceptive users and non-users, significant barriers to contraceptive access on community re-entry exist. More studies are warranted to explore the sexual and reproductive health of previously incarcerated women.

Justice System Involvement Among Adolescents in the Emergency Department.

OBJECTIVE: To assess justice system involvement among adolescents in the pediatric emergency department and identify associations with risk and protective factors. STUDY DESIGN: We conducted a cross-sectional, computerized survey of adolescents to assess for personal, justice system involvement, and nonhousehold justice system involvement (ie, important people outside of household). We assessed sexual behaviors, violent behaviors, substance use, school suspension/expulsion, parental supportiveness, and participant mood (score <70 indicates psychological distress). We compared differences between groups using the χ2 tests, Fisher exact tests, t tests, and performed multivariable logistic regression analyses. RESULTS: We enrolled 191 adolescents (mean age 16.1 years, 61% female). Most (68%) reported justice system involvement: personal (13%), household (42%), and nonhousehold (40%). Nearly one-half (47%) were sexually active and 50% reported school suspension/expulsion. The mean score for mood was 70.1 (SD 18); adolescents with justice system involvement had had lower mood scores (68 vs 74, P = .03) compared with those without justice system involvement. In a multivariable model, school expulsion/suspension was significantly associated with reporting any justice system involvement (OR 10.4; 95% CI 4.8-22.4). CONCLUSIONS: We identified the pediatric emergency department as a novel location to reach adolescents at risk for poor health outcomes associated with justice system involvement. Future work should assess which health promotion interventions and supports are desired among these adolescents and families.

Recommendations for Delivering COVID-19 Vaccine in Jails: Evidence from Kansas, Iowa, Nebraska, and Missouri.

We report on data we collected from a 2018 survey examining jails' human papillomavirus virus vaccine delivery capacity and on a secondary analysis we conducted to describe factors similarly associated with delivery planning for the COVID-19 vaccine. We provide recommendations for delivering the COVID-19 vaccine in jails, based on evidence from Kansas, Iowa, Nebraska, and Missouri. Our key finding is that jails have limited staff to implement vaccination and will require collaboration between jail administrators, jail medical staff, and local health departments.

Collaborating to offer HPV vaccinations in jails: results from a pre-implementation study in four states.

BACKGROUND: Correctional facilities are an underutilized venue for reaching young adults who have not vaccinated for human papillomavirus (HPV). The objective of this study was to identify factors that are associated with jail and local health department (LHD) interest in partnering to offer HPV vaccinations to young adults in jail. METHODS: Consolidated framework for implementation research (CFIR)-guided surveys were conducted with jail administrators in Iowa, Kansas, Missouri, and Nebraska, September 2017-October 2018. Jail survey data were analyzed using chi square distribution and relative risk regression. Using data from sister surveys conducted with LHD administrators in the same counties (results previously reported), we identified characteristics of counties in which both the jail and LHD indicated interest in collaborating to offer HPV vaccinations in the jail. RESULTS: Jail survey response was 192/347 (55.3%). Surveys with LHDs yielded 237/344 (68.9%) responses. Eleven communities were identified where both the jail and LHD expressed interest. Only "any vaccines provided in jail" predicted shared interest (RR: 5.36; CI: 2.52-11.40; p < .01). For jail administrators, offering other vaccines was 3 times (CI:1.49-6.01; p < .01) and employing a nurse 1.65 times more likely (CI: 1.20-2.28; p < .01) to predict interest in collaborating to offer HPV vaccination. Open-ended responses indicated that managing linkages and stakeholder investment were areas of emphasis where collaborations to provide vaccinations in the jails had been previously implemented. CONCLUSIONS: Interest in jail-LHD partnerships to provide HPV vaccinations in jails exists in the Midwest but will require building-out existing programs and linkages and identifying and strengthening shared values, goals, and benefits at all levels.

Criminal Justice Involvement and Abnormal Cervical Cancer Screening Results Among Women in an Urban Safety Net Hospital.

OBJECTIVE: The aim of the study was to elucidate the risk factors underlying abnormal cytology-based cervical cancer screening (Pap testing) in justice-involved women (JIW) compared with non-JIW in an urban safety net hospital. METHODS: Retrospective chart review of women with a history of correctional involvement who received care at Grady Health System between 2010 and 2018 and had a Pap test was performed (n = 191). An age-matched cohort of women with no correctional involvement and had a Pap test at Grady served as the control (n = 394). Variables of interest were age, HIV, smoking, race, mental health history, and history of incarceration. Outcomes of interests were rate of abnormal Pap tests and follow-up. χ2 and logistic regression models evaluated associations between the variables of interest and outcomes. RESULTS: Rates of abnormal Pap tests were significantly higher in JIW (35.6%) than controls (18.5%, p < .0001). Compared with controls, JIW were significantly more likely to have high-grade cervical cytology (odds ratio [OR] = 3.89, p < .0005) and be lost to gynecologic follow-up (OR = 8.75, p < .0001) and a history of severe mental illness (29.5% vs 4.3%, p < .0001). Those with abnormal Pap tests were likely to be HIV-positive (OR = 20.7, p < .001) and have a history of incarceration (OR = 2.33, p < .001). Predictors of high-grade Pap test were smoking history (OR = 0.16, p = .014), HIV-positive (OR = 3.66, p = .025), and history of incarceration (OR = 3.96, p < .0005). CONCLUSIONS: Justice-involved women represent a high-risk subpopulation with significantly increased rates of high-grade cytology and lost to follow-up. This underscores the need for attention to screening programs and follow-up interventions for JIW.

Understanding the Impact of an Integrated Crisis Team: A Qualitative Study of Emergency Department Staff.

Approximately one in eight visits to the Emergency Department (ED) in the United States are due to a behavioral health crisis. A Midwest community created an Integrated Crisis Team (ICT) as part of its county-wide effort to improve quality of care for people with mental health and/or substance use disorders. This ICT, which is embedded in the ED, ensured trained crisis clinicians were available in the ED, among other strategies. Semi-structured interviews were conducted with 15 staff members and a thematic analysis was used to assess ED staff members' perceptions of the impact of the ICT on staff and patient experience, and to identify barriers to implementation. Results indicated that the ICT facilitated a collaborative team effort in the ED and improved patient care in the ED. This evaluation informs key stakeholders about the importance of integrating a crisis team within an ED to better serve behavioral health patients.

COVID-19 vaccine hesitancy among women leaving jails: A qualitative study.

In many correctional facilities across the United States, COVID-19 vaccine refusal rates are as high as 50%. Most women leaving jails have low SES, health literacy, and mistrust of governmental institutions, thus exacerbating existing health disparities and making women leaving jail vulnerable. Data from 25 interviews with recently released women suggest that interventions to promote vaccines to this population will have to address health education and mitigate mistrust, misinformation, and conspiracy theories.

A Systematic Evaluation of Barriers and Facilitators to the Provision of Services for Justice-Involved Women.

The community health delivery system (CHDS) are vital agencies to the success of integration and the provision of services to improve the health and well-being of justice-involved women. Many agencies face barriers and challenges in providing services to vulnerable populations, such as justice-involved women, and, as a result, often offer individual rather than coordinator care. Thus, it is necessary to explore CHDS systemic barriers and challenges to identify opportunities for coordinated care. We conducted semi-structured interviews with 26 CHDS directors or designees to identify systemic barriers and challenges, organizational processes, experiences with vulnerable populations, services and programs, and care coordination and perceived women's barriers and challenges to the provision of services including decision-making processes and access. Qualitative analyses were used to construct thematic descriptions in five areas: (1) mental health as an unmet need, (2) financial constraints, (3) limited organizational capacity, (4) implicit bias, and (5) minimal cultural support of vulnerable populations.

Correlates of sexually transmitted infection testing following women's release from jail.

Given incarcerated women's frequent transitions between jail and community, it is important to seize opportunities to provide comprehensive health care. A potential time to provide care might be when getting tested for sexually transmitted infections (STIs). Our objective was to determine the proportion of women receiving STI testing and correlates, following jail release. This secondary analysis was of one-year follow-up data from women who participated in a jail-based cervical health literacy intervention in three Kansas City jails from 2014 to 2016. Most (82%) completed the survey in the community. The analysis included 133 women. Mean age 35 years (19-58 years). Sixty-two percent obtained STI testing within one-year post-intervention. Using logistic regression this was associated with younger age (odds ratio [OR] = 0.87; 95% confidence interval [CI] 0.80, 0.95), receiving high school education (OR = 4.33; 95% CI 1.00, 18.74), having insurance (OR = 4.32; 95% CI 1.25, 14.89), no illicit drug use (OR = 0.09; 95% CI 0.01, 0.81), and no drinking problem (OR = 0.04; 95% CI 0.00, 0.45). In this study, many women sought STI testing following jail release. Clinicians/public health practitioners may find it useful to engage these high-risk women in broader women's health services seeking STI testing.

Local Health Department Interest in Implementation of a Jail-Based Human Papillomavirus Vaccination Program in Kansas, Iowa, Missouri, and Nebraska.

CONTEXT: Local health departments (LHDs) play a vital role in community vaccination programs for human papillomavirus (HPV) infection, but little research has been done to assess LHD interest in cross-sectoral partnerships to vaccinate high-risk groups, specifically incarcerated persons. OBJECTIVE: To describe factors associated with interest in a novel implementation strategy linking LHDs with jails in 4 Midwestern states to deliver HPV vaccine. DESIGN: Survey based on the Consolidated Framework for Implementation Research (CFIR) model given to LHD administrators. A modified Poisson relative risk regression was used to assess the relationship between independent variables and LHD interest in implementation of a jail-based HPV vaccination program. SETTING: LHDs in Kansas, Missouri, Iowa, and Nebraska. PARTICIPANTS: From September 2017 to April 2018, two-thirds (237/344) of invited LHD administrators from the 4 states responded to the survey. MAIN OUTCOME MEASURE: LHD interest in implementation of a jail-based HPV vaccination program. RESULTS: Forty-five percent of LHDs were interested in learning more about implementing a jail-based HPV vaccination program, and 2% already offered or had plans to offer HPV vaccine in their jails. Barriers to implementation were cost (66%), inmates' short incarcerations (47%), and availability of medical staffing (43%). LHD characteristics associated with interest in implementation of a jail-based HPV vaccination program included "inner setting" CFIR variables, which capture the structural and cultural context for program implementation: 7 or more employees (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.24-3.95), perception of importance to provide HPV vaccine in jails (OR = 3.70; 95% CI, 2.00-6.84), and already providing any vaccines in jails (OR = 2.62; 95% CI, 1.18-5.80). CONCLUSIONS: Nearly half of LHDs in the region expressed interest in partnering with local entities to meet HPV vaccination needs of high-risk groups. Research on cross-sectoral partnerships and what these collaborations look like in practice is needed for public health impact.

A State-Level Examination of School Nurses' Perceptions of Condom Availability Accompanied by Sex Education.

School nurses are often sources of health-care support for teens with sexually transmitted infections (STIs) and unintended pregnancies. However, providing prevention (e.g., condoms) and teaching technical skills (e.g., condom use) needed to reduce high-risk sexual behavior may require a change in perceptions and policies. This study used a cross-sectional study design to assess nurses' perceptions of condom availability accompanied by sex education programs among high school nurses (n = 87) in Kansas. Results showed that school nurses in this study supported condom availability, were comfortable providing condoms, and felt condom availability was within the scope of their job but were less likely to provide condoms because of external barriers. Common barriers include administration, parents, cost, community support, and policies. School nurses, by virtue of their access to the majority of Kansas' adolescents, have the potential to provide sex education and tools such as condoms, so young people can prevent STIs and unintended pregnancies.

Human Papillomavirus Vaccine Knowledge and Intention Among Adult Inmates in Kansas, 2016-2017.

OBJECTIVES: To assess human papillomavirus (HPV) knowledge and vaccine awareness, intention, and uptake among adult inmates in Kansas jails. METHODS: We administered a survey with questions adapted from the US National Cancer Institute's Health Information National Trends Survey to 571 adult inmates in 3 Kansas jails from October 10 to 12, 2016, and January 25 to 27, 2017, to assess HPV knowledge and vaccine awareness, intention, and uptake. RESULTS: Although most adults across demographic groups recognized HPV as causing cervical cancer, knowledge was lower about other HPV-related cancers. Vaccine awareness was higher for women (70%) than men (41%). Only 8% of age-eligible men reported ever receiving the vaccine. Most adults across demographic groups reported "definitely" wanting to get the vaccine if offered in jail at no cost. CONCLUSIONS: Low uptake of HPV vaccine and high interest in receiving the vaccine in jails may indicate that vaccination availability for jail populations needs to be reexamined. Public Health Implications. Expanding HPV vaccine programs or partnerships to facilitate vaccine provision in jails could increase inmates' knowledge of and intention to receive vital health services.

Assessing fidelity: balancing methodology and reality in jail interventions.

BACKGROUND: While fidelity to research protocols is important to ensure generalizable outcomes, interventions in criminal justice settings present unique challenges to uniform implementation. The goal of this paper is to describe the fidelity methods and outcomes for a sexual health intervention implemented in three local county jails. METHODS: As part of a longitudinal cohort study, four trained fidelity assessors observed 25 of the 230 sessions presented (including both intervention and comparison groups) at three separate times during the 29 months of the intervention. Assessment methods included the assessors' field notes, a nine-item facilitator quality scale and a content inclusion scale with 6-13 items specific for each of the five sessions. RESULTS: Facilitator quality score ranged from 87.6 to 99.2%. Content inclusion scores ranged from 77.3 to 88%. Specific challenges to fidelity were found in two areas: the jail environment and the participants' response to content. CONCLUSIONS: The realities of conducting research in jails and prisons must be addressed in real time by adjusting program content to fit both unexpected facility and participant situations. Skilled facilitators are essential to this effort.