Telehealth and Willingness to Pay for Internet Services.

Introduction: Telehealth is becoming integral to health care delivery, which may create a higher need for better internet. This is the first study to examine whether users are willing to spend more on their internet if they are (1) more experienced in using telehealth, (2) more optimistic about telehealth benefits, and (3) less concerned about the difficulty of using telehealth. Methods: We surveyed 5,200 Americans about their willingness to pay (WTP) for internet speed and quality on the one hand, and their (1) prior use of telehealth, (2) opinion about the benefits of telehealth, and (3) opinion about the difficulties of using telehealth. We stratified the sample using the three aspects above and conducted a conjoint analysis to estimate the WTP for internet speed and quality within each stratum. Results: Compared with respondents who had never used telehealth, respondents who had used five to six different types of telehealth services were willing to spend 50.4% more on their internet plans. Users who most firmly believed in the benefits of telehealth were willing to spend 59.2% more than the most pessimistic users. Users who had the lowest concerns about the difficulty of using telehealth were willing to spend 114% more than users with the most perceived difficulty. Discussion: We found strong ties between the WTP for internet and prior telehealth use and perceptions of telehealth benefits and barriers. Thus, internet expenditures may be influenced by users' anticipation of using telehealth. Future studies may investigate the causality of the relationship.

Emergency Nurses' Experience Providing Care and Perceptions About Using Telemedicine for Sexual Assault Patients.

Most emergency medical clinicians are not trained to conduct forensic sexual assault exams yet are often the first to care for survivors of recent sexual assault. Before the implementation of live sexual assault nurse examiner (SANE) consultation provided via telemedicine ("teleSANE") in one state, results of an online survey of emergency nurses (N = 116) found only 13% felt extremely confident providing quality forensic sexual assault examinations. Two-thirds of emergency nurses felt using teleSANE during sexual assault care would support their clinical decision-making skills. Findings suggest that teleSANE may be a promising strategy to improve access to specialized sexual assault care.

Vaccine Acceptance During a Novel Student-led Emergency Department COVID-19 Vaccination Program.

INTRODUCTION: The coronavirus 2019 (COVID-19) pandemic not only exacerbated barriers to healthcare but has also highlighted the trend toward increased vaccine hesitancy. Our goal was to improve COVID-19 vaccine uptake through a student-led, emergency department-based (ED) vaccination program. METHODS: This prospective, quality-improvement pilot program used medical and pharmacy student volunteers as COVID-19 vaccine screeners in a southern, urban, academic ED. Patients eligible for vaccination were offered either the Janssen-Johnson & Johnson or the Pfizer-BioNTech COVID-19 vaccine and were educated about vaccine concerns. Vaccine acceptance rates were recorded, as well as reasons for vaccine hesitancy, vaccine brand preferences, and demographics. The primary and secondary quantitative outcomes were overall vaccine acceptance and change in vaccine acceptance after student-provided education, respectively. We performed logistic regression to identify potential variables that correlated with vaccine acceptance. Guided by the Consolidated Framework for Implementation Research, focus group interviews with four key stakeholder groups explored implementation facilitators and barriers. RESULTS: We screened 406 patients for COVID-19 vaccination eligibility and current vaccine status, the majority of whom were unvaccinated. Of unvaccinated or partially vaccinated patients, vaccine acceptance before education was 28.3% (81/286), and vaccine acceptance after education was 31.5% (90/286) (% difference, 3.1% [95% CI 0.3%-5.9%], P=0.03). The most common hesitancy factors cited were concerns about side effects and safety. Results from the regression analysis indicated that increasing age and Black race were associated with an increased odds of vaccine acceptance. Focus groups revealed implementation barriers, including patient resistance and workflow issues, and facilitators, including student involvement and public health promotion. CONCLUSION: Using medical and pharmacy student volunteers as COVID-19 vaccine screeners was successful, and brief education provided by the students led to a modest increase in vaccine acceptance, with overall acceptance of 31.5%. Numerous educational benefits are described.

Use of Cellular-Enabled Remote Patient Monitoring Device for Hypertension Management in Pregnant Women: A Feasibility Study.

INTRODUCTION: Hypertension affects 5-10% of pregnancies in the United States. Chronic hypertension during pregnancy can have a significant impact on maternal and neonatal outcomes, especially in rural populations. Pregnancies complicated by hypertension are currently managed through frequent clinic visits or extended hospital stays. Cellular-enabled remote patient monitoring devices provide an alternative treatment method for women in rural areas. RESEARCH AIM: This study aimed to measure the feasibility of and patient satisfaction with using an integrated model of cellular-enabled remote patient monitoring devices for blood pressure supported by a 24/7 nurse call center. METHODS: In a mixed methods pilot study, twelve women with chronic hypertension during pregnancy were given cellular-enabled BodyTrace™ blood pressure cuffs and weight scales. Participants' blood pressures were continuously monitored by a nurse call center. Participants completed a survey and a brief semi-structured interview after two weeks. RESULTS: Participants scored low on stress and anxiety with mean scores of 5.45 (SD = 3.56) and 8.09 (SD 3.62), respectively. Participants scored high on behavioral intention, system usability, and perceived benefits with mean scores of 8.73 (SD = 2.53), 75.91 (SD = 23.70), and 19.64 (SD = 5.92), respectively. Participants perceived benefits to using the device, including increased monitoring by health professionals, increased self-awareness, decreased number of clinic visits, and convenience of use. Perceived disadvantages included higher readings when compared to clinical readings. DISCUSSION: Cellular-enabled remote patient monitoring devices for blood pressure are a valuable tool for managing treatment of pregnancies complicated by hypertension.

Factors Affecting Telemedicine Implementation in Emergency Departments and Nurses' Perceptions of Virtual Sexual Assault Nurse Examiner Consultation for Sexual Assault Survivors.

INTRODUCTION: Emergency department (ED) nurses play a critical role in caring for sexual assault patients, but many have not received training on how to conduct a proper sexual assault forensic medical examination. Live or real-time sexual assault nurse examiner (SANE) consultation provided via telemedicine (known as "teleSANE") during sexual assault examinations is a promising new practice to address this issue. PURPOSE: The purpose of this study was to assess ED nurses' perceptions of influences on telemedicine use, as well as the utility and feasibility of teleSANE, and identify potential influences on teleSANE implementation in EDs. METHODS: Guided by the Consolidated Framework for Implementation Research, this developmental evaluation involved semistructured qualitative interviews with 15 ED nurses from 13 EDs. RESULTS: Interviews revealed facilitators and barriers to current telemedicine use across Consolidated Framework for Implementation Research levels. Facilitators included state-level grant funding and technical assistance. Barriers included clinician discomfort being on video and access to ongoing training. Participants believed teleSANE consultation would improve patient care and forensic evidence collection but had concerns for patient privacy and acceptability. Most participants worked in EDs that have the information technology support and telemedicine equipment needed to support teleSANE implementation, although many requested ongoing education and trainings on teleSANE and sexual assault care to improve clinician confidence and account for high staff turnover. DISCUSSION: Findings highlight the unique needs of sexual assault survivors receiving telemedicine services in EDs, particularly those in rural communities with heightened privacy concerns and limited access to specialty care.

Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities.

INTRODUCTION: Veterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare. METHODS: This qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices. RESULTS: Although most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided. DISCUSSION: Best practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.

Implementation of group cognitive processing therapy in correction centers: Anticipated determinants from formative evaluation.

Nearly all people in prison have experienced trauma, and many meet the criteria for posttraumatic stress disorder (PTSD). Untreated PTSD increases the risk of substance use problems after release, contributing to a well-documented cycle of trauma, addiction, and incarceration. However, evidence-based, trauma-focused therapy for PTSD is rarely offered in prisons, and there is little research that can guide implementation efforts. In preparation for an effectiveness-implementation hybrid II pilot trial examining group-delivered cognitive processing therapy (CPT) in prisons, we conducted a formative evaluation using interviews structured according to the consolidated framework for implementation research (i.e., CFIR). Participants were correction center leadership, treatment staff, health care staff, and security staff (n = 22) and incarcerated persons (n = 14; 57.1% female). We found that CPT was highly compatible with residents' needs and the centers' available resources, culture, existing programs, and current workflow. CPT was also acceptable to all stakeholders. Potential barriers were the lower relative priority for CPT compared with programs that are reinforced at the system level, limited staff time to deliver CPT, limited staff knowledge about PTSD, and center features that could distract from CPT groups and/or training or be countertherapeutic. Taken together, CPT is a promising trauma-focused therapy for corrections, but these findings underscore the importance of identifying and matching potential barriers to effective implementation strategies a priori and work in the policy arena to promote sustainability.

Characteristics and Context of Veterans Experiencing Serious Suicidal Ideation or Suicide Attempt by Firearm which led to Hospitalization.

OBJECTIVE: Suicide by former United States military service members is of great public health concern, and one area, veterans' suicide attempts involving firearms, is understudied. One group that has a unique perspective on this are veterans with a psychiatric admission following a firearm-related suicide crisis, such as making a suicide plan or a suicide rehearsal with a firearm within the preceding 72 hours. This study seeks to address this gap in the literature by describing the characteristics and context of non-fatal suicide events involving firearms among veterans. METHOD: This convergent parallel mixed-methods design study collected both quantitative and qualitative data from male veterans (N = 15) who were hospitalized due to a suicide attempt or serious ideation using a firearm. Veterans admitted to a Veterans Affairs Medical Center (VAMC) were interviewed and asked to complete a survey. Qualitative data on characteristics and context were analyzed using a thematic analysis. RESULTS: The fifteen male U.S. military veterans described their personal characteristics, such as their beliefs, family beliefs and structure, emotions, and employment status. Most participants were unemployed (n = 10; 67%), divorced (n = 7; 47%) or married (n = 5; 33%). Seven themes related to context emerged from qualitative interviews to include: combat trauma, non-combat trauma and negative life event(s), current and past suicide attempt(s), firearms, substance use, known deaths by suicide, and protective factors for suicide. CONCLUSION: Results suggest that engaging support networks and communities is essential when developing programs to promote identification of early warning signs and implementation of interventions or programs for reducing veteran suicide.

Emergency Department Nurses' Perceptions of Patient Substance Use, Impact on Sexual Assault Care, and Access to Follow-up Behavioral Health Resources.

INTRODUCTION: Patients may present to the emergency department for sexual assault care under the influence of drugs or alcohol. However, many emergency nurses are not prepared to meet their unique needs or aware of follow-up behavioral health resources. The purpose of this study was to (1) summarize current resources provided to patients and processes for referral to behavioral health services after sexual assault care, (2) explore emergency nurses' attitudes and behaviors toward patient substance use, and (3) explore nurses' perceptions of adjunct mobile health interventions for follow-up behavioral health care and describe anticipated barriers to use. METHODS: Fifteen emergency nurses participated in semi-structured qualitative interviews. RESULTS: Participants had mixed perceptions of patient intoxication during sexual assault care. They felt that conversations about substance use may be more appropriate after the ED visit. Participants recognized the opportunity to connect ED patients with substance use treatment or prevention resources but perceived that there are few local service providers. Most participants were not referring patients with substance use issues to behavioral health services after sexual assault care and said that their emergency departments did not have processes for referral to these services. Acceptability of mobile health for follow-up behavioral health care was high, but participants had concerns for patient privacy and internet access. Participants gave recommendations to improve referral practices and patient engagement with mobile health interventions. DISCUSSION: This study highlights the need for emergency nurses to consider patient intoxication during sexual assault care and opportunities to connect patients with resources post-assault.

'You're setting a lot of people up for failure': what formerly incarcerated women would tell healthcare decision makers.

BACKGROUND: Incarcerated women have a higher prevalence of health problems than the general population; however, little is known about their perspectives on the healthcare they receive. Here, we conducted semi-structured interviews with women who had been incarcerated (n = 63) which asked what they would tell healthcare decision-makers about their experiences of healthcare in prisons and the community post-incarceration if provided the opportunity. All participants had a history of sexual violence victimization and had at least one period of incarceration in a community corrections center in Arkansas due to the goals of the larger study from which data were drawn. RESULTS: Four themes arose when participants were asked what they would tell people who make decisions about community healthcare: 1) the healthcare system is not working (52%; n = 33), 2) have compassion for us (27%; n = 17), 3) recognize that we have specific and unique needs (17%; n = 11), and 4) the transition from incarceration is challenging and requires more support (22%; n = 14). Three themes arose when we asked participants what they would tell people who make decisions about healthcare in prisons: 1) we had experiences of poor physical healthcare in prison (44%; n = 28), 2) more specialty care is needed in prison (49%; n = 31), and 3) healthcare providers treat women in prison poorly (37%; n = 23). CONCLUSIONS: Our findings underscore the need for systemic changes including greater oversight of prison-based healthcare services, enhanced access to medical subspecialties in prisons, and healthcare provider training on the unique needs of incarcerated and previously incarcerated women. Polices that expand healthcare access are also likely to benefit formerly incarcerated women given the challenges they experience seeking community-based care.

Formative evaluation of Zero Suicide in the emergency department: Identifying strategies to overcome implementation barriers.

BACKGROUND: Zero Suicide has been widely promoted as a comprehensive suicide prevention approach in healthcare systems, yet less is known about the barriers to implementing this approach in the emergency department. OBJECTIVES: This developmental evaluation aimed to assess emergency department providers' perceived knowledge and self-efficacy regarding suicide prevention practices, as well as apply the Consolidated Framework for Implementation Research to explore potential facilitators and barriers to implementing Zero Suicide and identify strategies to overcome barriers. METHODS: A sequential mixed methods approach was used, including a survey assessing emergency department providers' perceived knowledge and attitudes and semi-structured interviews exploring potential determinants of implementation. RESULTS: Survey respondents (n = 43) perceived that they have the knowledge and self-efficacy to implement clinical elements of Zero Suicide; however, interview participants (n = 18) revealed that some clinical elements are not implemented consistently and perceive implementation barriers across multiple levels, including limited training on suicide risk assessment and limited resources needed to engage and re-engage at-risk patients in their suicide care management plan and provide follow-up supportive contacts during patients' transitions in care. CONCLUSION: To overcome identified barriers in this setting, targeted implementation strategies are needed, including integration in electronic health record systems, leadership advocacy, and ongoing staff training.

Experiences of Transgender and Gender Nonbinary Patients in the Emergency Department and Recommendations for Health Care Policy, Education, and Practice.

BACKGROUND: Transgender and gender nonbinary (trans/NB) individuals face many barriers to accessing health care in the United States due to systemic and clinician discrimination. Such experiences can lead to avoidance or delays in seeking care. These issues are relevant for emergency department (ED) clinicians and staff because trans/NB patients may use the ED in times of crisis. OBJECTIVES: The purpose of this study was to qualitatively explore experiences of trans/NB individuals accessing health care in the ED and provide recommendations for improvements. METHODS: This study involved semi-structured qualitative interviews with nine trans/NB individuals living in Arkansas about their experiences when visiting local EDs. RESULTS: Interviews revealed four main themes: 1) system and structural issues; 2) interactions with clinicians/staff influence care received; 3) perceptions of clinician knowledge and education about trans/NB health; and 4) impact on future health and health care access. Participants recommended education for current and future ED clinicians and staff to improve knowledge of best practices for trans/NB health care. Recommendations were also made to improve ED policy for inclusive and affirming intake processes, intake forms, and electronic health record (EHR) documentation, including documentation and use of patients' chosen name and pronouns. CONCLUSION: The negative experiences and discrimination reported by trans/NB patients in ED visits underscores the importance of improving ED clinician knowledge of gender-affirming care practices, ED intake policies and practices, and EHR documentation in EDs.

Implementing and Sustaining SHARE: An Exposure-Based Psychotherapy Group for Incarcerated Women Survivors of Sexual Violence.

Although incarcerated women are a highly victimized population, therapy for sexual violence victimization (SVV) sequela is not routinely offered in prison. SHARE is a group therapy for SVV survivors that was successfully implemented and sustained in a women's correction center. Here, we aimed to identify implementation factors and strategies that led to SHARE's success and describe incarcerated women's perspectives on the program. We conducted a retrospective process evaluation using interviews structured according to EPIS, a well-established implementation science framework. Participants (N = 22) were incarcerated women, members of the SHARE treatment team, and members of the correction center's leadership, therapeutic team, and volunteer program. Factors that facilitated SHARE implementation varied by EPIS phase and organization. Positive inter-organizational and interpersonal relationships were key across phases, as were the synergies between both the strengths and needs of each organization involved in implementation. Incarcerated women reported a strong need for SHARE and did not report any concerns about receiving trauma therapy in a carceral setting. Therapy for SVV sequelae, including exposure-based therapy, is possible to implement and sustain in carceral settings. Community-academic partnerships may be a particularly feasible way to expand access to SVV therapy for incarcerated women.

Making change happen in criminal justice settings: leveraging implementation science to improve mental health care.

BACKGROUND: It is a constitutional right to receive health care, including mental health care, while incarcerated. Yet, even basic evidence-based mental health care practices have not been routinely integrated into criminal justice (CJ) settings. Strategies from implementation science, or the study of methods for integrating evidence-based practices into routine care, can accelerate uptake of established interventions within low-resource, high-need settings such as prisons and jails. However, most studies of mental health practices in CJ settings do not use implementation frameworks to guide efforts to integrate treatments, systematically select or report implementation strategies, or evaluate the effectiveness of strategies used. CASE PRESENTATIONS: After introducing implementation science and articulating the rationale for its application within CJ settings, we provide two illustrative case examples of efforts to integrate mental health interventions within CJ settings. Each case example demonstrates how an implementation framework either was applied or could have been applied to promote intervention adoption. The first focuses on poor implementation of a mental health screener in a county jail, retrospectively highlighting how use of a determinants framework (e.g., the Consolidated Framework for Implementation Research [CFIR]) could help staff identify factors that led to the implementation failure. The second describes an investigator-initiated research study that used a process framework (the Exploration, Preparation, Implementation, Sustainment [EPIS] framework) to systematically investigate and document the factors that led to successful implementation of a psychotherapy group for survivors of sexual violence in a women's community corrections center. Both are presented in accessible language, as our goal is that this article can be used as a primer for justice health researchers, community partners, and correctional leadership who are unfamiliar with implementation science. CONCLUSIONS: Scientific research on the application of implementation science to justice settings is growing, but lags behind the work done in health systems. Given the tremendous need for mental and behavioral health intervention across the full spectrum of justice settings, information on how to successfully implement evidence-based intervention and prevention efforts is sorely needed but possible to obtain with greater integration of knowledge from implementation science.

Community-Engaged Development, Implementation, and Evaluation of an Interprofessional Education Workshop on Gender-Affirming Care.

Background: Transgender/nonbinary (trans/NB) patients face stigma in health care settings. Health care professionals' training on trans/NB issues has historically been lacking. Interprofessional education (IPE) provides an opportunity to improve knowledge and attitudes across health care professions. The purpose of this study was to: (a) describe the development and implementation of an IPE workshop on gender-affirming care through a trans/NB community-academic partnership and (b) examine the impact of the workshop on student knowledge and attitudes. Methods: The workshop included a slide presentation on basic terminology and concepts, video clips of trans/NB patient-provider interactions, facilitated discussions of affirming practices, and a trans/NB panel. Nonparametric statistical analysis of pre- and post-survey data from 58 workshop participants measured changes in student knowledge and attitudes. Findings: Students demonstrated statistically significant improvements in knowledge (t=-12.72; p<0.01) and interpersonal comfort (t=-2.06; p<0.05) as well as sex and gender beliefs (t=-3.06; p<0.05) on subscales from the Transgender Attitudes & Beliefs Scale. The results demonstrated no differences on the human value subscale (t=-0.69; p=0.49) or on health care professional questions (t=-1.23; p=0.23). Conclusions: A community-academic partnership developed and implemented this brief interactive educational intervention, which can improve both knowledge and attitudes about trans/NB individuals' health among health professional students.

Transform Health Arkansas: A Transgender-Led Partnership Engaging Transgender/Non-Binary Arkansans in Defining Health Research Priorities.

BACKGROUND: Transgender/non-binary (trans/NB) individuals face major challenges, including within health care. OBJECTIVES: Transform Health Arkansas (THA) engaged trans/ NB Arkansans in defining their greatest health-related concerns to inform responsive, partnered, participatory research. METHODS: The THA partnership engaged trans/NB individuals through an interactive, trans/NB-led process in nine summits across the state and collected surveys on research interests. Descriptive analysis examined respondent characteristics by gender identity, mode of survey completion, and most pressing concerns. RESULTS: The summits, attended by 54 trans/NB and 29 cisgender individuals, received positive evaluations. The top five priorities among 140 survey respondents included (1) transition-related insurance coverage, (2) access to transition care, (3) education of health care providers, (4) public education, and (5) supportive health care systems. The THA has also led to trans/NB individuals educating a range of audiences about transgender issues. CONCLUSIONS: Next steps include dissemination, identification of evidence-based interventions addressing prioritized issues, and joint development of a research agenda.