Implementation Barriers and Recommendations for a Multisite Community Health Worker Intervention in Palliative Care for African American Oncology Patients: A Qualitative Study.

Background: Palliative care remains underutilized by African American patients with advanced cancer. Community health workers (CHWs) may help improve palliative care outcomes among this patient population. Objectives: To explore barriers to success of a proposed CHW intervention and synthesize design and implementation recommendations to both optimize our intervention and inform others working to alleviate palliative care disparities. Design: Semi-structured qualitative interviews. Setting/Subjects: Key informants were health care professionals across clinical, leadership, and community health fields. Participants were recruited through purposive sampling from Baltimore, Maryland; Birmingham, Alabama; and Salisbury, Maryland. Measurements: Interviewers used an interview guide grounded in established implementation science models. Data were analyzed through a combined abductive/deductive approach by independent coders. A framework methodology was used to facilitate thematic analysis. Results: In total, 25 professionals completed an interview. Key informants discussed multiple barriers, including at the patient level (lack of knowledge), clinician and facility level (decreased workflow efficiency), and health system level (limited funding). Recommendations related to the intervention's design included high quality preintervention CHW training and full integration of CHWs into the care team to "bridge" divides between outpatient, inpatient, and at-home settings. Intervention delivery recommendations included clearly defining care team roles and balancing flexibility and standardization in CHW support approaches. These recommendations were then used to adapt the planned intervention and its implementation process. Conclusions: Clinicians, cancer center leaders, and CHWs identified multilevel potential barriers to the intervention's success but also described recommendations that may mitigate these barriers. Key informant input represents an important step prior to initiating CHW-based interventions.

The impact of COVID-19 on HIV treatment and care delivery in South and Southeast Asia: a qualitative study.

The COVID-19 pandemic has significantly impacted HIV treatment worldwide, but its effects on South and Southeast Asia, particularly in India, Indonesia, and Thailand, have been less evident. Our aim was to study the perceptions of providers and policymakers to understand how interventions were implemented as part of pandemic responses and how their effectiveness was viewed. We conducted a qualitative study with semi-structured interviews focusing on the shifts in HIV care in response to the pandemic. Between June and July 2021, 40 individuals were invited for interviews; 33 (83%) agreed. Participants included 25 (76%) providers and 8 (24%) policymakers, who were from India (10; 30%), Indonesia (10; 30%), and Thailand (10; 30%), along with 3 (9.1%) regional policymakers. Sixteen (48%) were female. Our findings revealed four major themes: (1) limitations in accessing HIV care due to movement restrictions and shutdowns, such as transportation issues; (2) diversion of healthcare resources away from HIV care to COVID-19 responses, leading to reallocation of providers and hospital space; (3) setbacks in HIV-related policy implementation as COVID-19 emergency responses took priority; (4) the expansion of HIV differentiated service delivery interventions, allowing longer gaps between visits and larger-volume prescription refills to delay returns to healthcare facilities. These changes have raised concerns about the long-term consequences on HIV epidemic control and future pandemic responses. However, they have also presented opportunities for innovative care delivery, which should be sustained to address these challenges effectively.

Voices, Images, And Experiences Of Community Health Workers: Advancing Antiracist Policy And Practice.

Community health workers (CHWs) are front-line public health personnel who share common attributes with or have a nuanced understanding of the communities they serve. Their membership in marginalized communities gives them expertise in delivering contextualized interventions that mitigate their clients' social risk factors, but it also places them at greater risk for exposure to various harms. We employed the photovoice method to illuminate how the lived experiences of CHWs working, residing, or both in Baltimore City, Maryland, dovetail with facets of their jobs. In partnership with our sixteen predominantly racial and ethnic minoritized study participants, we surfaced the ways in which CHWs negotiated and subsequently leveraged experiences with social risk factors rooted in structural racism to shape their approach to intervention delivery for structurally vulnerable communities. We also uncovered several occupational hazards that participants faced as a function of their identities. Our findings underscore the need to embed antiracist principles in the fabric of policies and practices that directly affect the CHW workforce.

Palliative Care Curriculum and Training Plan for community health workers.

African American patients are less likely than White patients to access palliative care. Community health workers (CHWs) are non-clinical public health workers who may address this gap. We developed a Palliative Care Curriculum and Training Plan for CHWs as part of an ongoing randomised controlled trial evaluating the effectiveness of a CHW palliative care intervention for African American patients with advanced cancer. This study aimed to determine whether the Palliative Care Curriculum and Training Plan leads to gains in knowledge, perceived competence on CHW study-based tasks, and satisfaction among CHWs. The curriculum was delivered over 3 months using synchronous, asynchronous and experiential training components. CHWs were assessed through survey questionnaires and semistructured interviews. We trained a total of three CHWs, one from each of our enrolment sites: Johns Hopkins Hospital, TidalHealth Peninsula Regional and University of Alabama at Birmingham Hospital. CHWs demonstrated an increase in knowledge, with a mean pre-training test score of 85% (SD 10.49) and post-training test score of 96% (SD 4.17). The training led to increases in perceived competence among CHWs. Areas for future training were identified. This curriculum serves as a template for CHW training focused on palliative care, oncology and health disparities.

Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC): a study protocol for a hybrid type 1 randomized controlled trial.

BACKGROUND: There are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention. METHODS: We will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms. DISCUSSION: We expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States. TRIAL REGISTRATION: Registered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022.

The Relationship Between Intersectional Drug Use and HIV Stigma and HIV Care Engagement Among Women Living with HIV in Ukraine.

This study used an intersectional approach to explore the association between enacted and internalized drug use and HIV stigma on HIV care outcomes among HIV-positive women who inject drugs in Ukraine. Surveys were conducted in Kyiv in 2019-2020. Among the 306 respondents, 55% were engaged in HIV care. More than half (52%) of participants not engaged in care reported internalized stigma related to both drug use and HIV status (i.e., intersectional stigma), compared to only 35% of those who were engaged in HIV care. Among those engaged in care, 36% reported intersectional enacted stigma compared to 44% of those not engaged in care; however, this difference was not statistically significant in the univariable analysis (p = 0.06). In the univariable analysis, participants who reported intersectional internalized stigma had 62% lower odds of being engaged in HIV care (OR 0.38, 95% CI 0.22, 0.65, p < 0.001). In the adjusted model, reported intersectional internalized stigma (aOR 0.52, 95% CI 0.30, 0.92, p = 0.026), reported intersectional enacted stigma (aOR 0.47, 95% CI 0.23, 0.95, p = 0.036), and knowing their HIV status for more than 5-years (aOR 2.29, 95% CI 1.35, 3.87, p = 0.002) were significant predictors of HIV care engagement. These findings indicate that interventions to improve HIV care engagement must address women's experiences of both HIV and drug use stigma and the different mechanisms through which stigma operates.

Impacts of COVID-19 on HIV/AIDS-Related Services in California.

The degree to which COVID-19 has disrupted the advances in reducing new HIV infections and preventing AIDS-related deaths is unknown. We present findings related to the effect COVID-19 had on HIV, sexual health and harm reduction service delivery in the state of California. We conducted a qualitative rapid assessment with health care providers, as well as representatives from non-medical support service agencies serving clients living with HIV in a range of counties in California. Some organizations adapted fairly easily while others struggled or were unable to adapt at all. Clinics were better positioned than community-based organizations to accommodate COVID restrictions and to quickly reestablish services. Influential forces that softened or calcified the hardships created by COVID-19 included influx of funding, flexibility in managing funds, networking and relationships, and workforce vulnerabilities. These data clearly suggest that an enhanced level of flexibility within funding streams and reporting requirements should be continued.

Key Elements and Mechanisms of a Peer-Support Intervention to Reduce Loneliness and Isolation among Low-Income Older Adults: A Qualitative Implementation Science Study.

This paper describes the evaluation of a longitudinal peer-support program developed to address loneliness and isolation among low-income, urban community-dwelling older adults in San Francisco. Our objective was to determine barriers, challenges, and successful strategies in implementation of the program. In-depth qualitative interviews with clients (n = 15) and peers (n = 6) were conducted and analyzed thematically by program component. We identified barriers and challenges to engagement and outlined strategies used to identify clients, match them with peers, and provide support to both peers and clients. We found that peers played a flexible, non-clinical role and were perceived as friends. Connections to community resources helped when clients needed additional support. We also documented creative strategies used to maintain inter-personal connections during the COVID-19 pandemic. This study fills a gap in understanding how a peer-support program can be designed to address loneliness and social isolation, particularly in low-income, urban settings.

Training promotores to lead virtual hereditary breast cancer education sessions for Spanish-speaking individuals of Latin American heritage in California.

BACKGROUND: Awareness about hereditary breast cancer and the preventative steps to minimize disease risk is lower in Hispanic/Latina individuals than non-Hispanic White women in the United States. For this reason, we developed a promotor-based hereditary breast cancer education and risk identification program for self-identified Hispanic/Latina women, which included training promotores in basic genetics and hereditary breast cancer. This study explored promotores' experiences receiving training and participating in virtual practice sessions as well as changes in knowledge about hereditary breast cancer. METHODS: A total of ten promotores underwent a two-week basic training led by the promotores organization and an eight-hour in person hereditary breast cancer training workshop. Demographic information along with pre- and post-training surveys were completed by ten promotores who participated in the training workshop. Surveys were given to determine changes in knowledge of hereditary breast cancer and genetics. Of the ten promotores, two were selected to lead community education sessions and participated in 6 semi-structured interviews. All interviews and practice sessions were conducted using a virtual platform. RESULTS: The data revealed that after the 8-h workshop and practice sessions, promotores felt confident about their ability to conduct virtual education sessions with the community. Interviews identified key facilitators to success such as a supportive environment, practice presentations, and personal motivation. Learning the online platform was considered the biggest challenge by the promotores, as opposed to learning complex genetics topics. CONCLUSIONS: These results provide further evidence supporting promotores' willingness and ability to provide health education on relatively complex topics. It also offers insight into the challenges of presenting information to vulnerable populations using an online platform and the additional support that is required to ensure a positive outcome.

A peer intervention reduces loneliness and improves social well-being in low-income older adults: A mixed-methods study.

BACKGROUND: Evidence-based interventions addressing loneliness and social isolation are needed, including among low-income, community-dwelling older adults of diverse racial and ethnic backgrounds. Our objective was to assess the effect of a peer intervention in addressing loneliness, isolation, and behavioral health needs in this population. METHODS: We conducted a mixed-method, two-year longitudinal study of a peer-outreach intervention in 74 low-income older adults recruited via an urban senior center in San Francisco. Structured participant surveys were conducted at baseline and every 6 months for up to 2 years. Outcomes included loneliness (3-item UCLA loneliness scale), social interaction (10-item Duke index), self-perceived socializing barriers (range: 0-10), and depression (PHQ-2 screen). Data were analyzed using mixed-effects linear and logistic regression adjusted for age and gender. Qualitative, semi-structured interviews with participants (N = 15) and peers (N = 6) were conducted in English and Spanish and analyzed thematically. RESULTS: Participants were on average 71 years old (range: 59-96 years), with 58% male, 15% LGBT, 18% African American, 19% Latinx, 8% Asian, 86% living alone, and 36% with an ADL impairment. On average, 43 contact visits (IQR: 31-97 visits) between participants and peers occurred over the first year. Loneliness scores decreased by, on average, 0.8 points over 24 months (p = 0.015). Participants reported reduced depression (38%-16%, p < 0.001) and fewer barriers to socializing (1.5 fewer, p < 0.001). Because of the longitudinal relationship and matching of characteristics of peers to participants, participants reported strong feelings of kinship, motivations to reach out in other areas of life, and improved mood. CONCLUSION: Diverse older adults in an urban setting participating in a longitudinal peer program experienced reduced loneliness, depression, and barriers to socializing. Matching by shared backgrounds facilitated rapport and bonding between participants and peers.

An exploration of patient-provider dynamics and childbirth experiences in rural and urban Peru: a qualitative study.

BACKGROUND: Between 2006 and 2013, Peru implemented national programs which drastically decreased rates of maternal and neonatal mortality. However, since 2013, maternal and neonatal mortality in Peru have increased. Additionally, discrimination, abuse, and violence against women persists globally and impacts birthing experiences and mental health. This qualitative study sought to better understand the attitudes and beliefs regarding childbirth among women and providers in Southern Peru. This study also explores how these beliefs influence utilization of skilled care, patient-provider dynamics, and childbirth experiences and identifies factors that impact providers' provision of care. METHODS: Thirty semi-structured interviews were conducted with 15 participants from rural Colca Canyon and 15 participants from urban Arequipa between April and May 2018. In each region, 10 women who had experienced recent births and five providers were interviewed. Provider participants predominantly identified as female and were mostly midwives. All interviews were conducted, transcribed, and coded in Spanish. A framework analysis was followed, and data were charted into two separate thematic frameworks using contextual and evaluative categories of conceptualization of childbirth. RESULTS: All recent births discussed were facility-based births. Four domains emerged: women's current birth experiences, provision of childbirth care, beliefs about childbirth among women and providers, and future health-seeking behavior. Findings suggest that women's feelings of helplessness and frustration were exacerbated by their unmet desire for respectful maternity care and patient advocacy or companionship. Providers attributed strain to perceived patient characteristics and insufficient support, including resources and staff. CONCLUSIONS: Our findings suggest current childbirth experiences placed strain on the patient-provider dynamic and influenced women's attitudes and beliefs about future experiences. Currently, the technical quality of safe childbirth is the main driver of skilled birth attendance and facility-based births for women regardless of negative experiences. However, lack of respectful maternity care has been shown to have major long-term implications for women and subsequently, their children. This is one of the first studies to describe the nuances of patient-provider relationships and women's childbirth experiences in rural and urban Peru.

Attitudes about community pharmacy access to HIV prevention medications in California.

OBJECTIVE: Increasing access to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) is a high priority for the Ending the HIV Epidemic Initiative. Expanding access to PrEP and PEP through a variety of health care settings, including community pharmacies, may increase access in communities most in need. California is the first state to allow community pharmacists to furnish PrEP and PEP directly to consumers. Our objective was to assess attitudes among key stakeholders about a California policy to allow community pharmacists to furnish HIV PrEP and PEP. METHODS: We conducted a qualitative case study with key pharmacy stakeholders. Semistructured phone interviews were audio-recorded and transcribed verbatim. We generated analytical memos for each interview and working with these analytical memos, we conducted a constant comparison across cases to identify commonalities and differences. RESULTS: We launched the study in October 2018 and interviewed pharmacists (n = 7) working in a variety of settings, including retail-, clinic-, and community-based pharmacies. We also interviewed medical providers (n = 2) working in high-volume PrEP clinics and sought input from representatives of large retail chain pharmacies (n = 2). Overall, pharmacists and medical provider informants shared similar opinions about the central benefits as well as the key challenges related to pharmacist-delivered PrEP and PEP services. Benefits included: community pharmacists are widely accessible, PrEP and PEP protocols are similar to other preventative medications, policy may lead to efficiencies in the health care workforce, and community pharmacists are authorities on medication adherence. Challenges included: implementation issues may limit pharmacist involvement, and missed opportunities to diagnose and treat other health conditions. CONCLUSION: This study characterizes the types of benefits and challenges that can be expected when PrEP and PEP prescribing privileges are extended to community pharmacists. This information may be useful to policymakers and other stakeholders considering legislation to permit direct prescription of PrEP and PEP by pharmacists.

The 'Snake song': a pilot study of musical intervention in Eswatini.

INTRODUCTION: In Eswatini in Southern Africa, rural populations experience unnecessary snakebite-inflicted injuries and deaths. Children are at the highest risk because of their small size and curious nature. This qualitative study explores the current knowledge and attitudes about snakebite, and the perceptions of a musical intervention, titled Iculo ngenyoka ('Snake song' in Zulu), as an educational tool aimed to raise awareness about snakes in the Lubombo region, Eswatini. METHODS: Semi-structured interviews with community members (n=56), parents/guardians/key informant (n=11) and children aged 7-17 years (n=45) were conducted between May and June 2018. Participants were selected from four communities within the Lubombo region. Data were analyzed using a framework analysis approach. RESULTS: The current sources of snake education evolved from information learned in the homesteads, schools, and through personal experiences. The majority of interviewees perceived music as a culturally appropriate, engaging and memorable method to learn about snakes. Iculo ngenyoka was perceived as an effective tool to raise awareness about snakes in the community. CONCLUSION: This study is the first to explore the importance of musical interventions in educating vulnerable communities about snakes. The Iculo ngenyoka song offers a portable medium for communicating messages about snakebite prevention, affirming the value of snakebite awareness and promoting cooperative efforts to address the burden of snakebite envenoming in the region. The results emphasize the demand for education and the potential use of Iculo ngenyoka and similar musical tools to raise awareness about snakebite in Eswatini. Re-translation and other customizations of structured musical education tools for children could be applied broadly if shown to be effective.

Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study.

BACKGROUND: The United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS). METHODS AND FINDINGS: Data were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014-2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37-54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02-1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00-1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02-1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation. CONCLUSIONS: In this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes.

Documenting best practices for maintaining access to HIV prevention, care and treatment in an era of shifting immigration policy and discourse.

Changes in the United States federal-level political landscape have been felt within immigrant communities, and the public health clinics that serve them. We sought to document how HIV prevention and care clinics are reaching and retaining their immigrant community patients during a period of retrenchment of accessible public resources and immigrant rights. From May 2018 through January 2019, we conducted 20 in-depth interviews with clinicians, case workers, advocates, legal experts, and peer navigators in Northern and Central California. Interviews were recorded and transcribed. Several themes emerged which can be grouped into three primary areas: changes post-election, challenges meeting the needs of patients, and best practices for maintaining access to prevention and care services. Post-election, providers reported some of their patients skipping clinic appointments due to fear of Immigration and Customs Enforcement (ICE) raids and deportation while other patients had moved to locations that they felt were less policed. Challenges emerged around linguistic competency, meeting basic needs such as housing stability and employment, and treating mental health sequelae resulting from trauma experienced in home countries or during migration itself. Best practices included hiring bi-lingual and bi-cultural staff, linking to legal services to assist with immigration status, holding trainings around immigrant rights and responses to ICE raids, and building trust with immigrant patients by assuring them that their status would not be collected or reported. In light of adverse policy changes affecting immigrants, agencies have begun to institute best practices to mitigate the negative impact of those policies on their clients and patients.

A Qualitative Assessment of Mothers' Experience With Pediatric Anemia Care in Arequipa, Peru.

Background: Despite national efforts to control pediatric anemia in Peru, each year, 67.4% of all newborns are diagnosed with anemia during their first year of life. The literature on Peruvian mothers' understanding and beliefs of pediatric anemia is limited. In the present study, we aimed to understand mother's perspective of pediatric anemia and explore their perceptions on how to prevent and treat anemia in Peru. Methods: During May-June 2018, we administered a short demographic questionnaire and conducted language-sensitive interviews with mothers of children clinically diagnosed with anemia in three different governmental health centers in Arequipa, Peru. Interviews were audio-recorded and transcribed verbatim. We used the Framework Analysis approach to analyze qualitative data. Results: A total of 14 Peruvian mothers were interviewed. Across interviews, three main themes emerged: (I) Mothers' Understanding of Pediatric Anemia; (II) Attitudes about Provider Recommendations for Pediatric Anemia Control; and (III) Barriers to Effective Pediatric Anemia Control. Peruvian mothers expressed skepticism toward national pediatric anemia guidelines as they believe recommendations received at health clinics jeopardized their children's overall health. Participants identified several barriers to effective anemia control: limited and confusing health information received during pediatric healthcare appointments, lack of systematic protocols in health clinics, and inconsistent referral processes. Conclusion: We identified factors that limit the acceptance of current pediatric anemia control guidelines followed at governmental health centers in Arequipa, Peru. Understanding maternal beliefs concerning pediatric anemia can guide future anemia control guidelines at the primary care level for pediatric patients in Peru.

Medical-Legal Partnerships to Support Continuity of Care for Immigrants Impacted by HIV: Lessons Learned from California.

The United States (US) has experienced a surge of anti-immigrant policies and rhetoric, raising concerns about the influence on health outcomes for immigrants living in the US. We conducted qualitative interviews (n = 20) with health care and social service providers, attorneys, and legal/policy experts in California to understand how agencies were maintaining access to HIV care and prevention for immigrant clients. We conducted a thematic analysis to describe the role of medical-legal partnerships (MLPs) and document best practices. Informants reported high demand for legal services. Referrals were facilitated by case managers, medical providers, and pre-existing relationships between clinics and legal agencies. Informants identified a need for additional funding and further guidance on screening for and supporting patients with legal needs. MLPs have the capacity to create sustainable, efficient, comprehensive structural changes that minimize barriers to HIV prevention and treatment and improve health outcomes among immigrant populations.

Leveraging Governance to Derive Value from Advanced Analytics.

In today's ever-changing health care market, the need for more agile data to support population health, value-based revenue models, and market consolidation is only increasing. To leverage emerging advanced analytics technologies, you must have a clear picture of the who, what, where and why of your data. This commentary explores how to utilize governance capabilities and technologies to ensure you derive value from your analytics investments.

The collaborative care model for HIV and depression: Patient perspectives and experiences from a safety-net clinic in the United States.

OBJECTIVES: Collaborative care models may improve outcomes for both HIV and depression. The model includes routine screening and re-assessment of depressive symptoms as well as care coordination services delivered by an ancillary provider focused on mental health. We sought to explore patient experiences and attitudes about the services received through the collaborative care model, including measurement-based care using the Patient Health Questionnaire-9. METHODS: We conducted 17 qualitative interviews with patients in a collaborative care model implemented at an HIV primary care clinic in a safety-net hospital in the United States. Interviews were analyzed using Framework Analysis. RESULTS: Our findings illustrate the ways in which the collaborative care model for depression may be meaningful to patients in HIV care settings. Participants appreciated the support offered through the collaborative care model. Most participants perceived measurement-based care as useful to their providers, and an additional subset used the Patient Health Questionnaire-9 for their own self-management and awareness of depression. Over time, the collaborative care model appeared to motivate some patients to address depressive symptoms. CONCLUSION: The collaborative care model may be particularly helpful to patients in the way that it reinforces how depressive symptoms can be measured and managed. Furthermore, routine screening and re-measurement for depressive symptoms using the Patient Health Questionnaire-9 hold promise as an additional self-management tool to complement other clinical and supportive services.