Increasing the Acceptability of Lethal Means Safety Counseling for Firearms: Tips and Scripts.

In lethal means safety counseling (LMSC), clinicians encourage patients to limit their access to common and lethal means of suicide, especially firearms. However, previous studies have shown that clinicians may hesitate to deliver this evidence-based intervention, in part because of concerns that patients might not find such discussions acceptable. Based on a published review of 18 qualitative studies examining diverse perspectives on LMSC, we discuss strategies that may help clinicians increase the acceptability of LMSC among their patients and present supporting scripts, rationales, and resources. The studies included in the review examined the perspectives of clinicians, patients, firearm owners, and other relevant groups across a wide range of clinical settings on LMSC for firearms. The authors of these studies recommend that clinicians approach LMSC in a nonjudgmental manner with awareness of their own biases, demonstrate cultural competency by acknowledging the role of firearms in patients' lives, and adapt LMSC to patients' previous experiences with firearms, safety, and injury. Clinicians may also want to contextualize and provide a rationale for LMSC, decide whether or not to directly ask about access to firearms, and recommend a range of storage options tailored to the patient. Free locking devices or discount coupons for purchasing such devices may increase the acceptability and efficacy of these discussions. The strategies recommended in this paper are the first to be based on a comprehensive set of relevant studies. Future research is needed to examine whether these strategies do in fact increase the acceptability of LMSC and promote other outcomes such as increased feasibility and efficacy.

The Moderating Effects of HIV Relevant Factors on the Relationship Between Intimate Partner Violence and Intention to Start HIV Pre-exposure Prophylaxis (PrEP) Among Cisgender Women.

Intimate partner violence (IPV) and HIV are serious and related public health problems that detrimentally impact women's health. Because women who experience IPV are more likely to acquire HIV, it is critical to promote HIV prevention strategies, such as HIV pre-exposure prophylaxis (PrEP), that increase autonomy. This study of cisgender women eligible for HIV PrEP took place between 2017 and 2019 in Philadelphia and New York City. This study aimed to examine the relationship between four types of IPV (control, psychological, physical, sexual) and intention to start PrEP among PrEP-eligible cisgender women and assess the extent to which HIV relevant factors moderated the association between IPV experience and intention to start PrEP. In this sample of PrEP-eligible women (n = 214), 68.7% indicated intention to start PrEP in the next 3 months. Ethnicity was strongly associated with intention to start PrEP, with Hispanic women having the highest odds of intending to start PrEP in the next 3 months. Having a controlling partner significantly predicted intention to start PrEP. Women with more than one sex partner and a controlling partner had higher odds of intending to start PrEP as compared with those who had one or no partners and had no IPV control. These findings point to a need for patient-centered interventions that address the need for safety and autonomy among cisgender, PrEP-eligible women.

Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex.

Importance: Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups. Objective: To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex. Design, Setting, and Participants: This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022. Main Outcomes and Measures: The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group. Results: Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect. Conclusions and Relevance: In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

"I Wasn't Expecting That Question": Responses to Requests for Abortion Referral at College Student Health Centers.

BACKGROUND: Women 18-24 years of age have the highest proportion of unintended pregnancies of any age group, and thus represent a significant population in need of abortion services. Prior research indicated that only half of college student health centers provide appropriate abortion referrals. Our objective was to better understand the referral experience and barriers to abortion referral at college student health centers. PROCEDURES: We conducted a "secret caller" study at all 4-year colleges in Pennsylvania between June 2017 and April 2018, using a structured script requesting abortion referral. Calls were transcribed, coded using an iteratively developed codebook, and analyzed for themes related to barriers and facilitators of abortion referral. MAIN FINDINGS: A total of 202 completed transcripts were reviewed. Themes that emerged were knowledge, experience, and comfort with abortion referral; support, empathy, and reassurance; coercion; misleading language; questioning the caller's autonomy; and institutional policy against referral. Most staff lacked knowledge and comfort with abortion referral. Although some staff members made supportive statements toward the caller, others used coercive language to try to dissuade the caller from an abortion. Many staff cited religious institutional policies against abortion referral and expressed a range of feelings about such policies. CONCLUSIONS: Abortion referrals at student health centers lack consistency. Staff members frequently did not have the knowledge needed to provide appropriate abortion referrals, used coercive language in responding to requests for referrals, and perpetuated abortion stigma. Some health staff used coercive or evasive language that further stigmatized the caller's request for an abortion referral. College health centers should improve training and resources around abortion referral to ensure they are delivering appropriate, high-quality care.

Barriers and Facilitators to Long-Acting Injectable HIV Pre-Exposure Prophylaxis Implementation in Primary Care Since Its Approval in the United States.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is a highly effective method to mitigate the HIV epidemic, but uptake of PrEP has been slow and is associated with racial and gender disparities. Oral PrEP requires high levels of adherence to be effective, which may disadvantage certain high-risk groups. The first injectable HIV PrEP, a drug given every 2 months rather than as a daily pill, was approved by the US Food & Drug Administration in December 2021. SETTING: A Family Medicine practice in a single health organization in the United States (November 2022 to February 2023). METHODS: We conducted interviews with patients and key stakeholders to characterize factors affecting long-acting injectable (LAI) PrEP implementation. Data collection and analysis were guided by the Consolidated Framework for Implementation Research. Interviews were transcribed and analyzed using guided content analysis. RESULTS: Twenty-five patients (n = 13) and practice stakeholders (n = 12) were interviewed. Overall, stakeholders described a very low uptake of LAI PrEP. Barriers to LAI PrEP included a lack of awareness, insurance and access issues, a lack of streamlined workflow, and a trust in pills over injectables. Facilitators to LAI PrEP implementation included the absence of a pill burden, a culture of shared decision making, and pharmacy support. CONCLUSIONS: Although uptake has been slow, we have identified several promising strategies for improving rollout and implementation of LAI PrEP. Approaches that can bolster rollout of LAI PrEP include having an interdisciplinary care team that is supported by PrEP navigators and pharmacists and are informed by a patient-centered model of care to increase patient engagement and trust.

Insulin Pump Alarms During Adverse Events: A Qualitative Descriptive Study.

OBJECTIVE: Explore alarm signals cited in insulin pump-associated adverse events (AEs), describe the clinical consequences and other root cause informing remarks that cooccurred with the alarm signals, and identify opportunities for improvements to patient education, instructional materials, and alarm systems to prevent future AEs. RESEARCH DESIGN AND METHODS: We explored the type, frequency, and associated clinical consequences of alarm signals cited in a pre-coded data set of 2294 insulin pump-associated AEs involving the MiniMed 670G, MiniMed 630G, and t:slim X2. We also explored the clinical consequences and other root cause informing remarks that cooccurred with the top 10 most frequently cited alarm signals. RESULTS: Overall, 403 AEs narratives cited at least one alarm signal. Of the 40 unique alarm signals cited, 42.5% were "alarms," 25.0% were "alerts," and 32.5% were not referenced in the instructional materials packaged with the corresponding pump. The top 10 most frequently cited alarm signals included two obstruction of flow alarms, which accounted for 49.9% of all AEs citing at least one alarm, and two unreferenced alarms. The most frequent cooccurring root cause informing remark varied across the top 10 alarm signals and revealed valuable insight into why these alarms may have occurred. CONCLUSIONS: Our findings demonstrate the value of analyzing alarm signals cited in insulin pump-associated AEs and reveal multiple opportunities for providers to educate patients on how to respond to alarm signals and manage their pumps to avoid AEs, and for insulin pump manufacturers to update instructional materials and improve alarm systems to support appropriate patient response.

Patterns in Food Insecurity During Pregnancy, 2004 to 2020.

This survey study assesses patterns in food insecurity during pregnancy among individuals in 14 US states participating in the Pregnancy Risk Assessment Monitoring System from 2004 to 2020.

Characterizing Twitter Content About HIV Pre-exposure Prophylaxis (PrEP) for Women: Qualitative Content Analysis.

BACKGROUND: HIV remains a persistent health problem in the United States, especially among women. Approved in 2012, HIV pre-exposure prophylaxis (PrEP) is a daily pill or bimonthly injection that can be taken by individuals at increased risk of contracting HIV to reduce their risk of new infection. Women who are at risk of HIV face numerous barriers to HIV services and information, underscoring the critical need for strategies to increase awareness of evidence-based HIV prevention methods, such as HIV PrEP, among women. OBJECTIVE: We aimed to identify historical trends in the use of Twitter hashtags specific to women and HIV PrEP and explore content about women and PrEP shared through Twitter. METHODS: This was a qualitative descriptive study using a purposive sample of tweets containing hashtags related to women and HIV PrEP from 2009 to 2022. Tweets were collected via Twitter's API. Each Twitter user profile, tweet, and related links were coded using content analysis, guided by the framework of the Health Belief Model (HBM) to generate results. We used a factor analysis to identify salient clusters of tweets. RESULTS: A total of 1256 tweets from 396 unique users were relevant to our study focus of content about PrEP specifically for women (1256/2908, 43.2% of eligible tweets). We found that this sample of tweets was posted mostly by organizations. The 2 largest groups of individual users were activists and advocates (61/396, 15.4%) and personal users (54/396, 13.6%). Among individual users, most were female (100/166, 60%) and American (256/396, 64.6%). The earliest relevant tweet in our sample was posted in mid-2014 and the number of tweets significantly decreased after 2018. We found that 61% (496/820) of relevant tweets contained links to informational websites intended to provide guidance and resources or promote access to PrEP. Most tweets specifically targeted people of color, including through the use of imagery and symbolism. In addition to inclusive imagery, our factor analysis indicated that more than a third of tweets were intended to share information and promote PrEP to people of color. Less than half of tweets contained any HBM concepts, and only a few contained cues to action. Lastly, while our sample included only tweets relevant to women, we found that the tweets directed to lesbian, gay, bisexual, transgender, queer (LGBTQ) audiences received the highest levels of audience engagement. CONCLUSIONS: These findings point to several areas for improvement in future social media campaigns directed at women about PrEP. First, future posts would benefit from including more theoretical constructs, such as self-efficacy and cues to action. Second, organizations posting on Twitter should continue to broaden their audience and followers to reach more people. Lastly, tweets should leverage the momentum and strategies used by the LGBTQ community to reach broader audiences and destigmatize PrEP use across all communities.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults.

BACKGROUND: Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults. METHODS: We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions. DISCUSSION: To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities. TRIAL REGISTRATION: Registered 05 May 2021, at ISRCTN #60,657,985. REPORTING GUIDELINES: Standards for Reporting Implementation Studies (see attached).

Perceptions of HIV risk screening strategies among patients seeking abortion, contraception, and pregnancy loss management in the United States.

OBJECTIVES: Women make up nearly a fifth of new human immunodeficiency virus (HIV) infections yearly in the United States, more than half of which could have been prevented with broader use of HIV pre-exposure prophylaxis (PrEP). We aimed to qualitatively assess (1) acceptability of an HIV risk screening strategy and PrEP provision in a family planning setting, and (2) the influence of family planning visit type (abortion, pregnancy loss management, or contraception) on HIV risk screening acceptability. STUDY DESIGN: Guided by the P3 (practice-, provider-, and patient-level) model for preventive care interventions, we conducted three focus group discussions including patients who had experienced induced abortion, early pregnancy loss (EPL), or contraception care. We developed a codebook of a priori and inductive concepts, and categorized themes by practice, provider, and patient considerations. RESULTS: We included 24 participants. Practice-level considerations included overall positive feelings about being screened for PrEP eligibility during family planning visits, though some expressed reservations about screening during EPL visits. Provider-level themes included the concept of screening tools as entry points into conversation and education, and the importance of nonjudgment in discussing sexually transmitted infection (STI) prevention. Participants often had to initiate STI prevention discussions and felt that contraception was overemphasized by their providers compared with STI prevention and PrEP care. Patient-level themes included the stigma of STIs and oral PrEP, and the dynamic nature of STI risk. CONCLUSIONS: Participants in our research had genuine interest in learning about PrEP during family planning visits. Findings from our research support the consistent inclusion of STI prevention education into family planning clinical practice using patient-centered STI screening methods. IMPLICATIONS: Family planning encounters, including visits for contraception and abortion, are generally appropriate times to discuss HIV PrEP. Patient-centered conversations are an important adjunct to HIV risk screening tools.

Barriers and facilitators to goals of care conversations with Veteran residents of community nursing homes.

BACKGROUND: Despite evidence that structured goals of care conversations (GoCCs) and documentation of life-sustaining treatment (LST) preferences improve the delivery of goal-concordant care for seriously ill patients, rates of completion remain low among nursing home residents. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program aims to improve the consistent documentation of LST preferences among Veterans receiving care in veterans affairs (VA)-paid community nursing homes (CNH); however, the barriers and facilitators of completing and documenting GoCCs in this unique context of care have not been described. METHODS: We conducted semi-structured, qualitative interviews with key stakeholders of the VA CNH programs located at six VA Medical Centers between July 2021 and July 2022. With a rapid approach to analysis, interview transcripts were reduced into memo templates using the Tailored Implementation for Chronic Disease Checklist and coded and analyzed using qualitative data analysis software. RESULTS: The 40 participants consisted of nurses (n = 13), social workers (n = 25), and VA physicians (n = 2). Most participants felt confident about conducting GoCC; however, several barriers were identified. At the staff level, our results indicated inconsistent completion of GoCC and documentation due to a lack of training, confusion about roles and responsibilities, and challenging communication within the VA as well as with CNH. At the organizational level, there was a lack of standardization across sites for how LST preferences were documented. At the patient level, we found key barriers related to patient and family readiness and issues finding surrogate decision makers. While COVID-19 brought end-of-life issues to the forefront, lockdowns hindered communication about the goals of care. CONCLUSION: Findings from this pre-implementation evaluation revealed multi-level barriers in conducting and documenting GoCCs with Veterans receiving VA-paid CNH care, as well as several facilitators that can be used to inform strategies for improvement.

Insulin Pump-Associated Adverse Events: A Qualitative Descriptive Study of Clinical Consequences and Potential Root Causes.

Objective: To explore the clinical consequences and potential root causes of insulin pump-associated adverse events (AEs) reported in the Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database. Research Design and Methods: Qualitative template analysis of narrative data in a 20% stratified random sample (n = 2429) of reported AEs that occurred during the first 6 months of 2020 involving five insulin pump models marketed at that time: (1) MiniMed™ 670G, (2) MiniMed™ 630G, (3) Omnipod®, (4) Omnipod DASH®, and (5) t:slim X2™. Results: Of the 2429 AEs, 92% included a clinical consequence in the narrative description, with critical hyperglycemia (i.e., blood glucose [BG] >400 mg/dL; 47%) and critical hypoglycemia (i.e., BG <54 mg/dL; 24%) being the most common consequence cited. Only 50% of the AE narratives included information to support the identification of a root cause. The most cited root cause informing remarks were issues with the pump or pod reservoir/cartridge (9%), the occurrence of an obstruction of flow alarm (8%), and problems with the infusion set or site (8%). Some clinical consequences and root cause informing remarks were cited more frequently in AE narratives involving specific insulin pump models, but manufacturer variability in the amount and type of information reported may have affected these findings. Conclusions: Our findings show general themes found in insulin pump-associated AE that providers can use to raise patient awareness of potential risks associated with insulin pump use and develop strategies to prevent future AEs. Improvements in AE investigation and reporting processes are still necessary.

Sexually Transmitted Infection Testing in the National Veterans Health Administration Patient Cohort During the Coronavirus Disease 2019 Pandemic.

Background: We performed a retrospective study of chlamydia, gonorrhea, syphilis, and human immunodeficiency virus (HIV) testing in the Veterans Health Administration (VHA) during 2019-2021. Methods: We determined the annual number of chlamydia, gonorrhea, syphilis, and HIV tests from 2019 through 2021 using electronic health record data. We calculated rates by age, birth sex, race, census region, rurality, HIV status, and use of preexposure prophylaxis. Results: The VHA system experienced a 24% drop in chlamydia/gonorrhea testing, a 25% drop in syphilis testing, and a 29% drop in HIV testing in 2020 versus 2019. By the conclusion of 2021, testing rates had recovered to 90% of baseline for chlamydia/gonorrhea, 91% for syphilis, and 88% for HIV. Declines and subsequent improvements in sexually transmitted infection (STI) testing occurred unequally across age, sex, race, and geographic groups. Testing for all 4 STIs in 2021 remained below baseline in rural Veterans. Excluding those aged <25 years, women experienced a steeper decline and slower recovery in chlamydia/gonorrhea testing relative to men, but quicker recovery in HIV testing. Asian Americans and Hawaiian/Pacific Islanders had a steeper decline and a slower recovery in testing for chlamydia/gonorrhea. Black and White Veterans had slower recovery in HIV testing compared with other race groups. People living with HIV experienced a smaller drop in testing for syphilis compared with people without HIV, followed by a near-total recovery of testing by 2021. Conclusions: After dramatic reductions from 2019 to 2020, STI testing rates returned to near-baseline in 2021. Testing recovery lagged in rural, female, Asian American, Hawaiian/Pacific Islander, and Black Veterans.

Stakeholder perceptions of lethal means safety counseling: A qualitative systematic review.

Introduction: Lethal means safety counseling (LMSC) is an evidence-based suicide prevention intervention during which providers encourage patients to limit their access to lethal means (e.g., firearms, medications). Despite agreement about the importance of LMSC, it is underutilized in clinical practice. Methods: To better understand the individual and contextual factors that influence LMSC and its implementation, we conducted a systematic review of qualitative studies examining stakeholder perceptions of the intervention. PubMed and PsycInfo were searched up to February 2021 using terms related to: (1) LMSC, firearms, or medications; (2) suicide, safety, or injury; and (3) qualitative methodology. Two coders used thematic synthesis to analyze findings from eligible papers, including developing a codebook and coding using an inductive and iterative approach (reliability k > 0.70). Confidence in review findings were evaluated using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach. Subthemes were assigned to domains in the Consolidated Framework for Implementation Research. Findings: Of the 19 papers identified, 18 discussed LMSC for firearms and 1 focused exclusively on LMSC for medications. The firearm-related studies explored perspectives of a variety of stakeholders (patients, providers, members of the firearms community, healthcare leaders, and family members) across multiple settings (emergency departments, pediatric and adult primary care, and outpatient mental health). Seven overarching themes emerged, including the: (1) importance of firearms to owners' identities and perceptions of ownership as a value and right, which can lead to perceived cultural tensions in clinical settings; (2) importance of patients understanding the context and rationale for LMSC; (3) value of providers showing cultural competency when discussing firearms; (4) influence of safety and risk beliefs on firearm behaviors; (5) need to navigate logistical concerns when implementing LMSC; (6) value of individualizing LMSC; (7) potential for trusted family members and friends to be involved in implementing LMSC. Conclusion: This synthesis of the qualitative literature informs clinical, operational, and research endeavors aimed at increasing the reach and effectiveness of LMSC. Future research should address the perspectives of individuals underrepresented in the literature (e.g., those from racial/ethnic minority groups) and further examine stakeholders' perceptions of LMSC for medication. [-2pt]. Systematic review registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021237515], identifier [CRD42021237515].

Gonorrhea and Chlamydia Testing and Case Rates Among Women Veterans in the Veterans Health Administration.

BACKGROUND: United States (US) rates of sexually transmitted infection (STI) in women, especially gonorrhea and chlamydia, have increased over the past decade. Women Veterans may be at increased risk for STIs due to high rates of sexual trauma. Despite the availability of effective diagnostic tests and evidence-based guidelines for annual screening among sexually active women under age 25, screening rates for gonorrhea and chlamydia remain low in the US and among Veterans. OBJECTIVE: To examine patient characteristics and health system factors associated with gonorrhea and chlamydia testing and case rates among women Veterans in the Veterans Health Administration (VHA) in 2019. DESIGN: We performed a retrospective cohort study of all women Veterans in VHA care between January 1, 2018, and December 31, 2019. PARTICIPANTS: Women Veteran patients were identified as receiving VHA care if they had at least one inpatient admission or outpatient visit in 2019 or the preceding calendar year. KEY RESULTS: Among women under age 25, 21.3% were tested for gonorrhea or chlamydia in 2019. After adjusting for demographic and other health factors, correlates of testing in women under age 25 included Black race (aOR: 2.11, CI: 1.89, 2.36), rural residence (aOR: 0.84, CI: 0.74, 0.95), and cervical cancer screening (aOR: 5.05, CI: 4.59, 5.56). Women under age 25 had the highest infection rates, with an incidence of chlamydia and gonorrhea of 1,950 and 267 cases/100,000, respectively. Incidence of gonorrhea and chlamydia was higher for women with a history of military sexual trauma (MST) (chlamydia case rate: 265, gonorrhea case rate: 97/100,000) and those with mental health diagnoses (chlamydia case rate: 263, gonorrhea case rate: 72/100,000.) CONCLUSIONS: Gonorrhea and chlamydia testing remains underutilized among women in VHA care, and infection rates are high among younger women. Patient-centered, system-level interventions are urgently needed to address low testing rates.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration.

BACKGROUND: Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. METHODS: PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. DISCUSSION: The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

Perspectives on Racism in Health Care Among Black Veterans With Chronic Kidney Disease.

Importance: The burden of chronic kidney disease (CKD) and end-stage kidney disease falls disproportionately on Black individuals in the US, with Black veterans experiencing substantial consequences, and only a portion of the disparities in health conditions and health care can be explained by nonbiological factors. Among Black individuals, racism is likely one of those factors, suggesting the need to examine the consequences of racism and the resulting social structures that establish and perpetuate these racial disparities. Objective: To investigate the health care experiences of Black veterans with CKD and identify and explore the racial discrimination encountered by this vulnerable population. Design, Setting, and Participants: This qualitative study used semistructured interview guides to investigate the health care experiences of 36 Black veterans with CKD who received care at the Corporal Michael Crescenz Veterans Affairs Medical Center in Philadelphia, Pennsylvania, from October 2018 to September 2019. Interview transcripts were analyzed using applied thematic analysis. Results: Among 36 Black veterans with CKD who characterized racism in the context of their care at a Veterans Affairs medical center, the mean (SD) age was 66.0 (7.8) years; 35 participants (97.2%) were male, 1 participant (2.8%) was female, and 19 participants (52.8%) were married. The mean (SD) duration of military service was 8.0 (7.0) years. Overall, 15 participants (41.7%) were not dependent on dialysis, and hypertension was the most common comorbidity (9 participants [25.0%]). Veterans described the ways in which racism produced emotional and physical stress, including psychological symptoms (eg, anger and hurt) and physiological symptoms (eg, headaches). Veterans described a strong sense of distrust in the health care system coupled with a need to be hypervigilant during clinical encounters. When encountering racism, veterans described bottling up their feelings, which sometimes led to maladaptive behavior (eg, substance use). Veterans also described individual and collective positive strategies (eg, faith) for coping with the stress of racism. Conclusions and Relevance: In this study, Black veterans with CKD experienced racism in the clinical setting that produced physical and emotional stress and a strong sense of distrust in the health care system. These findings highlight an important opportunity for education and training of health care professionals in the implementation of trauma-informed approaches to care as a means of addressing race-based stress and trauma.

Exploring Barriers and Facilitators to Glycemic Control and Shared Medical Appointment Engagement in Underserved Patients with Diabetes.

OBJECTIVE: The purpose of this study was to evaluate barriers and facilitators to glycemic control and diabetes shared medical appointment (SMA) engagement in underserved patients with type 2 diabetes. METHODS: Semi-structured focus groups were conducted in 50 patients using an interview script guided by a social determinants of health (SDOH) conceptual framework. RESULTS: Patients positively perceived the social support and access to care benefits of the SMA. While barriers related to self-care behaviors (particularly diet), financial issues, and unreliable transportation were common, notable differences among the four groups existed. Controlled patients were motivated by fear of diabetic complications. Poorly-controlled patients discussed comorbidities and negative influence of family as barriers to glycemic control. Diabetes distress and fatalism were endorsed by poorlycontrolled, non-engaged patients. CONCLUSIONS: Overcoming SDOH including transportation barriers, food insecurity, and diabetes distress and fatalism are promising areas of intervention for SMA models to improve care for underserved populations.

Awareness of HIV Preexposure Prophylaxis Among People at Risk for HIV: Results From the 2017-2019 National Survey of Family Growth.

BACKGROUND: Although daily preexposure prophylaxis (PrEP) is now widely accepted as a safe and effective method for reducing the risk of HIV in high-risk groups, uptake has been slow. The goal of this analysis was to identify factors associated with PrEP awareness among individuals at risk for HIV. METHODS: This investigation analyzed data from the Centers for Disease Control and Prevention nationally representative survey, National Survey of Family Growth, for the years 2017 to 2019. Logistic regression was used to explore the relationship between PrEP awareness and demographics, HIV risk factors, and provider HIV risk screening. RESULTS: Only 37% of survey respondents with an increased risk of HIV were aware of PrEP. Several segments of the at-risk population had lower odds of being aware of PrEP, including heterosexual women, heterosexual men, individuals younger than 20 years, and individuals with lower levels of education. Those who participate in sex in exchange for money or drugs had significantly lower odds of being aware of PrEP. In comparison, PrEP awareness was significantly higher among nonheterosexual men and both men and women whose partners were HIV positive. Lastly, those who had been screened by a provider for HIV risk had significantly higher odds of being aware of PrEP. CONCLUSIONS: This research supports the need for policies and programs to increase awareness of PrEP, especially among certain segments of the population at increased risk for HIV.