Menstruating while homeless: navigating access to products, spaces, and services.

BACKGROUND: People experiencing homelessness (PEH) in the United States face substantial challenges related to menstruation, exacerbated by the COVID-19 pandemic. Limited access to period products, heightened stigma, and gynecological challenges contribute to increased hardships for PEH, highlighting the need for improved services and policies to address period equity and overall well-being for this vulnerable population. METHODS: We conducted semi-structured qualitative interviews with PEH (n = 12) and community healthcare and social service providers (e.g., case managers, shelter directors, community health workers, and nurses, n = 12) in Lafayette, Indiana, a city located between Indianapolis and Chicago in the United States. We used thematic analysis techniques for data analysis. RESULTS: PEH's limited access to products, services, and safe spaces hindered effective menstruation management within restrictive community contexts. Although community healthcare and service providers offered some support, complex interactions with the healthcare system, stigma, and limited access to spaces exacerbated barriers. The COVID-19 pandemic further intensified these difficulties by closing public spaces, worsening economic conditions, and straining service provider resources. CONCLUSIONS: Results highlight critical organizational and policy gaps in the United States for menstruation management resources and services, emphasizing the need for better integration into health and well-being programs for PEH. These insights will advance reproductive and public health research, shedding light on the disparities faced by PEH in managing menstruation in Indiana and contributing to the national discourse on addressing these barriers. Amid the complex landscape of public health, particularly during and after the pandemic, prioritizing menstrual health remains essential for all individuals' overall well-being, including those experiencing homelessness.

"Sometimes I just forget them": capturing experiences of women about free menstrual products in a U.S. based public university campus.

BACKGROUND: Studies have proven that lack of access to menstruation products negatively affects school attendance, academic performance, and individual health. Implementing "period policies," or programs offering free menstruation products, are becoming popular in schools, businesses, and communities in high-income countries. U.S.-based Purdue University announced in February 2020 that free pads and tampons would be stocked in all women's and gender-neutral restrooms in campus buildings. This study aimed to capture the experiences of menstruators about free menstrual products and the impact of a university-wide free menstruation management product policy and program. A second purpose was to understand how access to menstrual management products is intertwined with broader socio-cultural experiences of a menstruator. METHODS: As part of a larger study, virtual focus group discussions (n = 32 across 5 focus groups) were conducted in February 2021. Eligible participants were student-menstruators attending Purdue University. We used thematic analysis techniques for data analysis, allowing for a constant comparative approach to data contextualization and theme identification. RESULTS: Focus group discussions revealed vivid menarche and menstruation experiences, shifting period culture, recollections of shame and stigma, and use of various technologies to manage menstruation. Recommendations for community-based programs offering free products included maintaining stock, making informed product choices, and broadly distributing program information to increase awareness of free product placements. CONCLUSIONS: Findings offer practical recommendations that will contribute to menstruation management and period poverty solutions for university communities.

A Qualitative Analysis of How Online Access to Mental Health Notes Is Changing Clinician Perceptions of Power and the Therapeutic Relationship.

BACKGROUND: As part of the national OpenNotes initiative, the Veterans Health Administration (VHA) provides veterans online access to their clinical progress notes, raising concern in mental health settings. OBJECTIVE: The aim of this study was to examine the perspectives and experiences of mental health clinicians with OpenNotes to better understand how OpenNotes may be affecting mental health care. METHODS: We conducted individual semi-structured interviews with 28 VHA mental health clinicians and nurses. Transcripts were analyzed using a thematic analysis approach, which allows for both inductive and deductive themes to be explored using an iterative, constant comparative coding process. RESULTS: OpenNotes is changing VHA mental health care in ways that mental health clinicians perceive as both challenging and beneficial. At the heart of these changes is a shifting power distribution within the patient-clinician relationship. Some clinicians view OpenNotes as an opportunity to better partner with patients, whereas others feel that it has the potential to undo the therapeutic relationship. Many clinicians are uncomfortable with OpenNotes, but acknowledge that this discomfort could both improve and diminish care and documentation practices. Specifically, we found that (1) OpenNotes is empowering patients, (2) OpenNotes is affecting how clinicians build and maintain the therapeutic relationship, and (3) mental health clinicians are adjusting their practices to protect patients and themselves from adverse consequences of OpenNotes. CONCLUSIONS: Our findings suggest that future research should monitor whether OpenNotes notes facilitates stronger patient-clinician relationships, enhancing patient-centered mental health care, or diminishes the quality of mental health care through disruptions in the therapeutic relationship and reduced documentation.

Qualitative analysis of US Department of veterans affairs mental health clinician perspectives on patient-centered care.

OBJECTIVE: Enhanced patient involvement in care has the potential to improve patient experiences and health outcomes. As such, large national and global healthcare systems and organizations, including the US Department of Veterans Affairs (VA), have made patient-centered care a primary goal. Little is known about mental health clinician perspectives on, and experiences with, providing patient-centered care. Our main objective was to better understand VA mental health clinicians' perceptions of patient-centered care, and ascertain possible facilitators and barriers to patient-centered practices in mental health settings. DESIGN: Qualitative study of six focus groups conducted in late 2013. SETTING AND PARTICIPANTS: Thirty-five mental health clinicians and staff from a large VA Medical Center. OUTCOMES: Transcripts were analyzed using an inductive and deductive thematic analysis approach. RESULTS: Participants described patient-centered care ideally as a process of shared discovery, and expressed general enthusiasm for patient-centered care. Participants described several ongoing patient-centered care practices but conveyed concerns about the practicalities of its full implementation. Participants expressed a strong desire to change the current biomedical culture and policies of the institution that may hinder clinicians' flexibility and clinician-clinician collaboration when serving patients. In particular, clinicians worried about being held responsible for addressing all of the needs or goals that a patient may identify. CONCLUSIONS: If patient-centered care is to be practiced fully in mental health settings, healthcare institutions need to develop multimodal strategies to enhance clinician-clinician and clinician-patient collaborations to promote and support a focus on discovery and shared accountability for outcomes.

'Our family picture is a little hint of heaven': race, religion and selective reproduction in US 'embryo adoption'.

People use selective reproductive technologies (SRT) in various family-making practices to assist with decisions about which children should be born. The practice of 'embryo adoption', a form of embryo donation developed by white American evangelical Christians in the late 1990s, is a novel site for reconceptualizing SRT and examining how they function among users. Based on ethnographic research conducted between 2008 and 2018 on US 'embryo adoption', this study provides an anthropological analysis of media produced by and about one white evangelical couple's race-specific preferences for embryos from donors of colour. This article shows how racializing processes and religious beliefs function as mutually reinforcing SRT for some 'embryo adoption' participants. Evangelical convictions justify racialized preferences, and racializing processes within and beyond the church reinforce religious acts. Race-specific preferences for embryos among white evangelicals promote selective decision-making not for particular kinds of children, a current focus in studies of SRT, but for particular kinds of families. This study expands the framework of SRT to include selection for wanted family forms and technologies beyond biomedical techniques, such as social technologies like racial constructs and religious convictions. Broadly, this article encourages greater attention to religion within analyses about race and reproduction by revealing how they are deeply entwined with Christianity, especially in the USA. Wherever constructions of race and religious convictions co-exist with selective reproductive decision-making, scholars should consider race, reproduction and religion as inextricable, rather than distinct, domains of analysis.

"Sometimes you wonder, is this really true?": Clinician assessment of patients' subjective experience of pain.

BACKGROUND: Pain is a subjective experience that must be translated by clinicians into an objective assessment to guide intervention. OBJECTIVE: To understand how patients' subjective experience of pain is translated by primary care clinicians into an objective clinical assessment of pain to effectively guide intervention. METHODS: We conducted nine multidisciplinary focus groups with a combined total of 60 Veteran affair (VA) primary care providers and staff from two large VA medical centers in California and Oregon. We used content analysis methods to identify key themes pertaining to clinical assessment of a subjective experience. RESULTS: We present four emergent themes. Theme 1: Pain is a highly individualized and subjective experience not adequately captured by a simple numeric scale; Theme 2: Conflict commonly exists between the patient's reported experience of pain and the clinician's observations and expectations of pain; Theme 3: Providers attempt to recalibrate the patient's reported experience to reflect their own understanding of pain; and Theme 4: Providers perceive that some patients may overreport their pain because they do not know how to standardize their subjective experience. CONCLUSIONS: A persistent challenge to pain assessment and management is how clinicians reconcile a patient's subjective self-reported experience with their own clinical assessment and personal biases. Future work should explore these themes from the patient perspective.

Making the Ethnic Embryo: Enacting Race in US Embryo Adoption.

How are frozen embryos donated for procreation racialized as "ethnic" subjects and what are the political implications of these enactments? Based on ethnographic research within an embryo adoption program in the United States, I examine the practices through which staff and participants produce "ethnicity" in embryos and trace its multiple permutations. Strategies used to stabilize race in embryos also disturb, fracture, and confound the bases for designating race. Analyzing race-making practices in embryo adoption reveals the interplay between practical challenges in assisted family-making practices and their wider political implications for reproductive politics.

"It Encourages Them to Complain": A Qualitative Study of the Unintended Consequences of Assessing Patient-Reported Pain.

The "Pain as the 5th Vital Sign" initiative intended to address undertreatment of pain by encouraging routine pain assessment and management. In the Veterans Health Administration, routine pain screening has been practiced in primary care for more than a decade, but has not improved the quality of pain management measured using several process indicators, and some have expressed concerns of potentially fostering undesirable use of prescription opioids. We sought to evaluate the consequences of routine pain screening on clinical practice. We conducted 9 interdisciplinary focus groups with 60 primary care providers and staff from 5 outpatient Veterans Health Administration clinics. We identified 5 themes reflecting 1 intended and 4 unintended consequences of routine pain screening: it 1) facilitates identification of patients with pain who might otherwise be overlooked, 2) may need to be targeted toward specific patients and contexts rather than universally applied, 3) often shifts visit focus away from more emergent concerns, 4) may encourage "false positives" and prompt providers to intervene when treatment is not a priority, and 5) engenders a "pain problem" and hinders patients from considering alternative strategies. These findings suggest changes to support patient-centered pain assessment and improve targeted screening and interventions for population pain management. PERSPECTIVE: This article describes some of the potential unintended consequences of implementing routine pain screening in primary care. This information may help clinicians be more strategic in their consideration and use of pain screening among their patients.

Trust in Mental Health Clinicians Among Patients Who Access Clinical Notes Online.

OBJECTIVE: This study explored patient perspectives of how online access to clinical notes (OpenNotes) within the Veterans Affairs (VA) health care system may affect patients' relationships with their mental health clinicians. METHODS: Semistructured qualitative interviews were conducted with 28 patients receiving VA mental health care who had accessed OpenNotes. Transcripts were coded and analyzed with a constant comparative approach. RESULTS: Respondents consistently reported that patient-clinician relationships-feelings of trust in particular-are critical to the therapeutic process and that reading clinical notes strengthens or strains patients' trust in mental health clinicians. Perceptions of transparency and respect as conveyed in notes were central to maintaining trust. CONCLUSIONS: Findings suggest that ensuring consistency between what occurs during appointments and what appears in clinical notes, as well as highlighting patient individuality and strengths in notes, may help engender patient trust and avoid negative consequences of OpenNotes in mental health care.

VA mental health clinician experiences and attitudes toward OpenNotes.

OBJECTIVE: To describe Department of Veterans Affairs (VA) mental health clinician attitudes toward and experiences with OpenNotes (also known as Blue Button), which provides patients direct access to clinical notes online. METHOD: A 35-item online survey was administered to 263 mental health clinicians and nurses from one VA Medical Center. RESULTS: Seventy-nine percent of eligible subjects participated. Most respondents agreed or somewhat agreed that OpenNotes is a good idea in general, but only half agreed that making mental health notes available online is a good idea. Most believed that patients will better remember plans of care and be better prepared for visits. Most also felt that patients will worry more and request changes in notes. Many clinicians reported being less detailed and changing the tone of their notes. CONCLUSION: As a group, mental health clinicians are positive about OpenNotes in general but ambivalent about the use of OpenNotes in mental health care. The results call for research on outcomes of OpenNotes use in mental health and to develop education and support to help clinicians adapt to OpenNotes.

A Virtual Hope Box smartphone app as an accessory to therapy: proof-of-concept in a clinical sample of veterans.

A "Hope Box" is a therapeutic tool employed by clinicians with patients who are having difficulty coping with negative thoughts and stress, including patients who may be at risk of suicide or nonsuicidal self-harm. We conducted a proof-of-concept test of a "Virtual" Hope Box (VHB)-a smartphone app that delivers patient-tailored coping tools. Compared with a conventional hope box integrated into VA behavioral health treatment, high-risk patients and their clinicians used the VHB more regularly and found the VHB beneficial, useful, easy to set up, and said they were likely to use the VHB in the future and recommend the VHB to peers.