Intimate partner violence in the lives of Indigenous and Black women in the upper Midwest of the United States during the COVID-19 pandemic: A mixed-methods protocol examining help-seeking behaviours and experiences.

Violent behaviour perpetrated against women has long-lasting negative physical and mental health consequences for women, their children, their families, and their communities. Intimate partner violence (IPV) is associated with many adverse physical, psychological, and emotional consequences. Structural racism and historical trauma affect women's trust and further hinder the ability of Indigenous and Black women to seek help after experiencing IPV. The availability of IPV support services, which can include shelter, food, group therapy, legal assistance, and advocacy, can be inaccessible to women due to the inability to access often limited resources in urban environments and reasons compounded by potential geographic distance if living in rural areas or living in community. Understanding the unique reasons why Indigenous and Black women do not seek help, and the barriers they experience when seeking help after IPV, is critical. Pandemics have the potential to create further complexities on how IPV is experienced. Black and Indigenous women experiencing IPV were therefore at even greater risk for IPV-related harm because of state and local "stay at home" measures put in place to minimise the spread COVID-19. The purpose of this manuscript is to explicate the methods for a large R01 study in the Upper Midwest.

A protocol for the safe recruitment of Indigenous and Black women experiencing intimate partner violence during the COVID-19 pandemic into a large mixed methods study: The Sisters by Choice Study.

Intimate partner violence (IPV) is a complex and pervasive public health problem disproportionately affecting Indigenous and Black women. During the COVID-19 pandemic, IPV became more complicated for advocates because social distancing, quarantine, and isolation measures further endangered women experiencing IPV. This manuscript is based on an ongoing community-engaged study in an upper Midwestern state. Our primary goal for this study is to generate urgently needed knowledge on the impact of the COVID-19 pandemic on Indigenous and Black women's help-seeking behaviours following IPV by systematically documenting barriers women faced during the pandemic. Engaging women in a large study that seeks to garner information about their experiences of violence is complex and challenging and requires significant planning, especially for ensuring participants' safety. In this write-up, we detail the safety planning protocol developed for the purposes of recruiting and engaging women in rural and urban areas in an upper Midwestern state in the United States. Our goal is to provide scholars conducting research in the area of violence with practical considerations for safely conducting a study of this nature.

Development of the Ready to Care Survey for VA Women's Health Primary Care Provider.

INTRODUCTION: Women Veterans are at increased risk for poor pregnancy outcomes and are increasingly using Veteran Affairs (VA) for maternity benefits. VA Women's Health Primary Care Providers (WH-PCPs) are well positioned to improve maternal outcomes for women Veterans, yet little is understood about their experience and comfort with perinatal care. The objective of this study was to develop and validate a survey that could be utilized to assess WH-PCPs' experience, comfort, and attitudes towards perinatal care. METHODS: After a review of the literature, we adapted a previously published survey to address four content areas including clinical experience, comfort level, and attitudes towards perinatal care and knowledge of VA specific maternity services. This survey was piloted with five WH-PCPs before undergoing two rounds of content validation with content experts. Content validity indexes (CVI) were calculated based on the content experts' ratings. Qualitative feedback from the content experts were summarized and reviewed by the research team. The CVI and qualitative responses were utilized to guide the decision to revise, refine, or delete survey questions. RESULTS: After the first round of content validation, we deleted three questions, revised three questions, and add three questions to the content areas of clinical experience and comfort. In the domain of attitudes towards perinatal care, we deleted one question and revised two questions and three questions were added to the knowledge of VA specific maternity services domain. After the second round of content validation, only one question was deleted from the attitudes domain. DISCUSSION: We developed and validated the Ready to Care Survey for VA WH-PCP using two rounds of content validation. The final survey had face and content validity. This survey tool can be used to assess VA WH-PCP's knowledge and readiness in caring for Veterans of child-bearing age for operational and research needs.

Factors that Sustained the Integration of Behavioral Health into Nurse-Led Primary Care.

Lack of access to primary and behavioral healthcare is prevalent in communities experiencing systematically greater obstacles to healthcare. This study describes the implementation of the Coordinated Care Model in a nurse-led primary care clinic and identifies the essential factors for sustained integration. A mixed-methods explanatory sequential study design was used to collect and analyze quantitative and qualitative data. Participants reported an overall statistically significant mean increase (M = 2.47, SD ± 2.01, p < 0.001) in the level of integration pre-and post-integration. Qualitative results indicated that the optimization and accentuation of team strengths, the Lundeen model of holistic care, and addressing physical and psychological barriers lead to sustained level of integration. Integrated practices are essential in assessing and supporting the holistic needs of individuals, families, and communities. Future studies should examine facilitators or impediments to integrated practice in other healthcare settings, long-term health outcomes of clients in integrated care, and the cost-effectiveness of integration.

Pharmacist-initiated adherence promotion activities for persons living with HIV in ambulatory care settings: Instrument development and initial psychometric testing.

OBJECTIVES: Consistent adherence to antiretroviral therapy (ART) remains a challenge for half the people living with HIV (PLWH) in the U.S. Pharmacists have the expertise in pharmacology and pharmacotherapeutics to manage ART and optimize PLWH outcomes. We developed and validated the psychometric properties of a scale to measure the breadth and depth of adherence promotion activities provided by pharmacists to PLWH in ambulatory care settings. METHODS: An initial 37-item instrument was developed from 31 pharmacists' interviews and a comprehensive literature review. Psychometric properties were assessed from responses to questionnaires of 10 content experts and 184 ambulatory pharmacists in 37 States. Psychometric tests included: content validity index (CVI); Exploratory Factor Analysis (EFA); and internal reliability using Cronbach's alpha (α). RESULTS: 26 items were eliminated in the item reduction stage. The final 11-item adherence promotion activities scale (APAS) was a single factor with high loadings (0.51-0.85), good internal consistency (α ≤ 0.93) and an explained variance of 60%. For known-groups validity, HIV-certified pharmacists had comparatively higher and statistically significant APAS score compared to non-certified pharmacists (4.00, p < .001). CONCLUSIONS: Preliminary psychometric testing-factor analysis, and high internal consistency-depict that APAS can be useful in scientific research and pharmacy practice to assess the nature and range of pharmacists' above-and-beyond prescription services in real-world ambulatory settings. Further validation work is needed to establish conclusive reliability and validity of the newly developed scale.

Community perspectives of second-generation alcohol misuse and HIV risk in rural Kenya: A gendered syndemic lens.

Sub-Saharan Africa is at the intersection of the HIV epidemic and the highest burden of alcohol-related disease and injury. Alcohol consumption is associated with an increased likelihood of HIV infection, high rates of intimate partner violence and is considered both a cause and a contributor of economic stress and poverty. Our study integrates the syndemic and socio-ecological system theoretical frameworks to qualitatively explore the effect of second-generation alcohol consumption on sexual risk behaviours, alcohol misuse, violence and economic stress (SAVE) factors and HIV infection risk. We recruited 80 people from rural Kenya to participate in 12 focus groups. Consistent with the literature, we found evidence of syndemic associations of second-generation alcohol consumption with SAVE factors, including HIV infection risk. Structural-level factors including availability of cheap second-generation alcohol and widespread unemployment are the biggest risk factors for alcohol misuse. Because of the psychological effect of women's increasing economic independence on men, gendered syndemic programming - that includes both men and women - and addresses the complex web of risk factors for second-generation alcohol misuse can interrupt the vicious cycle of poverty, violence, sexual risk behaviours and mitigate HIV infection risk in rural Kenya.

Antibiotic Use After Removal of Penicillin Allergy Label.

BACKGROUND: Penicillin allergy is commonly reported in the pediatric emergency department. We previously performed 3-tier penicillin allergy testing on children with low-risk symptoms, and 100% tolerated a penicillin challenge without an allergic reaction. We hypothesized that no serious allergic reactions would occur after re-exposure to penicillin and that prescription practices would change after testing. METHODS: We performed a follow-up case series of 100 children whose test results were negative for penicillin allergy. Research staff administered a brief follow-up phone survey to the parent and primary care provider of each patient tested. We combined the survey data and summarized baseline patient characteristics and questionnaire responses. We then completed a 3-tier economic analysis from the prescription information gathered from surveys in which cost savings, cost avoidance, and potential cost savings were calculated. RESULTS: A total of 46 prescriptions in 36 patients were reported by the primary care provider and/or parents within the year after patients were tested for penicillin allergy. Twenty-six (58%) of the prescriptions filled were penicillin derivatives. One (4%) child developed a rash 24 hours after starting the medication; no child developed a serious adverse reaction after being given a penicillin challenge. We found that the cost savings of delabeling patients as penicillin allergic was $1368.13, the cost avoidance was $1812.00, and the total potential cost savings for the pediatric emergency department population was $192 223.00. CONCLUSIONS: Children with low-risk penicillin allergy symptoms whose test results were negative for penicillin allergy tolerated a penicillin challenge without a severe allergic reaction developing. Delabeling children changed prescription behavior and led to actual health care savings.

Are community-based pharmacists underused in the care of persons living with HIV? A need for structural and policy changes.

OBJECTIVE: To describe community pharmacists' perceptions on their current role in direct patient care services, an expanded role for pharmacists in providing patient care services, and changes needed to optimally use pharmacists' expertise to provide high-quality direct patient care services to people living with human immunodeficiency virus (HIV) infections. DESIGN: Cross-sectional study. SETTING: Four Midwestern cities in the United States in August through October 2009. PARTICIPANTS: 28 community-based pharmacists practicing in 17 pharmacies. INTERVENTIONS: Interviews. MAIN OUTCOME MEASURES: Opinions of participants about roles of specialty and nonspecialty pharmacists in caring for patients living with HIV infections. RESULTS: Pharmacists noted that although challenges in our health care system characterized by inaccessible health professionals presented opportunities for a greater pharmacist role, there were missed opportunities for greater level of patient care services in many community-based nonspecialty settings. Many pharmacists in semispecialty and nonspecialty pharmacies expressed a desire for an expanded role in patient care congruent with their pharmacy education and training. CONCLUSION: Structural-level policy changes needed to transform community-based pharmacy settings to patient-centered medical homes include recognizing pharmacists as important players in the multidisciplinary health care team, extending the health information exchange highway to include pharmacist-generated electronic therapeutic records, and realigning financial incentives. Comprehensive policy initiatives are needed to optimize the use of highly trained pharmacists in enhancing the quality of health care to an ever-growing number of Americans with chronic conditions who access care in community-based pharmacy settings.

Methods and protocol of a mixed method quasi-experiment to evaluate the effects of a structural economic and food security intervention on HIV vulnerability in rural Malawi: The SAGE4Health Study.

BACKGROUND: Poverty and lack of a predictable, stable source of food are two fundamental determinants of ill health, including HIV/AIDS. Conversely, episodes of poor health and death from HIV can disrupt the ability to maintain economic stability in affected households, especially those that rely on subsistence farming. However, little empirical research has examined if, and how, improvements in people's economic status and food security translate into changes in HIV vulnerability. METHODS: In this paper, we describe in detail the methods and protocol of an academic-NGO collaboration on a quasi-experimental, longitudinal study of the mechanisms and magnitude of the impact of a multilevel economic and food security program (Support to Able-Bodied Vulnerable Groups to Achieve Food Security; SAFE), as implemented by CARE. Primary outcomes include HIV vulnerability (i.e., HIV risk behaviors, HIV infection), economic status (i.e., income, household assets) and food security (including anthropometric measures). We recruited participants from two types of areas of rural central Malawi: traditional authorities (TA) selected by CARE to receive the SAFE program (intervention group) and TAs receiving other unrelated CARE programming (controls). In the intervention TAs, we recruited 598 program participants (398 women, 200 men) and interviewed them at baseline and 18- and 36-month follow-ups; we interviewed 301 control households. In addition, we conducted random surveys (n = 1002) in the intervention and control areas with a 36-month assessment interval, prior to and after implementation of SAFE. Thus, we are examining intervention outcomes both in direct SAFE program participants and their larger communities. We are using multilevel modeling to examine mediators and moderators of the effects of SAFE on HIV outcomes at the individual and community levels and determine the ways in which changes in HIV outcomes feed back into economic outcomes and food security at later interviews. Finally, we are conducting a qualitative end-of-program evaluation consisting of in-depth interviews with 90 SAFE participants. DISCUSSION: In addition to examining pathways linking structural factors to HIV vulnerability, this research will yield important information for understanding the impact of a multilevel environmental/structural intervention on HIV, with the potential for other sustainable long-term public health benefits.

Community-Based Pharmacists' Needs for HIV-Related Training and Experience.

OBJECTIVE: To examine pharmacists' self-reported competence in providing care to persons living with HIV (PLWH) and their HIV-related training and experience needs. METHODS: We interviewed 28 community-based pharmacists providing care to PLWH in 4 Midwestern cities. RESULTS: Less than half (46%) of the pharmacists considered themselves competent to provide PLWH care, and less than a third (29%) worked with PLWH during their pharmacy residency. Specialty pharmacists need training on opportunistic infections and HIV-related comorbidities, nonspecialty pharmacists need general training in HIV treatment and patient communications skills, and all pharmacists require a mechanism to keep updated in the latest HIV treatment recommendations. CONCLUSION: In the current era of patient-centered care, a pharmacist that is well rounded-not just in dispensing antiretroviral medications but highly knowledgeable in different aspects of ART and HIV-specific patient care-can make a valuable contribution to the health care team. Pharmacy school curricula and continuing professional education need to be aligned to meet the knowledge and competency needs of community pharmacists who are strategically positioned to provide care to PLWH.

Missed Opportunities for Early HIV diagnosis: Critical Insights from Stories of Kenyan Women Living with HIV.

Early HIV testing is critical to prevention and timely treatment. Missed opportunities for HIV diagnosis can result in unnecessary deaths at a time when access to antiretroviral treatment proves life saving. While HIV prevention and treatment research has increased, less research exists on women's experiences with HIV diagnosis, despite the fact that women are most affected. Insights from local women are critical in designing culturally meaningful interventions that thwart missed opportunities for early HIV diagnosis. The purpose of our study was to uncover steps women took to know their HIV diagnosis. Using narrative inquiry methodology informed by post-colonial feminism, we interviewed 40 HIV- positive women in Kenya. Five themes emerged related to uptake of HIV testing for women: (a) spouse's critical illness or death; (b) years of suffering from HIV-related symptoms; (c) sick children; (d) prenatal testing; and (e) personal desire to know one's HIV status. These findings centered on women experiences provide an important basis for health promotion interventions related to HIV prevention, earlier detection, and treatment.

The innovative and collective capacity of low-income East African women in the era of HIV/AIDS: contesting western notions of African Women.

Historically, African women have been viewed through a colonizing and Eurocentric lens emphasizing poverty, oppression, and suffering. A postcolonial, feminist approach to our two qualitative studies with human immunodeficiency virus (HIV)-infected women in Malawi and Kenya led us to depart from this discourse, highlighting women's capacity. Through this article, not only is a forum created for African women's voices to be heard as subaltern knowledge leading to transformational change, but also health care providers are made aware, through women's words, of how they might capitalize on grassroots women's movements, particularly in resource-poor communities, to implement effective HIV prevention and treatment strategies.

Marriage as a risk factor for HIV: learning from the experiences of HIV-infected women in Malawi.

The gender inequalities that characterise intimate partner relationships in Malawi, a country with one of the highest HIV prevalence rates in the world, arguably place marriage as an important risk factor for HIV infection among women, yet few studies detail the complex interactions of marriage and risk. In order to develop HIV-prevention interventions that have lasting impacts in such communities, we need a deeper understanding of the intricacies of women's lives, how and why they are involved in marital relationships, and the implications of these relationships for HIV transmission or prevention. This article describes how women understand marriage's effects on their lives and their HIV risks. Drawing from focus group discussions with 72 women attending antiretroviral clinics in Malawi, we explore why women enter marriage, what women's experiences are within marriage and how they leave spouses for other relationships. Based on their narratives, we describe women's lives after separation, abandonment or widowhood, and report their reflections on marriage after being married two or three times. We then review women's narratives in light of published work on HIV, and provide recommendations that would minimise the risks of HIV attendant on marriage.

Is the US AIDS drug assistance program cost-effective?

Each year, the US AIDS drug assistance program (ADAP) provides access to prescription drugs-including antiretrovirals-to more than 110,000 persons living with HIV (PLWH) who lack adequate medical insurance. PLWH on effective antiretroviral therapy live longer lives, with enhanced quality of life, and are less likely to transmit HIV to others. There are thus significant benefits associated with the ADAP program. But there also are substantial costs. A mathematical model was used to assess the cost-effectiveness of the US ADAP program. Findings indicate that by providing antiretrovirals to underinsured persons, the ADAP program prevented 3,191 secondary infections and saved 24,922 quality-adjusted life years in 2008. The net cost per quality-adjusted life year saved was $11,955, which suggests that the ADAP program is cost-effective by conventional standards.

Perceptions of the character of God as narrated by East African women living with HIV.

Two qualitative research studies conducted with women living with HIV in Malawi (N = 72) and Kenya (N = 54) separately revealed personal faith as a primary coping mechanism that mitigates the effects of stigma and promotes spiritual, physical, and mental health. Fourth characteristics of God emerged that sustain the women in daily life.

Multiple drug cost containment policies in Michigan's Medicaid program saved money overall, although some increased costs.

Michigan's Medicaid program implemented four cost containment policies--preferred drug lists, joint and multistate purchasing arrangements, and maximum allowable cost--during 2002-04. The goal was to control growth of drug spending for beneficiaries who were enrolled in both Medicaid and Medicare and taking antihypertensive or antihyperlipidemic prescription drugs. We analyzed the impact of each policy while holding the effect of all other policies constant. Preferred drug lists increased both preferred and generic drugs' market share and reduced daily cost--the cost per day for each prescription provided to a beneficiary. In contrast, the maximum allowable cost policy increased daily cost and was the only policy that did not generate cost savings. The joint and multistate arrangements did not affect daily cost. Despite these policy trade-offs, the cumulative effect was a 10 percent decrease in daily cost and a total cost savings of $46,195 per year. Our findings suggest that policy makers need to evaluate the impact of multiple policies aimed at restraining drug spending, and further evaluate the policy trade-offs, to ensure that scarce public dollars achieve the greatest return for money spent.

A patient-centered pharmacy services model of HIV patient care in community pharmacy settings: a theoretical and empirical framework.

Reflecting trends in health care delivery, pharmacy practice has shifted from a drug-specific to a patient-centered model of care, aimed at improving the quality of patient care and reducing health care costs. In this article, we outline a theoretical model of patient-centered pharmacy services (PCPS), based on in-depth, qualitative interviews with a purposive sample of 28 pharmacists providing care to HIV-infected patients in specialty, semispecialty, and nonspecialty pharmacy settings. Data analysis was an interactive process informed by pharmacists' interviews and a review of the general literature on patient centered care, including Medication Therapy Management (MTM) services. Our main finding was that the current models of pharmacy services, including MTM, do not capture the range of pharmacy services in excess of mandated drug dispensing services. In this article, we propose a theoretical PCPS model that reflects the actual services pharmacists provide. The model includes five elements: (1) addressing patients as whole, contextualized persons; (2) customizing interventions to unique patient circumstances; (3) empowering patients to take responsibility for their own health care; (4) collaborating with clinical and nonclinical providers to address patient needs; and (5) developing sustained relationships with patients. The overarching goal of PCPS is to empower patients' to take responsibility for their own health care and self-manage their HIV-infection. Our findings provide the foundation for future studies regarding how widespread these practices are in diverse community settings, the validity of the proposed PCPS model, the potential for standardizing pharmacist practices, and the feasibility of a PCPS framework to reimburse pharmacists services.

Pharmacists' strategies for promoting medication adherence among patients with HIV.

OBJECTIVES: To provide pharmacists' perspectives on medication adherence barriers for patients with human immunodeficiency virus (HIV) and to describe pharmacists' strategies for promoting adherence to antiretroviral medications. DESIGN: Multisite, qualitative, descriptive study. SETTING: Four midwestern U. S. states, from August through October 2009. PARTICIPANTS: 19 pharmacists at 10 pharmacies providing services to patients with HIV. INTERVENTION: Pharmacists were interviewed using a semistructured interview guide. MAIN OUTCOME MEASURES: Barriers to medication adherence, pharmacist interventions, challenges to promoting adherence. RESULTS: Pharmacists reported a range of adherence barriers that were patient specific (e.g., cognitive factors, lack of social support), therapy related (e.g., adverse effects, intolerable medications), and structural level (e.g., strained provider relationships). They used a combination of individually tailored, patient-specific interventions that identified and resolved adherence barriers and actively anticipated and addressed potential adherence barriers. Pharmacist interventions included medication-specific education to enhance patient self-efficacy, follow-up calls to monitor adherence, practical and social support to motivate adherence, and patient referrals to other health care providers. However, the pharmacists faced internal (e.g., lack of time, lack of trained personnel) and external (e.g., insurance policies that disallowed patient enrollment in automatic prescription refill program) challenges. CONCLUSION: Pharmacists in community settings went beyond prescription drug counseling mandated by law to provide additional pharmacy services that were tailored to the needs of patients with HIV. Given that many individuals with HIV are living longer, more research is needed on the effectiveness and cost effectiveness of pharmacists' interventions in clinical practice, in order to inform insurance reimbursement policies.