Conditions of successful treatment referral practices with justice-involved youth: Qualitative insights from probation and service provider staff involved in JJ-TRIALS.

INTRODUCTION: Compared to the general U.S. adolescent population, young people involved in the juvenile justice system are at greater risk of experiencing substance use (SU) issues. There are critical opportunities across the juvenile justice continuum, at points of interface with community-based treatment services, to screen and assess for SU issues, identify unmet treatment needs, and refer those in need to treatment. The treatment referral process is, however, complex, and contingent on a seamless nexus between juvenile justice operations and the wider treatment provider landscape. Given the lack of successful SU referrals among justice-involved youth and the variable referral rates across jurisdictions, this study's aim is to provide a qualitative, explanatory understanding of the conditions that together contribute to successful referring practices. METHODS: The study is based on an analysis of a qualitative dataset comprising focus group data with probation and community-based behavioral health treatment staff working in 31 sites in 6 different states as part of the clustered randomized trial of an organizational change intervention known as JJ-TRIALS (Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System). The data contain respondents' narratives on the achievements, successes, and challenges with implementing the intervention. The data were analyzed through a combination of strategies to identify the conditions that both facilitate and impede referral processes between probation offices and community-based SU treatment providers. RESULTS: Participants across sites discussed the positive impacts that the JJ-TRIALS intervention had on their improved ability to communicate, collaborate, and collect data. From the interviews, seven main conditions were observed to contribute to successful SU treatment referral practices: (1) communication (inter-organizational); (2) collaboration; (3) data-driven practices; (4) family engagement; (5) institutionalized policy and referral documentation; (6) efficient referral policies and procedures; and (7) suitable and accessible system of treatment providers. CONCLUSION: Findings highlight the value of a holistic understanding of successful treatment referrals for justice-involved youth and help inform research and practice efforts to identify and measure the many dimensions of referral-making at the interface of juvenile probation and behavioral health services.

A mixed methods evaluation of family-driven care implementation in juvenile justice agencies in Georgia.

BACKGROUND: Improving family engagement in juvenile justice (JJ) system behavioral health services is a high priority for JJ systems, reform organizations, and family advocacy groups across the United States. Family-driven care (FDC) is a family engagement framework used by youth-serving systems to elevate family voice and decision-making power at all levels of the organization. Key domains of a family-driven system of care include: 1) identifying and involving families in all processes, 2) informing families with accurate, understandable, and transparent information, 3) collaborating with families to make decisions and plan treatments, 4) responding to family diversity and inclusion, 5) partnering with families to make organizational decisions and policy changes, 6) providing opportunities for family peer support, 7) providing logistical support to help families overcome barriers to participation, and 8) addressing family health and functioning. FDC enhances family participation, empowerment, and decision-making power in youth services; ultimately, improving youth and family behavioral health outcomes, enhancing family-child connectedness, and reducing youth recidivism in the JJ setting. METHODS: We evaluated staff-perceived adoption of the eight domains of FDC across detention and community services agencies in the state of Georgia. We collected mixed methods data involving surveys and in-depth qualitative interviews with JJ system administrators, staff, and practitioners between November 2021- July 2022. In total, 140 individuals from 61 unique JJ agencies participated in surveys; and 16 JJ key informants participated in qualitative interviews. RESULTS: FDC domains with the highest perceived adoption across agencies included identifying and involving families, informing families, collaborative decision-making and treatment planning, and family diversity and inclusion. Other domains that had mixed or lower perceived adoption included involving families in organizational feedback and policy making, family peer support, logistical support, and family health and functioning. Adoption of FDC domains differed across staff and organizational characteristics. CONCLUSIONS: Findings from this mixed methods assessment will inform strategic planning for the scale-up of FDC strategies across JJ agencies in the state, and serve as a template for assessing strengths and weaknesses in the application of family engagement practices in systems nationally.

Implementation of trauma-informed care and trauma-responsive services in clinical settings: a latent class regression analysis.

Introduction: Engagement and retention in health care is vital to sustained health among people living with HIV (PLWH), yet clinical environments can deter health-seeking behavior, particularly for survivors of interpersonal violence. PLWH face disproportionate rates of interpersonal violence; clinical interactions can provoke a re-experiencing of the sequalae of trauma from violence, called re-traumatization. Trauma-informed care (TIC) is a strengths-based approach to case that minimizes potential triggers of re-traumatization and promotes patient empowerment, increasing acceptability of care. Yet, Ryan White HIV/AIDS clinics, at which over 50% of PLWH received care, have struggled to IMPLEMENT TIC. In this analysis, we sought to (1) identify unique sub-groups of HIV clinics based on clinical attributes (i.e., resources, leadership, culture, climate, access to knowledge about trauma-informed care) and (2) assess relationships between sub-group membership and degree of implementation of TIC and trauma-responsive services offered. Methods: A total of 317 participants from 47 Ryan White Federally-funded HIV/AIDS clinics completed a quantitative survey between December 2019 and April 2020. Questions included assessment of inner setting constructs from the Consolidated Framework for Implementation Research (CFIR), perceived level of TIC implementation, and trauma-responsive services offered by each respondent's clinic. We employed latent class analysis to identify four sub-groups of clinics with unique inner setting profiles: Weak Inner Setting (n = 124, 39.1%), Siloed and Resource Scarce (n = 80, 25.2%), Low Communication (n = 49, 15.5%), and Robust Inner Robust (n = 64, 20.2%). We used multilevel regressions to predict degree of TIC implementation and provision of trauma-responsive services. Results: Results demonstrate that clinics can be distinctly classified by inner setting characteristics. Further, inner setting robustness is associated with a higher degree of TIC implementation, wherein classes with resources (Robust Inner Setting, Low Communication) are associated with significantly higher odds reporting early stages of implementation or active implementation compared to Weak class membership. Resourced class membership is also associated with availability of twice as many trauma-responsive services compared to Weak class membership. Discussion: Assessment of CFIR inner setting constructs may reveal modifiable implementation setting attributes key to implementing TIC and trauma-responsive services in clinical settings. Introduction.

Using qualitative comparative analysis to understand the conditions that produce successful PrEP implementation in family planning clinics.

BACKGROUND: Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention to U.S. women. However, PrEP has not been widely integrated into family planning services, especially in the Southern U.S., and data suggest there may be significant implementation challenges in this setting. METHODS: To understand contextual factors that are key to successful PrEP implementation in family planning clinics, we conducted in-depth qualitative interviews with key informants from 38 family planning clinics (11 clinics prescribed PrEP and 27 did not). Interviews were guided by constructs from the Consolidated Framework for Implementation Research (CFIR), and qualitative comparative analysis (QCA) was used to uncover the configurations of CFIR factors that led to PrEP implementation. RESULTS: We identified 3 distinct construct configurations, or pathways, that led to successful PrEP implementation: (1) high "Leadership Engagement" AND high "Available Resources"; OR (2) high "Leadership Engagement" AND NOT located in the Southeast region; OR (3) high "Access to Knowledge and Information" AND NOT located in the Southeast region. Additionally, there were 2 solution paths that led to absence of PrEP implementation: (1) low "Access to Knowledge and Information" AND low "Leadership Engagement"; OR (2) low "Available Resources" AND high "External Partnerships". DISCUSSION: We identified the most salient combinations of co-occurring organizational barriers or facilitators associated with PrEP implementation across Title X clinics in the Southern U.S. We discuss implementation strategies to promote pathways that led to implementation success, as well as strategies to overcome pathways to implementation failure. Notably, we identified regional differences in the pathways that led to PrEP implementation, with Southeastern clinics facing the most obstacles to implementation, specifically substantial resource constraints. Identifying implementation pathways is an important first step for packaging multiple implementation strategies that could be employed by state-level Title X grantees to help scale up PrEP.

The Importance of Anti-Racism in Trauma-Informed Family Engagement.

Students of color are disproportionately affected by exposure to adverse childhood experiences (ACEs), racial trauma, and traumatic stress. Trauma-informed interventions in schools can promote healing among ACE-impacted students of color. These interventions require collaboration with family members to decide upon services and referrals; however, educators commonly face challenges with engaging families. The study purpose is to understand barriers and facilitators to engaging families in trauma-informed mental health interventions for ACE-impacted students of color. As part of a larger school-based trauma-informed trial (Link for Equity), 6 focus groups were conducted with parents/guardians of color and school staff (n = 39) across 3 Midwestern school districts. Participants were asked open-ended questions about trauma, discrimination, school supports, and family engagement. Transcripts were coded by two team members, and thematic analysis was used to identify barriers/facilitators to family involvement. Results indicated that families of ACE-impacted students of color commonly experienced racism including microaggressions and stereotypes from the school community, which deterred engagement and prevented trusting relationships between families and school staff. Parents highlighted feeling excluded from decisions related to their child's education and that their voices were not heard or understood. Participants discussed the need for schools to consider how family obstacles (such as mental health and trauma) may prevent families from engaging with staff, and they recommended structural changes, such as anti-racism trainings for educators. Findings highlight the need for anti-racist work that addresses interpersonal and structural racism in schools, in order to promote family engagement in trauma-informed mental health interventions.

The Impact of Religious Participation and Religious Upbringing on the Sexual Behavior of Emerging Adults in the Southern United States.

Emerging adults face a disproportionate burden of unintended pregnancies and sexually transmitted diseases, especially in the southern United States. This study investigates how multiple dimensions of current religiosity as well as religious upbringing influence the sexual behaviors, including contraceptive usage, of individuals 18-25 years old (n=211) in the South. Based on regression analyses, results suggest that emerging adults with higher levels of current religiosity are more likely to remain abstinent, but less likely to use pregnancy prevention methods, such as birth controls pills and long-acting reversible contraceptives. Having a religious upbringing is also associated with lower contraceptive usage. Through the assessment of multiple dimensions of religiosity and various sexual behaviors, this study presents a nuanced picture of the complex associations between religion and sexual health, specifically among emerging adults in the southern United States.

Exploring the heterogeneity of factors that may influence implementation of PrEP in family planning clinics: a latent profile analysis.

BACKGROUND: Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention. However, PrEP has not been widely integrated into family planning services, especially in the Southern US, and data suggest there may be significant implementation challenges in this setting. Because Title X clinics vary greatly in provider-, organizational-, and systems-level characteristics, there is likely variation in capacity to implement PrEP across clinics. METHODS: We conducted a survey from February to June 2018 among providers and administrators of non-PrEP-providing Title X-funded clinics across 18 southern states. Survey items were designed using the Consolidated Framework for Implementation Research (CFIR) to assess constructs relevant to PrEP implementation. To explore the heterogeneity of CFIR-related implementation determinants and identify distinct sub-groups of Title X clinics, a latent profile analysis was conducted using nine CFIR constructs: complexity, relative advantage, cost, attitudes, implementation climate, compatibility, leadership engagement, available resources, and cosmopolitanism. We then conducted a multi-level analysis (accounting for nesting of participants within clinics) to test whether group membership was associated with readiness for implementation of PrEP, controlling for key sociodemographic characteristics. RESULTS: Four hundred and fourteen healthcare providers/administrators from 227 non-PrEP-providing Title X clinics participated in the study. We identified six sub-groups of clinics that each had distinct patterns of PrEP implementation determinants. Clinic sub-groups included "Highest Capacity for Implementation", "Favorable Conditions for Implementation", "Mixed Implementation Context", "Neutral Implementation Context", "Incompatible Setting for Implementation", and "Resource-Strained Setting". Group membership was related to numerous provider-level (i.e., ability to prescribe medication) and clinic-level (i.e., provision of primary care) characteristics. In comparison to the "Neutral" group (which held neutral perceptions across the implementation determinants), the "Highest Capacity" and "Favorable Conditions" groups had significantly higher levels of implementation readiness, and the "Resource-Strained" group had a significantly lower level of implementation readiness. CONCLUSIONS: Latent profile analyses can help researchers understand how implementation readiness varies across healthcare settings, promoting tailoring of implementation strategies to unique contexts.

Application of the Consolidated Framework for Implementation Research to Facilitate Delivery of Trauma-Informed HIV Care.

Background: The high prevalence of trauma and its negative impact on health among people living with HIV underscore the need for adopting trauma-informed care (TIC), an evidence-based approach to address trauma and its physical and mental sequelae. However, virtually nothing is known about factors internal and external to the clinical environment that might influence adoption of TIC in HIV primary care clinics. Methods: We conducted a pre-implementation assessment consisting of in-depth interviews with 23 providers, staff, and administrators at a large urban HIV care center serving an un-/under-insured population in the southern United States. We used the Consolidated Framework for Implementation Research (CFIR) to guide qualitative coding to ascertain factors related to TIC adoption. Results: Inner setting factors perceived as impacting TIC adoption within HIV primary care included relative priority, compatibility, available resources, access to knowledge and information (ie, training), and networks and communications. Relevant outer setting factors included patient needs/resources and cosmopolitanism (ie, connections to external organizations). Overall, the HIV care center exhibited high priority and compatibility for TIC adoption but displayed a need for system strengthening with regard to available resources, training, communications, cosmopolitanism, and patient needs/resources. Conclusions: Through identification of CFIR inner and outer setting factors that might influence adoption of TIC within an HIV primary care clinic, our findings begin to fill key knowledge gaps in understanding barriers and facilitators for adopting TIC in HIV primary care settings and highlight implementation strategies that could be employed to support successful TIC implementation.

Primary Care and Pre-exposure Prophylaxis Services in Publicly Funded Family Planning Clinics in the Southern United States.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is underutilized by US women. Cost and resource concerns are barriers to PrEP delivery in settings that see men. Family planning clinics may be ideal PrEP delivery settings for women, but as they are not uniform in their clinical services, cost and resource concerns may vary. OBJECTIVE: We examined factors that influence perceptions of costs and resources related to PrEP delivery in Title X-funded family planning clinics in Southern states, which overlaps with high HIV-burden areas. DESIGN: We conducted a web-based survey among a convenience sample of clinicians and administrators of Title X clinics across 18 Southern states (DHHS regions III, IV, VI). We compared cost- and resource-related survey items and other clinic- and county-level variables between clinics by whether their clinics also provided other primary care services. We analyzed interviews for cost and resource themes. PARTICIPANTS: Title X clinic staff in the South. KEY RESULTS: Among 283 unique clinics, a greater proportion of clinics that also provided primary care currently provided PrEP compared with those that did not provide primary care (27.8% vs. 18.3%, p = 0.06), but this difference was not statistically significant. Among 414 respondents in clinics that were not providing PrEP, those in clinics with primary care services were more likely to respond that they had the necessary financial resources (p < 0.01) and staffing (p < 0.01) for PrEP implementation compared to those without primary care services. In interviews, respondents differed on concerns about costs of labs and staffing based on whether their clinic had concomitant primary care services or not. CONCLUSIONS: Among publicly funded Southern family planning clinics, current PrEP provision was higher among clinics with concomitant primary care. Among clinics not providing PrEP, those with concomitant primary care services have lower perceived cost and resource barriers and therefore may be optimal for expanding PrEP among women.

Barriers and facilitators to implementation of trauma support services at a large HIV treatment center in the Southern United States.

The high prevalence of trauma among people living with HIV underscore the need for tailored, integrated trauma management ("trauma-informed care" or TIC) to improve retention, adherence to care, and overall well-being. Although TIC has been identified as a priority area for HIV care, uptake has been limited. To investigate barriers and facilitators to integrating trauma support services within HIV primary care, surveys (n=94) and interviews (n=44) were administered to providers, staff, and patients at a large HIV treatment center. Results highlighted the availability of several trauma services, including psychotherapy and support groups, but also revealed the absence of provider training on how to respond to patient trauma needs. Identified gaps in TIC services included written safety and crisis prevention plans, patient education on traumatic stressors, and opportunities for creative expression. Providers and staff supported implementation of trauma support services and employee trainings, but expressed a number of concerns including resource and skill deficiencies. Patient-reported barriers to TIC services included lack of awareness of services and difficulties navigating the healthcare system. This assessment revealed support and methods for strengthening integration of trauma support services within HIV primary care, which future TIC implementation efforts should address.

Models of HIV Pre-Exposure Prophylaxis Care Used in Title X Family Planning Clinics in the Southern U.S.

PURPOSE: HIV pre-exposure prophylaxis (PrEP) is underutilized by adolescent and young adult women, especially in the Southern U.S. Family planning (FP) clinics are potentially ideal PrEP delivery sites for adolescent and young adult women, but little is known about their PrEP services. We describe models of PrEP care in Title X FP clinics in the South and explore clinic resources that are needed to facilitate PrEP provision. METHODS: Providers and administrators from 38 clinics participated in qualitative interviews. We assessed five steps of PrEP care: (1) HIV risk assessment; (2) PrEP education; (3) laboratory testing; (4) PrEP prescription; and (5) PrEP monitoring. RESULTS: Among 38 clinics, 23 conducted at least one step and were classified into three models. Model 1 (n = 8) and Model 2 (n = 4) clinics provided up to Steps 1 and 2, respectively, but referred to an external PrEP provider. Model 3 clinics (n = 11) conducted all steps. Few barriers were identified for Step 1; using an HIV risk assessment tool was a key facilitator. PrEP educational materials facilitated Step 2; clinics not providing education believed they could easily do so with training and educational resources. Funding- and staff-related resource barriers were noted for Steps 3-5, including costs of laboratory tests and lack of time for longitudinal visits. CONCLUSIONS: PrEP-providing publicly funded FP clinics in the Southern U.S. use referral services for many steps of PrEP care, which introduce patient burden. Increasing onsite PrEP services will require addressing concerns related to training, educational materials, cost, and staffing.

Bridging Systems to Implement HIV/STI Programming Within the Juvenile Justice System: Strengths and Challenges of a Local Change Team Approach.

Justice-involved youth are at risk for HIV/STIs but do not access services. The complex challenges of improving the delivery of health-related services within juvenile justice (JJ) settings warrant exploration of strategies to close this service gap. This study describes the successes and challenges of utilizing a local change team (LCT) strategy comprising JJ and health agency staff to implement HIV/STI programming in JJ settings, across six counties in six states in the U.S. Five focus groups comprising n = 28 JJ and health agency staff who served as LCT members were conducted. Results demonstrated the structured nature of the collaborative process and strength of commitment among LCT members were necessary for successful implementation of HIV/STI programming. The use of LCTs comprising membership of JJ and (behavioral) health systems has broader applicability to other health and behavioral health issues faced by youth on probation that JJ staff may feel ill equipped to address.

Building a Contextually-Relevant Understanding of Resilience among African American Youth Exposed to Community Violence.

Studies consistently demonstrate that African American youth experience disproportionate levels of community violence, which is associated with negative health and well-being outcomes among these youth. The frequency and severity of community violence exposure is a unique challenge for these youth and requires tailored approaches to promote resilience after community violence exposure. However, limited research exists that operationalizes resilience after community violence based on the unique context and lived experience of African American youth. Developing a more contextually relevant understanding of resilience is critical to reducing health inequities experienced by African American youth and promoting their well-being. Five focus groups were conducted with 39 African American adolescents (ages 13-18) exposed to community violence. Participants also completed a brief survey that included questions on demographics, adverse childhood experiences, social capital, and resilience. Focus-group transcripts were independently coded by two members of the research team and analyzed using an inductive approach. Youth highlighted key indicators of resilience including the ability to persevere, self-regulate, and change to adapt/improve. Youth also described family, peer, and cultural contexts that impact how resilience is produced and manifested, highlighting trust, perceived burdensomeness, self-determination, connectedness, and mental health stigma as key factors within these contexts. Results of this qualitative study support the development of health promotion programs for African American youth exposed to community violence that address unique risks and build on existing protective factors within family, peer, and cultural contexts.

Distinguishing Children's Hospitals From Non-Children's Hospitals in Large Claims Data.

BACKGROUND: The first methodologic step needed to compare pediatric health outcomes at children's hospitals (CHs) and non-children's hospitals (NCHs) is to classify hospitals into CH and NCH categories. However, there are currently no standardized or validated methods for classifying hospitals. The purpose of this study was to describe a novel and reproducible hospital classification methodology. METHODS: By using data from the 2015 American Hospital Association survey, 4464 hospitals were classified into 4 categories (tiers A-D) on the basis of self-reported presence of pediatric services. Tier A included hospitals that only provided care to children. Tier B included hospitals that had key pediatric services, including pediatric emergency departments, PICUs, and NICUs. Tier C included hospitals that provided limited pediatric services. Tier D hospitals provided no key pediatric services. Classifications were then validated by using publicly available data on hospital membership in various pediatric programs as well as Health Care Cost Institute claims data. RESULTS: Fifty-one hospitals were classified as tier A, 228 as tier B, 1721 as tier C, and 1728 as tier D. The majority of tier A hospitals were members of the Children's Hospital Association, Children's Oncology Group, and National Surgical Quality Improvement Program-Pediatric. By using claims data, the percentage of admissions that were pediatric was highest in tier A (88.9%), followed by tiers B (10.9%), C (3.9%), and D (3.9%). CONCLUSIONS: Using American Hospital Association survey data is a feasible and valid method for classifying hospitals into CH and NCH categories by using a reproducible multitiered system.

Improving Substance Use Services for Juvenile Justice-Involved Youth: Complexity of Process Improvement Plans in a Large Scale Multi-site Study.

Despite the high prevalence of substance use disorders among juvenile offenders, most do not receive services. System-level process improvement plans to address unmet service needs can be optimized by combining data-driven decisions and facilitated meetings with behavioral health stakeholders. This paper operationalizes and analyzes the level of specified complexity among process improvement plans evident within 36 juvenile probation and drug courts across 7 states. To inform more effective implementation strategies, this analysis identifies and prioritizes promising courses of agency enhancement toward addressing unmet substance use needs.

Integrating program-tailored universal trauma screening into HIV care: an evidence-based participatory approach.

Trauma is prevalent among HIV-infected populations and associated with negative HIV care outcomes. While several agencies have called for integrating trauma-informed care into HIV services, uptake has been limited and effective methods have not been delineated. To develop comprehensive trauma screening strategies tailored to a large, urban HIV care center, we aimed to first understand provider and staff perceptions of the center's current level of trauma screening and barriers and facilitators to universal screening uptake. We used a mixed-methods convergent parallel design: quantitative assessments with 31 providers and staff and in-depth interviews with 19 providers and staff. Quantitative assessments highlighted center strengths (i.e. assessing effects of trauma, explaining care plans to patients, providing opportunities for questions) and gaps (i.e. asking about head injuries, emotional safety). Qualitative interviews suggested center screening practices were highly-variable and limited, identified gaps in interdepartmental communication regarding results of trauma screening that led to repeated screenings and potential patient re-traumatization, screening barriers (i.e. limited time, competing clinical priorities) and facilitators (i.e. provider-driven, standardized, non-disruptive screening with clear cut-points and follow-up steps). This study provides tangible strategies for the center to begin integrating universal trauma screening, many of which could be adapted by other U.S. HIV clinics.

Provider education decreases opioid prescribing after pediatric umbilical hernia repair.

PURPOSE: To improve opioid stewardship for umbilical hernia repair in children. METHODS: An educational intervention was conducted at 9 centers with 79 surgeons. The intervention highlighted the importance of opioid stewardship, demonstrated practice variation, provided prescribing guidelines, encouraged non-opioid analgesics, and encouraged limiting doses/strength if opioids were prescribed. Three to six months of pre-intervention and 3 months of post-intervention prescribing practices for umbilical hernia repair were compared. RESULTS: A total of 343 patients were identified in the pre-intervention cohort and 346 in the post-intervention cohort. The percent of patients receiving opioids at discharge decreased from 75.8% pre-intervention to 44.6% (p < 0.001) post-intervention. After adjusting for age, sex, umbilicoplasty, and hospital site, the odds ratio for opioid prescribing in the post- versus the pre-intervention period was 0.27 (95% CI = 0.18-0.39, p < 0.001). Among patients receiving opioids, the number of doses prescribed decreased after the intervention (adjusted mean 14.3 to 10.4, p < 0.001). However, the morphine equivalents/kg/dose did not significantly decrease (adjusted mean 0.14 to 0.13, p = 0.20). There were no differences in returns to emergency departments or hospital readmissions between the pre- and post-intervention cohorts. CONCLUSIONS: Opioid stewardship can be improved after pediatric umbilical hernia repair using a low-fidelity educational intervention. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Mitigating Negative Consequences Of Community Violence Exposure: Perspectives From African American Youth.

The burden of community violence on young African Americans includes disproportionate rates of physical and mental health consequences. To develop appropriate and sustainable interventions that mitigate the negative consequences after violence exposure, it is critical to incorporate the lived experiences and perspectives of African American youth. We conducted five focus groups that collectively included thirty-nine African American youth living in income-disadvantaged urban neighborhoods in Kansas City, Missouri, to examine their experiences and perceptions of community violence and identify priorities to reduce the negative consequences of community violence. Youth-identified priorities included increasing proactive responses from multiple community sectors; reducing racial discrimination; and creating safe environments, including access to mental health care and other supportive services. Incorporating these findings into current policy and cross-sector initiatives offers a promising opportunity to improve the health and well-being of African American youth exposed to community violence.

Low provider and staff self-care in a large safety-net HIV clinic in the Southern United States: Implications for the adoption of trauma-informed care.

OBJECTIVE: This mixed-methods needs assessment study examined self-care practices among providers, staff, and administrators at an HIV clinic and identified barriers and facilitators to strengthening self-care services in this setting. METHODS: Surveys (n = 31) and qualitative interviews (n = 23) were conducted with staff, providers, and administrators at a large, safety-net HIV clinic. RESULTS: Surveys indicated an overall absence of formal self-care services including resources to manage stress, opportunities to debrief, and formal mechanisms to voice concerns. Based on interviews with staff and providers, deficiencies in self-care services included support for dealing with complex patients, formal mechanisms for feedback, and time for self-care. Administrators recognized the need for more support, acknowledged that opportunities for employees to voice concerns were lacking, and felt that implementing multi-disciplinary team meetings could improve morale and reduce stress and burnout. CONCLUSION: This assessment revealed a need to enhance self-care in safety-net HIV services. Adoption of trauma-informed care, which includes activities to strengthen self-care, could reduce workplace burnout.

A survey of pediatric surgeons' practices with enhanced recovery after children's surgery.

PURPOSE: Enhanced Recovery After Surgery (ERAS) protocols have been shown to improve outcomes in adult abdominal surgical populations. Our purpose was to survey pediatric surgeons' opinions regarding applicability of individual ERAS elements to children's surgery. METHODS: A survey of the American Pediatric Surgical Association was conducted electronically. Using a 5-point Likert scale, respondents rated their willingness to implement 21 adult ERAS elements in an adolescent undergoing elective colorectal surgery. RESULTS: Of an estimated 1052 members, 257 completed the survey (24%). The majority of the respondents (n=175, 68.4%) rated their familiarity with ERAS as "moderately", "very", or "extremely familiar". However only 19.2% (n=49) replied that they were "already implementing" an ERAS protocol in their practice. Most respondents replied that they were "already doing" or "definitely willing" to implement 14 of the 21 (67%) ERAS elements. For the remaining 7 elements, >10% of surgeons answered that they were only "somewhat willing" to, "uncertain" about or "unwilling" to implement these interventions. CONCLUSIONS: Most respondents were willing to implement the majority of adult ERAS concepts in children undergoing abdominal surgery. However, we identified 7 elements that remain contentious. Further investigation regarding the safety and feasibility of these elements is warranted before applying them to children's surgery. LEVEL OF EVIDENCE: Level V.