"Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs.

BACKGROUND: The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs. OBJECTIVE: The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis. DESIGN: Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns. PARTICIPANTS: We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island. APPROACH: Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels. KEY RESULTS: Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction. CONCLUSIONS: Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.

Provider Experience Recommending HPV Vaccination Before Age 11 Years.

OBJECTIVES: To describe health care providers' experiences recommending human papillomavirus (HPV) vaccination before age 11 years as part of a multisession intervention to improve HPV vaccination coverage. STUDY DESIGN: Between 2016 and 2018, we conducted 30-minute qualitative interviews with intervention participants approximately 1 month after intervention completion. Interviews explored participants' experiences with new strategies, including changing the age of routine recommendation. Thematic analysis of interview transcripts involved both deductive and inductive approaches. RESULTS: Twenty-six participants at 5 clinical sites were interviewed. Most were female (88%) primary care providers (46%), and worked 1.5-3.0 clinical days weekly. Many providers described initial skepticism about recommending vaccination before age 11 years, fearing that removing the HPV vaccine from the adolescent bundle with tetanus and meningitis vaccines would decrease parental acceptance. However, providers uniformly reported high parental acceptance owing to reduced stigma relating to sexual activity and the opportunity to administer fewer shots at each visit. Providers also noted that initiating vaccination earlier increased opportunities to complete the series and decreased the need for resource-intensive vaccine recall programs. CONCLUSIONS: Providers had positive experiences recommending HPV vaccination before age 11 years. Routine recommendation before age 11 years may offer advantages related to fewer shots per visit, fewer missed opportunities, and reduction of parental concerns related to sexual activity.

HIV Pre-exposure Prophylaxis for People Who Inject Drugs: The Context of Co-occurring Injection- and Sexual-Related HIV Risk in the U.S. Northeast.

Background: People who inject drugs (PWID) are at increased risk for HIV infection through sharing contaminated needles and injection equipment, and engaging in condomless sex. Objectives: To qualitatively examine the overlapping nature of these behaviors among PWID in the US Northeast. Methods: We recruited HIV-uninfected PWID and key informants through community-based organizations. Qualitative interviews explored sexual partnerships as they related to sharing contaminated needles and injection equipment, engaging in condomless sex, and associated indications for PrEP among PWID. Results: Among 33 PWID, 66% engaged in condomless vaginal or anal sex in the past 3 months, and 27% had three or more sexual partners in this same time period. Over half engaged in any past month distributive or receptive syringe sharing (64%). We identified three contexts through which overlapping sexual and injection-related HIV risks emerged, including (1) multiple concurrent sexual partnerships; (2) using and injecting drugs with sexual partners (including increase injecting of crystal methamphetamine); and (3) exchanging sex for money or drugs (including among male PWID). Condom use was inconsistent across these contexts. Limited interactions with healthcare providers often resulted in sexual risks being overlooked in light of competing health concerns. Conclusions: Sexual risk for HIV acquisition is complex and multi-faceted among PWID yet may be overlooked by prevention and healthcare providers. Comprehensive HIV prevention efforts must acknowledge the distinct contexts in which overlapping injection and sexual risk behaviors occur. Increased sexual health screening and risk reduction services including PrEP for PWID may help curtail transmission in this population.

Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions.

BACKGROUND: People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). However, PrEP has been underutilized in this population, and PrEP adherence intervention needs are understudied. METHODS: To inform PrEP intervention development, we reviewed evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID. Guided by a behavioral model of healthcare utilization and using the PICOS framework, we conducted a systematic review in four electronic databases to identify original research studies of ART adherence in HIV-infected PWID in the United States and Canada between Jan 1, 2006-Dec 31, 2016. We synthesized and interpreted findings related to developing recommendations for PrEP adherence interventions for PWID. RESULTS: After excluding 618 duplicates and screening 1049 unique records, we retained 20 studies of PWID (mean n = 465) with adherence-related outcomes (via pharmacy records: n = 9; self-report: n = 8; biological markers: n = 5; electronic monitoring: n = 2). Predisposing factors (patient-level barriers to adherence) included younger age, female sex, and structural vulnerability (e.g., incarceration, homelessness). Enabling resources (i.e., facilitators) that could be leveraged or promoted by interventions included self-efficacy, substance use treatment, and high-quality patient-provider relationships. Competing needs that require specific intervention strategies or adaptations included markers of poor physical health, mental health comorbidities (e.g., depression), and engagement in transactional sex. CONCLUSIONS: HIV treatment adherence research carries important lessons for efforts to optimize PrEP adherence among PWID. Despite limitations, this systematic review suggests that strategies are needed to engage highly vulnerable and marginalized sub-groups of this underserved population (e.g., younger PWID, women who inject drugs) in PrEP adherence-related research and programming.

"We don't get much of a voice about anything": perspectives on photovoice among people who inject drugs.

BACKGROUND: In the context of the current US opioid crisis, people who inject drugs (PWID) are increasingly researched, but their ability to tell their own stories may be limited. Photovoice is a participatory action research method that allows participants to use photography to directly depict their experiences. METHODS: We conducted interviews with PWID (n = 33) as part of a qualitative study on the health needs of PWID in the USA to explore interest and acceptability of photovoice as a potential research method and way to share their voices. RESULTS: Participants identified facilitators and barriers to participating in a future photovoice project. Facilitators included a chance to depict one's unique experience, help others in need by sharing one's own story, and photography being a more "comfortable" way to tell their stories than traditional research methods. Barriers included safety concerns, embarrassment, and ability to retain cameras. Participants also identified areas of sensitivity related to documenting drug use. CONCLUSIONS: While we found broad acceptability of photovoice, barriers would need to be addressed and additional training and support for research staff and potential participants related to the ethics of public photography and engaging PWID in photovoice research would be required.

Evidence-based and guideline-concurrent responses to narratives deferring HCV treatment among people who inject drugs.

BACKGROUND: Hepatitis C virus (HCV) infection is increasingly prevalent among people who inject drugs (PWID) in the context of the current US opioid crisis. Although curative therapy is available and recommended as a public health strategy, few PWID have been treated. We explore PWID narratives that explain why they have not sought HCV treatment or decided against starting it. We then compare these narratives to evidence-based and guideline-concordant information to better enable health, social service, harm reduction providers, PWID, and other stakeholders to dispel misconceptions and improve HCV treatment uptake in this vulnerable population. METHODS: We recruited HIV-uninfected PWID (n = 33) through community-based organizations (CBOs) to participate in semi-structured, in-depth qualitative interviews on topics related to overall health, access to care, and knowledge and interest in specific HIV prevention methods. RESULTS: In interviews, HCV transmission and delaying or forgoing HCV treatment emerged as important themes. We identified three predominant narratives relating to delaying or deferring HCV treatment among PWID: (1) lacking concern about HCV being serious or urgent enough to require treatment, (2) recognizing the importance of treatment but nevertheless deciding to delay treatment, and (3) perceiving that clinicians and insurance companies recommend that patients who currently use or inject drugs should delay treatment. CONCLUSIONS: Our findings highlight persistent beliefs among PWID that hinder HCV treatment utilization. Given the strong evidence that treatment improves individual health regardless of substance use status while also decreasing HCV transmission in the population, efforts are urgently needed to counter the predominant narratives identified in our study. We provide evidence-based, guideline-adherent information that counters the identified narratives in order to help individuals working with PWID to motivate and facilitate treatment access and uptake. An important strategy to improve HCV treatment initiation among PWID could involve disseminating guideline-concordant counternarratives to PWID and the providers who work with and are trusted by this population.

Interventions to increase appointment attendance in safety net health centers: A systematic review and meta-analysis.

RATIONALE, AIMS AND OBJECTIVES: Missed appointments are a persistent problem across healthcare settings, and result in negative outcomes for providers and patients. We aimed to review and evaluate the effectiveness of interventions designed to reduce missed appointments in safety net settings. METHODS: We conducted a systematic review of interventions reported in three electronic databases. Data extraction and quality assessment were conducted according to PRISMA guidelines. Eligible studies were analyzed qualitatively to describe intervention types. A random effects model was used to measure the pooled relative risk of appointment adherence across interventions in the meta-analysis. RESULTS: Thirty-four studies met inclusion criteria for the qualitative synthesis, and 21 studies reported sufficient outcome data for inclusion in the meta-analysis. Qualitative analysis classified nine types of interventions used to increase attendance; however, application of each intervention type varied widely between studies. Across all study types (N = 12 000), RR was 1.08, (95% CI 1.03, 1.13) for any intervention used to increase appointment attendance. No single intervention was clearly effective: facilitated appointment scheduling [RR = 3.31 (95% CI: 0.30, 37.13)], financial incentives [RR = 1.88 (0.73, 4.82)] case management/patient navigator [RR = 1.09, (0.96, 1.24)], text messages [RR = 1.02 (0.96, 1.08)], transportation, [RR = 1.05 (0.98, 1.13)], telephone reminder calls [RR 1.12, (0.87, 1.45)], in-person referrals, [RR = 1.01 (0.90, 1.13)], patient contracts [RR = 0.87 (0.52, 1.46)] or combined strategies, [RR = 1.16 (1.03, 1.32)]. No strategy was clearly superior to others, p interaction = .50. CONCLUSIONS: Strategies to improve appointment adherence in safety net hospitals varied widely and were only modestly effective. Further research harmonizing intervention delivery within each strategy and comparing strategies with the most potential for success is needed.

Effect of provider recommendation style on the length of adolescent vaccine discussions.

OBJECTIVE: To determine whether providers' vaccine recommendation style affects length of the adolescent vaccine discussions. METHODS: We analyzed vaccine discussions using audio-recordings of clinical encounters where adolescents were eligible for HPV vaccines ± meningococcal vaccines. We measured length of vaccine discussions, the provider's use of an "indicated" (vaccination due at visit) or "elective" (vaccination is optional) recommendation style, and vaccine receipt. Parent and child demographics, parental vaccination intentions, and parental satisfaction with vaccine discussion were collected from pre- and post-visit surveys. We used linear and logit regressions with random effects to estimate recommendation style's association with discussion length and with vaccine receipt, respectively. RESULTS: We analyzed 106 vaccine discussions (82 HPV; 24 meningococcal) across 82 clinical encounters and 43 providers. Vaccine discussions were longer when providers presented vaccination as elective versus indicated (140 vs. 74 s; p-value < 0.001). Controlling for vaccine type, parental vaccination intent, and patient characteristics, an elective style was associated with 41 seconds longer vaccine discussion (p-value < 0.05). Providers used the indicated style more frequently with the meningococcal vaccine than with the HPV vaccine (96% vs. 72%; p-value < 0.05). Parents' odds of vaccinating were 9.3 times higher following an indicated versus an elective presentation (p-value < 0.05). Vaccine discussion length and presentation style were not associated with parental satisfaction. CONCLUSIONS: Our results suggest that using an indicated recommendation improves vaccine discussions' efficiency and effectiveness, but this style is used more often with meningococcal than HPV vaccines. Increasing providers' use of indicated styles for HPV vaccines has the potential to increase vaccination rates and save time during medical visits.

Provider and Practice Experience Integrating the Dose-HPV Intervention into Clinical Practice.

INTRODUCTION: Few studies have rigorously evaluated the drivers of successful implementation of interventions to improve human papillomavirus (HPV) vaccination rates. The aim of this study was to evaluate the implementation of Development of Systems and Education for HPV Vaccination (DOSE HPV), a performance improvement intervention. METHODS: Primary care providers (PCPs), nurses, and individuals with leadership roles from pediatric and family medicine practices who attended DOSE HPV intervention sessions participated in qualitative interviews immediately following intervention completion. The study team professionally transcribed interviews and performed qualitative coding using inductive methods. Final analysis employed the Promoting Action on Research implementation in Health Services (PARiHS) model. RESULTS: Twenty-six individuals participated: 12 PCPs, 5 nurses, and 9 individuals with dual leadership and PCP roles. Participants described five factors that they felt contributed to program success: (1) evidence-based, goal-directed education; (2) personalized data feedback; (3) clinical leadership support; (4) collaborative facilitation; (5) repeated contacts/longitudinal structure of the intervention. Barriers to implementing the intervention included: (1) inability to standardize workflow across practices; (2) low pediatric volume, (3) competing priorities/lack of incentives, (4) ineffective involvement of nurses, (5) poor communication between clinical leadership and staff. DISCUSSION: Although many HPV testing interventions have been implemented, findings have been mixed. It is clear that having an effective, evidence-based intervention by itself is not enough to get it into practice. Rather, it is crucial to consider implementation factors to ensure consistent implementation and sustainability. Key factors for the success of the DOSE HPV intervention appear to include a collaborative approach, provision of useful evidence to motivate behavior change, and repeated contacts to ensure accountability for implementing changes. Workflow issues, ineffective lines of communication, and competing priorities at both the visit and the patient and population management levels can hinder implementation.

Barriers and facilitators to implementing priority inpatient initiatives in the safety net setting.

BACKGROUND: Safety net hospitals, which serve vulnerable and underserved populations and often operate on smaller budgets than non-safety net hospitals, may experience unique implementation challenges. We sought to describe common barriers and facilitators that affect the implementation of improvement initiatives in a safety net hospital, and identify potentially transferable lessons to enhance implementation efforts in similar settings. METHODS: We interviewed leaders within five inpatient departments and asked them to identify the priority inpatient improvement initiative from the last year. We then conducted individual, semi-structured interviews with 25 stakeholders across the five settings. Interviewees included individuals serving in implementation oversight, champion, and frontline implementer roles. The Consolidated Framework for Implementation Research informed the discussion guide and a priori codes for directed content analysis. RESULTS: Despite pursuing diverse initiatives in different clinical departments, safety net hospital improvement stakeholders described common barriers and facilitators related to inner and outer setting dynamics, characteristics of individuals involved, and implementation processes. Implementation barriers included (1) limited staffing resources, (2) organizational recognition without financial investment, and (3) the use of implementation strategies that did not adequately address patients' biopsychosocial complexities. Facilitators included (1) implementation approaches that combined passive and active communication styles, (2) knowledge of patient needs and competitive pressure to perform well against non-SNHs, (3) stakeholders' personal commitment to reduce health inequities, and (4) the use of multidisciplinary task forces to drive implementation activities. CONCLUSION: Inner and outer setting dynamics, individual's characteristics, and process factors served as implementation barriers and facilitators within the safety net. Future work should seek to leverage findings from this study toward efforts to enact positive change within safety net hospitals.

HIV Pre-Exposure Prophylaxis for Conception Among HIV Serodiscordant Couples in the United States: A Cohort Study.

Practice guidelines on pre-exposure prophylaxis (PrEP) for HIV serodiscordant couples recommend PrEP when the viral load of the partner living with HIV is either detectable or unknown. However, adherence to combination antiretroviral therapy is inconsistent, and research has found that individuals vulnerable to HIV place value on additional protective barriers. We conducted a prospective cohort study to assess the feasibility, perceptions, and adherence associated with periconceptional PrEP use among females without HIV and their male partners living with HIV across four academic medical centers in the United States. We performed descriptive statistics, McNemar's test of marginal homogeneity to assess discordance in female/male survey responses, and Spearman's correlation to determine associations between dried blood spot levels and female self-reported adherence to PrEP. We enrolled 25 women without HIV and 24 men living with HIV (one male partner did not consent to the study). Women took PrEP for a median of 10.9 months (interquartile range 3.8-12.0) and were generally adherent. In total, 87% of women (20/23) had a dried blood spot with >700 fmol/punch or ≥4 doses/week, 4% (1/23) at 350-699 fmol/punch or 2-3 doses/week, and 9% (2/23) at <350 fmol/punch or <2 doses/week (correlation between drug levels and adherence is based on prior data). Dried blood spot levels closely aligned with self-reported adherence (Spearman's rho = 0.64, p = 0.001). There were 10 pregnancies among 8 participants, 4 of which resulted in spontaneous abortions. There was one preterm delivery (36 5/7 weeks), no congenital abnormalities, and no HIV transmissions. Ten couples (40%) were either lost to follow-up or ended the study early. Overall, women attempting conception with male partners living with HIV in the United States are interested and able to adhere to PrEP as an additional tool for safer conception.

Patterns, contexts, and motivations for polysubstance use among people who inject drugs in non-urban settings in the U.S. Northeast.

BACKGROUND: Polysubstance use (i.e., using ≥2 psychoactive substances concomitantly) is associated with increased morbidity and mortality and complicates drug treatment needs among people who inject drugs (PWID). We explored patterns, contexts, motivations, and perceived consequences of polysubstance use among PWID in small cities and towns in the U.S. Northeast. METHODS: Between October 2018 and March 2019, we conducted semi-structured interviews with 45 PWID living outside of the capital cities of Rhode Island and Massachusetts recruited online and through community-based organizations. Written transcripts were coded inductively and deductively using a team-based approach and analyzed thematically. RESULTS: All participants reported recent polysubstance use, with most using five or more classes of substances in the past three months. Polysubstance use often followed long personal drug use histories (i.e., years or decades of occasional drug use). Reasons for polysubstance use included obtaining synergistic psychoactive effects as a result of mixing drugs (i.e., using drugs to potentiate effects of other drugs) and managing undesirable effects of particular drugs (e.g., offsetting the depressant effects of opioids with stimulants or vice-versa). Polysubstance use to self-medicate poorly managed physical and mental health conditions (e.g., chronic pain, anxiety, and depression) was also reported. Inadequately managed cravings and withdrawal symptoms prompted concomitant use of heroin and medications for opioid use disorder, including among individuals reporting cocaine or crack as their primary "issue" drugs. Polysubstance use was perceived to increase overdose risks and to be a barrier to accessing healthcare and drug treatment services. CONCLUSION: Healthcare services and clinicians should acknowledge, assess, and account for polysubstance use among patients and promote harm reduction approaches for individuals who may be using multiple drugs. Comprehensive healthcare that meets the social, physical, mental health, and drug treatment needs of PWID may decrease the perceived need for polysubstance use to self-medicate poorly managed health conditions and symptoms.

Effect of a multi-component intervention on providers' HPV vaccine communication.

Objective: To evaluate the effect of a multi-component intervention including communication training on provider beliefs and recommendation practices around the human papillomavirus (HPV) vaccine using both self-reports and audio-recordings of clinical interactions. Methods: We conducted a mixed method study at five family medicine and pediatric practices. Providers self-reported beliefs and practices about HPV vaccination via surveys and qualitative interviews conducted pre- and post-intervention. We also assessed provider recommendation style using audio-recordings of clinical interactions pre- and post-intervention. Content analysis was used to identify themes in qualitative interviews. Matched pre- and post-intervention surveys were analyzed for changes in provider beliefs and attitudes. Pre- and post-intervention audio recordings of clinical interactions were analyzed for observed differences in recommendation styles. Bivariate analyses of quantitative data used Chi-square and Fisher's exact tests; t-tests were used for continuous variables. Results: Providers reported in interviews that the intervention led to communication changes by increasing their knowledge, reframing the HPV vaccine as a routine vaccination, and providing tools for engaging with parents. Surveys indicated that the proportion of providers reporting that the HPV vaccine is one of the most important adolescent vaccines increased from 71% pre-intervention to 100% post-intervention (p = .03). Audio-recording analysis demonstrated that use of an indicated (presumptive) recommendation style increased from 62.5% pre-intervention to 79.6% post-intervention (p = .047). Conclusions: Educating providers about HPV vaccination and giving them tools to facilitate communication with parents can reframe HPV as a routine adolescent vaccination and motivate providers to routinely use effective recommendation styles in practice.

Improving HPV Vaccination Rates: A Stepped-Wedge Randomized Trial.

OBJECTIVES: To evaluate the effectiveness of a stepped-wedge randomized trial of Development of Systems and Education for Human Papillomavirus Vaccination (DOSE HPV), a multilevel intervention. METHODS: DOSE HPV is a 7-session program that includes interprofessional provider education, communication training, data feedback, and tailored systems change. Five primary care pediatric and/or family medicine practices completed interventions between 2016 and 2018; all chose to initiate vaccination at ages 9 to 10. We compared vaccination rates in the preintervention, intervention, and postintervention periods among 9- to 17-year-olds using random-effects generalized linear regression models appropriate for stepped-wedge design, accounting for calendar time and clustering of patients by providers and clinic. Outcomes included (1) the likelihood that eligible patients would receive vaccination during clinic visits; (2) the likelihood that adolescents would complete the series by age 13; and (3) the cumulative effect on population-level vaccine initiation and completion rates. Postintervention periods ranged from 6 to 18 months. RESULTS: In the intervention and postintervention periods, the adjusted likelihood of vaccination at an eligible visit increased by >10 percentage points for ages 9 to 10 and 11 to 12, and completion of the vaccine series by age 13 increased by 4 percentage points (P < .001 for all comparisons). Population-level vaccine initiation coverage increased from 75% (preintervention) to 84% (intervention) to 90% (postintervention), and completion increased from 60% (preintervention) to 63% (intervention) to 69% (postintervention). CONCLUSIONS: Multilevel interventions that include provider education, data feedback, tailored systems changes, and early initiation of the human papillomavirus vaccine series may improve vaccine series initiation and completion beyond the conclusion of the intervention period.

Usability of Learning Moment: Features of an E-learning Tool That Maximize Adoption by Students.

INTRODUCTION: E-learning is widely used in medical education. To maximize the potential of E-learning tools, every effort should be made to encourage adoption by optimizing usability. We created Learning Moment (LM), a web-based application that integrates principles of asynchronous learning and learning portfolios into a platform on which students can document and share learning experiences that occur during clinical work. We sought to evaluate the usability of LM and identify features that optimize adoption by users. METHODS: We implemented LM in August 2016 at a busy, urban, tertiary care emergency department that hosts an emergency medicine residency, robust third and fourth year medical student clerkships as well as a physician assistant student rotation. We conducted a single-center, mix-methods study using the System Usability Scale (SUS) questionnaire and qualitative interviews. We sent e-mail invitations with subsequent reminders to all students who rotated in our emergency medicine clerkship from August 2016 to April 2017 to complete the SUS questionnaire anonymously and to participate in qualitative interviews. We employed purposive sampling to recruit students who used LM during their rotation to participate in our qualitative interviews. We conducted semi-structured interviews with 13 participants (10 individual interviews and one 3-person group interview) between January and March 2017 using an ethnographic approach and utilized a general inductive method to analyze and code for potential themes. RESULTS: Thirty of the seventy students invited to participate completed the SUS questionnaire (Response rate of 42.8%). The mean SUS score is 80.9 (SD 18.2, 80% CI 76.5 - 85.3). The internal consistency of the responses achieved the Cronbach's Alpha of 0.95. The participants stressed the importance of the following in the adoption of LM: maximal simplicity and usability, compatibility with learning preferences, and department-wide acceptance and integration. CONCLUSION: The overall perceived usability of LM was high. Our qualitative data revealed important implications for future designers to maximize adoption: include target users in every step of the design and development process to maximize simplicity and usability; build features that cater to a diversity of learning preferences; involve the entire department and find ways to incorporate the tool into the educational infrastructure and daily workflow.

Strategies used by people who inject drugs to avoid stigma in healthcare settings.

BACKGROUND: People who inject drugs (PWID) have limited engagement in healthcare services and report frequent experiences of stigma and mistreatment when accessing services. This paper explores the impact of stigma against injection drug use on healthcare utilization among PWID in the U.S. Northeast. METHODS: We recruited PWID through community-based organizations (CBOs; e.g., syringe service programs). Participants completed brief surveys and semi-structured interviews lasting approximately 45 min exploring HIV risk behaviors and prevention needs. Thematic analysis examined the emergent topic of stigma experiences in relation to healthcare utilization. RESULTS: Among 33 PWID (55% male; age range 24-62 years; 67% White; 24% Latino), most used heroin (94%) and injected at least daily (60%). Experiences of dehumanization in healthcare settings were common, with many participants perceiving that they had been treated unfairly or discriminated against due to their injection drug use. As participants anticipated this type of stigma from healthcare providers, they developed strategies to avoid it, including delaying presenting for healthcare, not disclosing drug use, downplaying pain, and seeking care elsewhere. In contrast to large institutional healthcare settings, participants described non-stigmatizing environments within CBOs, where they experienced greater acceptance, mutual respect, and stronger connections with staff. CONCLUSIONS: Stigma against injection drug use carries important implications for PWID health. Increased provider training on addiction as a medical disorder could improve PWID healthcare experiences, and integrating health services into organizations frequented by PWID could increase utilization of health services by this population.

Implementing a Pre-Exposure Prophylaxis Intervention for Safer Conception among HIV Serodiscordant Couples: Recommendations for Health Care Providers.

Couples in HIV serodiscordant relationships frequently desire children. Although partners who are virally suppressed pose almost no risk of transmitting HIV to their partners, partners who are inconsistently on therapy may transmit HIV to their partners when attempting to conceive. Pre-exposure prophylaxis (PrEP) is an available safer conception strategy for these couples but is not consistently offered. We sought to better understand barriers to PrEP implementation for couples seeking conception and patient perceptions on what providers could do to encourage use. We conducted in-depth, qualitative interviews with 11 participants representing six couples taking PrEP for safer conception in a safety-net hospital in New England. Semi-structured qualitative interviews assessed the following: Relationship nature and contextual factors; attitudes and perceptions regarding PrEP for safer conception; experience within health care systems related to HIV and PrEP; and facilitators, barriers, and other experiences using PrEP for safer conception. Four key themes have important implications for implementation of PrEP for safer conception: Knowledge and understanding gaps regarding HIV and PrEP among both members of the couple, role of insurance and financing in decision-making, learning to manage and adhere to a treatment plan, and the need for providers to enhance knowledge and offer further support. Addressing barriers to safer conception strategies at multiple levels is needed to prevent HIV transmission within serodiscordant couples who desire children. Providers can play an important role in lowering these barriers through the use of multiple strategies.

Standardizing an approach to the evaluation of implementation science proposals.

BACKGROUND: The fields of implementation and improvement sciences have experienced rapid growth in recent years. However, research that seeks to inform health care change may have difficulty translating core components of implementation and improvement sciences within the traditional paradigms used to evaluate efficacy and effectiveness research. A review of implementation and improvement sciences grant proposals within an academic medical center using a traditional National Institutes of Health framework highlighted the need for tools that could assist investigators and reviewers in describing and evaluating proposed implementation and improvement sciences research. METHODS: We operationalized existing recommendations for writing implementation science proposals as the ImplemeNtation and Improvement Science Proposals Evaluation CriTeria (INSPECT) scoring system. The resulting system was applied to pilot grants submitted to a call for implementation and improvement science proposals at an academic medical center. We evaluated the reliability of the INSPECT system using Krippendorff's alpha coefficients and explored the utility of the INSPECT system to characterize common deficiencies in implementation research proposals. RESULTS: We scored 30 research proposals using the INSPECT system. Proposals received a median cumulative score of 7 out of a possible score of 30. Across individual elements of INSPECT, proposals scored highest for criteria rating evidence of a care or quality gap. Proposals generally performed poorly on all other criteria. Most proposals received scores of 0 for criteria identifying an evidence-based practice or treatment (50%), conceptual model and theoretical justification (70%), setting's readiness to adopt new services/treatment/programs (54%), implementation strategy/process (67%), and measurement and analysis (70%). Inter-coder reliability testing showed excellent reliability (Krippendorff's alpha coefficient 0.88) for the application of the scoring system overall and demonstrated reliability scores ranging from 0.77 to 0.99 for individual elements. CONCLUSIONS: The INSPECT scoring system presents a new scoring criteria with a high degree of inter-rater reliability and utility for evaluating the quality of implementation and improvement sciences grant proposals.

A Novel Web-Based Experiential Learning Platform for Medical Students (Learning Moment): Qualitative Study.

BACKGROUND: Experiential learning plays a critical role in learner development. Kolb's 4-part experiential learning model consists of concrete experience, reflective observation, abstract conceptualization, and active experimentation in a recurring cycle. Most clinical environments provide opportunities for experiences and active experimentation but rarely offer structured means for reflection and abstract conceptualization that are crucial for learners to learn through experience. We created Learning Moment, a novel Web-based educational tool that integrates principles of asynchronous learning and learning portfolios to fulfill the reflection and abstract conceptualization aspects of Kolb's learning cycle in the modern clinical learning environment. Medical students log concise clinical "pearls" in the form of "learning moments" for reflection, review, and sharing with peers in a community of practice. OBJECTIVE: We sought to evaluate learners' experiences with Learning Moment via a qualitative study. METHODS: We employed purposive sampling to recruit medical students who used Learning Moment during their rotation. We conducted 13 semistructured interviews (10 individual interviews and one 3-person group interview) between January and March 2017 using an ethnographic approach and utilized a general inductive method to analyze and code for potential themes. RESULTS: A total of 13 students (five in their third year of medical school and eight in their fourth year) voluntarily participated in our qualitative interviews. Five of the 13 (38%) students intended to pursue emergency medicine as their chosen field of specialty. The median number of "learning moments" logged by these students is 6. From our analysis, three key themes emerged relating to the perceived impact of Learning Moment on student learning: (1) logging "learning moments" enhanced memorization, (2) improved learning through reflection, and (3) sharing of knowledge and experiences in a community of practice. CONCLUSIONS: Learning Moment was successfully implemented into the educational infrastructure in our department. Students identified three mechanisms by which the application optimizes experiential learning, including enabling the logging of "learning moments" to promote memorization, encouraging reflection to facilitate learning, and fostering the sharing of knowledge and experiences within a community of practice. The Learning Moment concept is potentially scalable to other departments, disciplines, and institutions as we seek to optimize experiential learning ecosystems for all trainees.

Limited Knowledge and Mixed Interest in Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs.

People who inject drugs (PWID) experience sexual and injection-related HIV risks, but uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among PWID has been low. Improving PrEP uptake in this population will require understanding of PrEP knowledge and interest. In 2017, we conducted in-depth, semistructured interviews with HIV-uninfected PWID and key informants (PrEP and harm reduction providers) in the US Northeast. Thematic analysis of coded data explored PrEP knowledge and the factors that influence PrEP interest. Among PWID (n = 33), median age was 36 years, 55% were male, 67% were white, and 24% identified as Hispanic/Latino. Accurate PrEP knowledge among PWID was low, which key informants (n = 12) attributed to PrEP marketing focused on other risk populations, as well as healthcare providers' lack of time and unwillingness to discuss PrEP with PWID. There was a discrepancy between self-reported HIV risk behaviors, which were common, and HIV risk perceptions, which varied and strongly influenced PrEP interest. Most PWID and key informants thought that PrEP would be most beneficial for those who shared syringes, used discarded syringes, engaged in transactional sex, or were homeless. Improving uptake of PrEP for HIV prevention among high-risk PWID will require education to increase PrEP knowledge and addressing factors that negatively influence PrEP interest such as perceptions regarding low HIV risk and the process for obtaining PrEP. This may require specialized PrEP marketing and outreach efforts and improved capacity of healthcare providers to effectively assess HIV risk (and perceptions) and communicate the benefits of PrEP to at-risk PWID.