Factors Shaping the Implementation of Strategies to Prevent Acute Kidney Injury: A Qualitative Study.

Reducing the prevalence of acute kidney injury (AKI) is an important patient safety objective set forth by the National Quality Forum. Despite international guidelines to prevent AKI, there continues to be an inconsistent uptake of these interventions by cardiac teams across practice settings. The IMPROVE-AKI study was designed to test the effectiveness and implementation of AKI preventive strategies delivered through team-based coaching activities. Qualitative methods were used to identify factors that shaped sites' implementation of AKI prevention strategies. Semi-structured interviews were conducted with staff in a range of roles within the cardiac catheterization laboratories, including nurses, laboratory managers, and interventional cardiologists (N = 50) at multiple time points over the course of the study. Interview transcripts were qualitatively coded, and aggregated code reports were reviewed to construct main themes through memoing. In this paper, we report insights from semi-structured interviews regarding workflow, organizational culture, and leadership factors that impacted implementation of AKI prevention strategies.

Individualized Intervention to Support Mental Health Recovery Through Implementation of Digital Tools into Clinical Care: Feasibility Study.

Myriad digital tools exist to support mental health but there are multiple barriers to using these tools in routine care. This study aimed to assess the feasibility of an intervention incorporating a support role to help the clinical team identify and use technology to promote recovery. The technology specialist intervention is 3 months in duration and comprises four stages: goal setting, researching and evaluating tools, demonstrating and selecting tools, and ongoing support. We implemented the intervention in a community mental health center and a dual diagnosis treatment program, working with eight clients and their case managers. Clients and case managers willingly engaged with the technology specialist and found the intervention beneficial. Integration and collaboration with the care team facilitated implementation of the technology specialist in these real-world settings. Clients reported that the intervention made it easy to try a digital tool. Six of the eight participants stated that they made substantial progress toward their goals. The technology specialist is a promising new role for mental health care delivery to augment traditional services and enhance individualized recovery.

A Mixed-Methods Evaluation of Patient Education Materials for Colorectal Cancer.

BACKGROUND: Patient education materials are created by professional organizations to inform patients about their disease and its treatment. However, it remains unclear if these materials are appropriate for patients. OBJECTIVE: This study aims to broadly evaluate the education materials for patients with colorectal cancer. DESIGN: Patient education materials from the National Comprehensive Cancer Network, the National Cancer Institute, and the American Society of Colon and Rectal Surgeons were assessed quantitatively by using 1) the Flesch-Kincaid readability formula and 2) the Patient Education Material Assessment Tool. The Patient Education Material Assessment Tool scores materials in 2 domains: understandability and actionability. These materials were further evaluated qualitatively via an exploratory focus group with patients and their caregivers (n = 5) and semi-structured interviews with board-certified/eligible colorectal surgeons (n = 10). SETTING: This study was conducted at academic centers and a regional professional society meeting. PARTICIPANTS: The mean patient age was 63. Most surgeons (8/10) practiced in an academic setting, and 4/10 were female. MAIN OUTCOME MEASURES: The primary outcomes measured were reading grade level and domain scores for the Patient Education Material Assessment Tool. Qualitative data were recorded, transcribed, and coded. Themes were generated through data interpretation and data reduction. RESULTS: Materials ranged from 7th to 11th grade reading level. National Comprehensive Cancer Network materials scored highest for understandability (92.2% ± 6.1%, mean ± SD), followed by National Cancer Institute (84.0% ± 6.6%) and American Society of Colon and Rectal Surgeons (82.2% ± 6.3%) materials. Actionability scores varied; the National Comprehensive Cancer Network materials scored 82.5% ± 1.7%, whereas the National Cancer Institute and American Society of Colon and Rectal Surgeons materials scored 23.3% ± 6.7% and 50.0% ± 8.2%. Critical gaps were identified in the content of these materials. Patients wanted more information about self-care, both emotional and physical. Specifically, patients sought details about postoperative bowel function. Whereas surgeons wanted information about the typical hospital course and recovery, all wanted materials to be customizable. LIMITATIONS: A limited number of materials were reviewed, and patient focus groups were exploratory. CONCLUSIONS: Commonly available printed education materials for colorectal cancer are written at a high reading grade level, vary in their usability, and neglect important details about postoperative recovery. See Video Abstract at http://links.lww.com/DCR/B535. EVALUACIN DE MTODOS MIXTOS DE MATERIALES EDUCATIVOS PARA PACIENTES SOBRE CNCER COLORECTAL: ANTECEDENTES:Los materiales educativos para pacientes son creados por organizaciones profesionales para informar a los pacientes sobre su enfermedad y su tratamiento. Sin embargo, no está claro si estos materiales son apropiados para los pacientes.OBJETIVO:Evaluar ampliamente los materiales para el cáncer colorrectal.DISEÑO:Los materiales educativos para pacientes de la Red Nacional Integral del Cáncer (NCCN), el Instituto Nacional del Cáncer (NCI) y la Sociedad Americana de Cirujanos de Colon y Recto (ASCRS) se evaluaron cuantitativamente utilizando (1) la fórmula de legibilidad de Flesch-Kincaid y (2) la herramienta de evaluación de material educativo para pacientes. La Herramienta de evaluación de materiales educativos para pacientes califica los materiales en dos dominios: comprensibilidad y viabilidad. Estos materiales fueron evaluados cualitativamente a través de un grupo de enfoque exploratorio con pacientes y sus cuidadores (n = 5) y entrevistas semiestructuradas con cirujanos colorrectales certificados o elegibles para certificación por el consejo (n = 10).ESCENARIO:Centros académicos y un encuentro regional de una sociedad profesional.PACIENTES:La edad media de los pacientes fue de 63 años. La mayoría de los cirujanos (8/10) practicaban en un entorno académico, y 4/10 eran mujeres.PRINCIPALES MEDIDAS DE RESULTADO:Nivel de grado de lectura y puntajes de dominios para la Herramienta de evaluación de materiales educativos para pacientes. Los datos cualitativos se registraron, transcribieron y codificaron. Los temas se generaron mediante la interpretación y la reducción de datos.RESULTADOS:Los materiales variaron desde el nivel de lectura del 7° al 11° grado. Los materiales de la NCCN obtuvieron la puntuación más alta en comprensibilidad (92.2 ± 6.1%, media ± DE), seguidos por los materiales de NCI (84.0 ± 6.6%) y ASCRS (82.2 ± 6.3%). Los puntajes de viabilidad variaron; Los materiales de NCCN obtuvieron una puntuación de 82.5 ± 1.7%, mientras que los materiales de NCI y ASCRS obtuvieron una puntuación de 23.3 ± 6.7% y 50.0 ± 8.2%, respectivamente. Se identificaron lagunas críticas en el contenido de estos materiales. Los pacientes querían más información sobre el autocuidado, tanto emocional como físico. Específicamente, los pacientes buscaron detalles sobre la función intestinal posoperatoria. Mientras que los cirujanos querían información sobre el curso hospitalario típico y la recuperación, y todos querían que los materiales fueran personalizables.LIMITACIONES:Se revisó una cantidad limitada de materiales y los grupos de enfoque de pacientes fueron exploratorios.CONCLUSIONES:Los materiales educativos impresos comúnmente disponibles para el cáncer colorrectal están escritos a un alto nivel de grado de lectura, varían en su usabilidad y omiten detalles importantes sobre la recuperación postoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B535.

Elastin in the Tumor Microenvironment.

Elastic fibers are found in the extracellular matrix (ECM) of tissues requiring resilience and depend on elasticity. Elastin and its degradation products have multiple roles in the oncologic process. In many malignancies, the remodeled ECM expresses high levels of the elastin protein which may have either positive or negative effects on tumor growth. Elastin cross-linking with other ECM components and the enzymes governing this process all have effects on tumorigenesis. Elastases, and specifically neutrophil elastase, are key drivers of invasion and metastasis and therefore are important targets for inhibition. Elastin degradation leads to the generation of bioactive fragments and elastin-derived peptides that further modulate tumor growth and spread. Interestingly, elastin-like peptides (ELP) and elastin-derived peptides (EDP) may also be utilized as nano-carriers to combat tumor growth. EDPs drive tumor development in a variety of ways, and specifically targeting EDPs and their binding proteins are major objectives for ongoing and future anti-cancer therapies. Research on both the direct anti-cancer activity and the drug delivery capabilities of ELPs is another area likely to result in novel therapeutic agents in the near future.

Opportunities to Improve a Mobile Obesity Wellness Intervention for Rural Older Adults with Obesity.

Older adults with obesity are at a high risk of decline, particularly in rural areas. Our study objective was to gain insights into how a potential Mobile Health Obesity Wellness Intervention (MOWI) in rural older adults with obesity, consisting of nutrition and exercise sessions, could be helpful to improve physical function. A qualitative methods study was conducted in a rural community, community-based aging center. Four community leaders, 7 clinicians and 29 patient participants underwent focus groups and semi-structured interviews. All participants had a favorable view of MOWI and saw its potential to improve health and create accountability. Participants noted that MOWI could overcome geographic barriers and provided feedback about components that could improve implementation. There was expressed enthusiasm over its potential to improve health. The use of technology in older adults with obesity in rural areas has considerable promise. There is potential that this intervention could potentially extend to distant areas in rural America that can surmount accessibility barriers. If successful, this intervention could potentially alter healthcare delivery by enhancing health promotion in a remote, geographically constrained communities. MOWI has the potential to reach older adults with obesity using novel methods in geographically isolated regions.

A digital advocate? Reactions of rural people who experience homelessness to the idea of recording clinical encounters.

BACKGROUND: Are the benefits of recording clinical encounters shared across different groups, or do they vary based on social position? Studies show that educated patients record their clinical visits to enhance their experience, but very little is known about recording benefits among "hard-to-reach" populations. OBJECTIVE: To examine the reactions of homeless people to the idea of using a smartphone to record their own clinical encounter, either covertly or with permission from their physician. METHOD: We conducted semi-structured interviews with individuals at a temporary housing shelter in Northern New England. A thematic analysis identified themes that were iteratively refined into representative groups. RESULTS: Eighteen (18) interviews were conducted, 12 with women and six with men. Initial reactions to clinical recordings were positive (11 of 18). A majority (17 of 18) were willing to use recordings in future visits. A thematic analysis characterized data in two ways: (i) by providing reliable evidence for review, they functioned as an advocacy measure for patients; (ii) by promoting transparency and levelling social distance, this technology modified clinical relationships. DISCUSSION: Recordings permitted the sharing of data with others, providing tangible proof of behaviour and refuting misconceptions. Asking permission to record appeared to modify relationships and level perceived social distance with clinicians. CONCLUSIONS: We found that while many rural, disadvantaged individuals felt marginalized by the wide social distance between themselves and their clinicians, recording technology may serve as an advocate by holding both patients and doctors accountable and by permitting the burden of clinical proof to be shared.

Clinicians' Perception of Patient Readiness for Treatment: An Emerging Theme in Implementation Science?

Despite a training program to help veterans administration (VA) clinicians implement evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), uptake has been limited. To understand clinicians' implementation challenges, we performed thematic analysis of semi-structured telephone interviews guided by the Promoting Action on Research Implementation in Health Services framework. Our sample included 22 psychotherapists in VA PTSD clinics in one region. We identified a theme not captured by our implementation framework: clinicians' perceptions about their patients' readiness for treatment. Clinician perception of patient readiness may be important to the uptake of EBPs and should be considered in mental health implementation work.

First-Person Perspectives on Dual Diagnosis Anonymous (DDA): A Qualitative Study.

OBJECTIVE: People with dually diagnosed substance abuse and mental illnesses often feel alienated at traditional 12-step meetings, yet they need the peer support provided by such groups. Dual Diagnosis Anonymous (DDA) is a peer-support program specifically for people with co-occurring disorders, which addresses many of the factors that members find alienating about traditional 12-step groups. This study aimed to elicit first-person perspectives on DDA. METHODS: Occupational therapy students conducted 13 focus groups with 106 DDA members in three settings: the community (6 groups, n = 36), correctional facilities (5 groups, n = 53), and the state psychiatric hospital (2 groups, n = 17). Researchers inductively analyzed focus group transcripts to identify prominent themes. RESULTS: The vast majority of participants were between the ages of 18 and 49 (n = 87, 82.1%) and were non-Hispanic/White (n = 82, 77.4%). Most participants had been using substances for more than 10 years and had a diagnosed mental illness for more than 10 years. The most common substance of choice among those in the community and corrections setting was multiple substances, while those in the state hospital identified alcohol most often. Bipolar disorder was the most common mental illness diagnosis among participants in the state hospital, but depression and anxiety were the two most common diagnoses in the community and corrections participants. Four primary themes emerged from the qualitative analysis: (1) feeling accepted by others in the group, (2) understanding the interactive nature of dual disorders, (3) the open discussions in DDA meetings, and (4) a focus on hope and recovery from both illnesses. CONCLUSIONS: DDA provides a helpful alternative for individuals who do not feel comfortable at traditional 12-step groups due to their mental illness. Members value the acceptance, understanding, discussion, and hope in DDA meetings.

"I always viewed this as the real psychiatry": provider perspectives on community psychiatry as a career of first choice.

The US needs engaged and skilled psychiatrists to support the recovery of people with severe mental illnesses and we are currently facing a shortage. This paper examines what attracts providers to community psychiatry and what sustains them in their work. Focus groups and interviews were used to elicit the perspectives of prescribing clinicians in three community mental health clinics in the US. Community psychiatry has inherent challenges, including facing high-risk decisions, encountering intense affects, and occasionally witnessing bad outcomes. Psychiatrists are motivated and sustained in this work by (1) cultivating relationships with patients and colleagues, (2) focusing on the mission of promoting recovery, and (3) engaging with clinical practice as intellectually stimulating work. Administrators support the engagement and morale of psychiatrists by creating workflows that allow psychiatrists to meaningfully apply their expertise to support patients' recovery. These findings hold implications for recruiting and retaining a new generation of physicians.

A qualitative study of career exploration among young adult men with psychosis and co-occurring substance use disorder.

OBJECTIVE: This article explores the meaning and importance of career exploration and career development in the context of integrated treatment for young adults with early psychosis and substance use disorders (i.e., co-occurring disorders). METHODS: Twelve young adult men (aged 18 to 35 years) with co-occurring disorders recruited from an integrated treatment center completed a series of three semi-structured in-depth qualitative interviews. Data were transcribed verbatim and analyzed using thematic analysis. Purposive sampling ensured participants represented a range of substance abuse treatment stages. RESULTS: Participants had a mean age of 26 (SD = 3) and identified as White. Two-thirds of participants (n = 8, 67%) had diagnosed schizophrenia-spectrum disorders, three (25%) had bipolar disorder, and one (8%) had major depression; four (33%) also had a co-occurring anxiety disorder. The most common substance use disorders involved cannabis (n = 8, 67%), cocaine (n = 5, 42%), and alcohol (n = 5, 42%). These young adult men with co-occurring disorders described past jobs that did not align with future goals as frustrating and disempowering, rather than confidence-building. Most young adult participants began actively developing their careers in treatment through future-oriented work or school placements. They pursued ambitious career goals despite sporadic employment and education histories. Treatment engagement and satisfaction appeared to be linked with career advancement prospects. CONCLUSIONS: Integrating career planning into psychosocial treatment is a critical task for providers who serve young adults with co-occurring disorders. Whether integrating career planning within early intervention treatment planning will improve clinical, functional, or economic outcomes is a promising area of inquiry for rehabilitation researchers and clinicians.

Long-term sobriety strategies for men with co-occurring disorders.

OBJECTIVE: Roughly half of people with severe mental disorders also experience a co-occurring substance use disorder, and recovery from both is a critical objective for health care services. While understanding of abstinence initiation has grown, the strategies people with co-occurring disorders use to maintain sobriety are largely unknown. This article reports strategies for relapse prevention as described by men with co-occurring disorders who achieved one or more years of sobriety. METHODS: We analyzed semi-structured interviews conducted with a sample of 12 men with co-occurring psychosis and substance use disorder who achieved and maintained sobriety for at least one year, supplemented with demographic and diagnostic clinical record data. These men were participating in residential or outpatient treatment at a private, nonprofit integrated treatment clinic. RESULTS: The 12 men were primarily Caucasian (91.7%) and unmarried (100%), and their ages ranged from 23 to 42 years. The two most common psychiatric disorders were schizoaffective disorder (n = 4, 33.3%) and bipolar disorder (n = 4, 33.3%), while the two most commonly misused substances were alcohol and cannabis. Qualitative analyses showed that participants maintained sobriety for at least one year by building a supportive community, engaging in productive activities, and carefully monitoring their own attitudes toward substances, mental health, and responsibility. Alcoholics Anonymous might act as a catalyst for building skills. CONCLUSIONS: People with co-occurring disorders who achieve sobriety use a variety of self-management strategies to prevent relapse-seeking support, activities, and a healthy mindset. The findings suggest a relapse prevention model that focuses on social networks, role functioning, and self-monitoring and conceptualizes self-care as critical to extending periods of wellness.

Reimagining Rural Health Equity: Understanding Disparities And Orienting Policy, Practice, And Research In Rural America.

A narrative has taken hold that public health has failed the US. We argue instead that the US has chronically failed public health, and nowhere have these failures been more apparent than in rural regions. Decades of underinvestment in rural communities, health care, and public health institutions left rural America uniquely vulnerable to the COVID-19 pandemic. Rural communities outpaced urban ones in deaths, and many rural institutions and communities sustained significant impacts. At the same time, the pandemic prompted creative actions to meet urgent health and social needs, and it illuminated opportunities to address long-standing rural challenges. This article draws on our cross-disciplinary expertise in public health and medical anthropology, as well as our research on COVID-19 and rural health equity in northern New England. In this Commentary, we articulate five principles to inform research, practice, and policy efforts in rural America. We contend that advancing rural health equity beyond the pandemic requires understanding the forces that generate rural disparities and designing policies and practices that account for rural disadvantage.

The Feasibility and Acceptability of Sharing Video Recordings of Amyotrophic Lateral Sclerosis Clinical Encounters With Patients and Their Caregivers: Pilot Randomized Clinical Trial.

BACKGROUND: Multidisciplinary clinics (MDCs) provide benefits to patients with amyotrophic lateral sclerosis (ALS) and their caregivers, but MDC visits are information-heavy and can last 4 hours, with patients and caregivers meeting with multiple specialists within each MDC visit. There are questions about the effectiveness of current methods of sharing information from MDCs with patients. Video recordings are a promising new method of sharing information that may allow patients and caregivers to revisit the MDC and remind them of clinical recommendations and conversations. OBJECTIVE: The objective of this trial is to determine the feasibility and acceptability of sharing information through video recordings of ALS MDC visits with patients and caregivers. METHODS: This study was a randomized, controlled pilot trial with 3 months of follow-up from April 2021 to March 2022 in a rural multidisciplinary neurology clinic. We recruited patients with ALS, their caregivers, and their clinicians. Patients and their caregivers were randomized to either receive their normal after-visit summary (treatment as usual) or to receive their normal after-visit summary and a video recording of their MDC visit (video). Each specialist visit had its own recording and was accessible by patients and caregivers using a secure web-based platform called HealthPAL over a 3-month follow-up period. Primary study outcomes were feasibility and acceptability of the video intervention measured by recruitment rate (target: 70%), percentage of participants watching videos (target: 75%), and the Feasibility of Intervention Measure and Acceptability of Intervention Measure (targets: 3/5). We hypothesized that video recording would be feasible and acceptable to patients and their caregivers. RESULTS: Of the 30 patients approached, 24 were recruited, while all caregivers (n=21) and clinicians (n=34) approached were recruited. A total of 144 specialist visits were recorded, approximately 12 specialist visits at a median of one MDC visit per patient. Of the recorded patients, 75% (9/12) viewed videos. High median intervention feasibility (4, SD 0.99) and acceptability (4, SD 1.22) of intervention measures were reported by patients and caregivers in the intervention arm. High median intervention feasibility (5, SD 0.21) and acceptability (4.88, SD 0.4) were reported by clinicians. Of the 24 patients, 50% (n=12) did not complete a 3-month follow-up, primarily due to death (n=10). CONCLUSIONS: Video recording is highly feasible and acceptable for patients, caregivers, and clinicians at a rural ALS clinic. Our level of attrition is a useful benchmark for future studies in MDC populations. Despite high rates of patient death, 1-week assessments highlight the value of recordings for both patients and caregivers. TRIAL REGISTRATION: ClinicalTrials.gov NCT04719403; https://clinicaltrials.gov/study/NCT04719403.

Digital Mental Health and Its Discontents: Assumptions About Technology That Create Barriers to Equitable Access.

Despite the potential of digital mental health interventions to aid recovery for people with serious mental illness, access to these digital tools remains a key barrier. In this column, the authors discuss three key assumptions that shape the integration of digital mental health tools into community health settings: clinical context, digital literacy, and financial burden. Clinical contexts have shifted with the increased use of telehealth, altering intervention environments; access to a mobile device is not the same as digital literacy; and digital mental health care is not necessarily affordable. Context-centered study design through ethnography will facilitate transfer of digital resources to real-world settings.

Perceptions toward Ebola vaccination and correlates of vaccine uptake among high-risk community members in North Kivu, Democratic Republic of the Congo.

The tenth Ebola Virus Disease (EVD) outbreak (2018-2020, North Kivu, Ituri, South Kivu) in the Democratic Republic of the Congo (DRC) was the second-largest EVD outbreak in history. During this outbreak, Ebola vaccination was an integral part of the EVD response. We evaluated community perceptions toward Ebola vaccination and identified correlates of Ebola vaccine uptake among high-risk community members in North Kivu, DRC. In March 2021, a cross-sectional survey among adults was implemented in three health zones. We employed a sampling approach mimicking ring vaccination, targeting EVD survivors, their household members, and their neighbors. Outbreak experiences and perceptions toward the Ebola vaccine were assessed, and modified Poisson regression was used to identify correlates of Ebola vaccine uptake among those offered vaccination. Among the 631 individuals surveyed, most (90.2%) reported a high perceived risk of EVD and 71.6% believed that the vaccine could reduce EVD severity; however, 63.7% believed the vaccine had serious side effects. Among the 474 individuals who had been offered vaccination, 397 (83.8%) received the vaccine, 180 (45.3%) of those vaccinated received the vaccine after two or more offers. Correlates positively associated with vaccine uptake included having heard positive information about the vaccine (RR 1.30, 95% CI 1.06-1.60), the belief that the vaccine could prevent EVD (RR 1.23, 95% CI 1.09-1.39), and reporting that religion influenced all decisions (RR 1.13, 95% CI 1.02-1.25). Ebola vaccine uptake was high in this population, although mixed attitudes and vaccine delays were common. Communicating positive vaccine information, emphasizing the efficacy of the Ebola vaccine, and engaging religious leaders to promote vaccination may aid in increasing Ebola vaccine uptake during future outbreaks.

Behind the scenes of a research and training collaboration: power, privilege, and the hidden transcript of race.

This paper examines a federally funded research and training collaboration between an Ivy League psychiatric research center and a historically Black university and medical center. This collaboration focuses on issues of psychiatric recovery and rehabilitation among African Americans. In addition, this multidisciplinary collaboration aims to build the research capacity at both institutions and to contribute to the tradition of research in culture and mental health within the medical social sciences and cultural psychiatry. This article provides a window into the complex, often messy, dynamics of a collaboration that cross cuts institutional, disciplinary, and demographic boundaries. Taking an auto-ethnographic approach, we intend to illustrate how collaborative relationships unfold and are constructed through ongoing reciprocal flows of knowledge and experience. Central to this aim is a consideration of how issues of power, privilege, and the hidden transcript of race shape the nature of our research and training efforts.

Patrolling your blind spots: introspection and public catharsis in a medical school faculty development course to reduce unconscious bias in medicine.

Cultural competence education has been criticized for excessively focusing on the culture of patients while ignoring how the culture of medical institutions and individual providers contribute to health disparities. Many educators are now focusing on the role of bias in medical encounters and searching for strategies to reduce its negative impact on patients. These bias-reduction efforts have often been met with resistance from those who are offended by the notion that "they" are part of the problem. This article examines a faculty development course offered to medical school faculty that seeks to reduce bias in a way that avoids this problem. Informed by recent social-psychological research on bias, the course focuses on forms of bias that operate below the level of conscious awareness. With a pedagogical strategy promoting self-awareness and introspection, instructors encourage participants to discover their own unconscious biases in the hopes that they will become less biased in the future. By focusing on hidden forms of bias that everyone shares, they hope to create a "safe-space" where individuals can discuss shameful past experiences without fear of blame or criticism. Drawing on participant-observation in all course sessions and eight in-depth interviews, this article examines the experiences and reactions of instructors and participants to this type of approach. We "lift the hood" and closely examine the philosophy and strategy of course founders, the motivations of the participants, and the experience of and reaction to the specific pedagogical techniques employed. We find that their safe-space strategy was moderately successful, largely due to the voluntary structure of the course, which ensured ample interest among participants, and their carefully designed interactive exercises featuring intimate small group discussions. However, this success comes at the expense of considering the multidimensional sources of bias. The specific focus on introspection implies that prior ignorance, not active malice, is responsible for biased actions. In this way, the individual perpetrators of bias escape blame for their actions while the underlying causes of their behavior go unexplored or unaccounted for.

A qualitative study of social facilitators and barriers to health behavior change among persons with serious mental illness.

This qualitative focus group study was conducted to explore social facilitators and barriers to health behavior change in persons with serious mental illness engaged in a healthy lifestyle intervention. Six focus group interviews were conducted with a total of 30 clients stratified by "high" and "low" achievers in the program based on clinically significant weight loss or significant increase in fitness. Thematic analysis of focus group discussions revealed that emotional, practical, and mutual support from family members and significant others were social facilitators to health behavior change, while unhealthy social environments was a barrier. Participants in the "high" achiever group reported more mutual support for health behavior change than participants in the "low" achiever group. Results highlight the need for researchers and clinicians to consider the potential role of family and significant others as health supporters for persons with mental illness who could encourage healthy behavior in the social environment.

Principles for enhancing the role of state vocational rehabilitation in IPS-supported employment.

OBJECTIVE: Research has established the Individual Placement and Support (IPS) model of supported employment as an effective approach for persons with severe mental illnesses. This article examines strategies for Vocational Rehabilitation (VR) to enhance employment outcomes through better collaboration with IPS programs. METHODS: Twenty-one focus groups were conducted in rural and urban locations in Illinois with mental health consumers, VR counselors, IPS specialists, and mental health professionals. Thematic analysis was conducted to identify features of strong collaborations between VR and IPS programs. RESULTS: Features of strong collaborations between VR and IPS programs included the following: (a) expertise, (b) consistency, (c) accessibility, and (d) integration. Five recommendations were developed from themes expressed in focus groups: (a) enhance mutual knowledge and understanding between VR and IPS practitioners, (b) examine and modify VR regulations and guidelines that conflict with IPS principles, (c) create clear guidelines for VR participation on IPS teams, (d) create guidelines for good relationships between VR and community mental health centers, and (e) develop tools to promote accountability in VR staff and systems to improve employment outcomes for people with mental illness. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Modest changes in the federal/state VR program could enhance that system's capability to foster employment outcomes for persons with severe mental illness.

Standardising the role of a digital navigator in behavioural health: a systematic review.

As the number and availability of digital mental health tools increases, patients and clinicians see benefit only when these tools are engaging and well integrated into care. Digital navigators-ie, members of health-care teams who are dedicated to supporting patient use of digital resources-offer one solution and continue to be piloted in behavioural health; however, little is known about the core features of this position. The aims of this systematic review were to assess how digital navigators are implemented in behavioural health, and to provide a standardised definition of this position. In January, 2023, we conducted a systematic literature search resulting in 48 articles included in this systematic review. Results showed high heterogeneity between four attributes of digital navigators: training specifications, educational background, frequency of communication, and method of communication with patients. Reported effect sizes for depression and anxiety were medium to large, but could not be synthesised due to study heterogeneity and small study sample size. This systematic review was registered with PROSPERO (CRD42023391696). Results suggest that digital navigator support can probably increase access to, engagement with, and clinical integration of digital health technology, with standards for training and defined responsibilities now emerging.