Why Won't Anyone Talk? Challenges Naming and Addressing Tokenism Within Health and Human Service Agencies Serving the LGBTQ+ Community.

Workplace tokenism, the use of superficial efforts to appear equitable, which often leads to burnout of marginalized groups, is pervasive, even in health and human service organizations dedicated to improving their community's health and well-being. An original research project to identify interventions addressing tokenism within Lesbian, Gay, Bisexual, Transgender, Queer plus serving health and human service agencies in New York was unable to engage staff in focus groups. A follow-up survey with 41 potential participants reported burnout as the main reason for nonparticipation. Qualitative data revealed desired aftercare for the retraumatizing nature of sharing individual experiences. Utilizing a community-based participatory research approach with an antiracism lens may mitigate challenges addressing tokenism, thereby increasing workplace inclusion of our Lesbian, Gay, Bisexual, Transgender, Queer plus community.

Results of Immediate Postpartum Long Acting Reversible Contraception Provision After Expanded Reimbursement Policy Implementation at an Academic Medical Institution.

INTRODUCTION: Immediate postpartum (IPP) Long Acting Reversible Contraception (LARC) is effective in reducing short birth spacing, which is highest among minoritized and younger women with lower socioeconomic status. The structural barrier of cost for pregnant people who desire IPP LARC insertion was alleviated in 2016 when New York State provided statewide reimbursement for Medicaid recipients. METHODS: Analyses of existing electronic medical records (EMR) were conducted on women who received IPP LARC between 3/2/17 and 9/2/19 at two hospitals after a term delivery, defined as gestational age 37 0/7 weeks or greater. Descriptive and bivariate statistics, including chi-square tests and Fischer's exact tests, based on cell sizes, were calculated using SAS (version9.4). RESULTS: Prior to the study period, IPP LARC was not placed in these hospitals. After reimbursement policy changes, electronic medical record data identified 501 women with full term delivery and IPP LARC placed, of which the majority were single (82.8%), Black (49.1%), and had public insurance (Medicaid and Medicaid Managed Care) (79.2%). DISCUSSION: Removing structural economic barriers for people using public insurance may increase health equity in contraceptive access and choice.

Use of open-text responses to recode categorical survey data on postpartum contraception use among women in the United States: A mixed-methods inquiry of Pregnancy Risk Assessment Monitoring System data.

BACKGROUND: Postpartum contraception prevents unintended pregnancies and short interpregnancy intervals. The Pregnancy Risk Assessment Monitoring System (PRAMS) collects population-based data on postpartum contraception nonuse and reasons for not using postpartum contraception. In addition to quantitative questions, PRAMS collects open-text responses that are typically left unused by secondary quantitative analyses. However, abundant preexisting open-text data can serve as a resource for improving quantitative measurement accuracy and qualitatively uncovering unexpected responses. We used PRAMS survey questions to explore unprompted reasons for not using postpartum contraception and offer insight into the validity of categorical responses. METHODS AND FINDINGS: We used 31,208 categorical 2012 PRAMS survey responses from postpartum women in the US to calculate original prevalences of postpartum contraception use and nonuse and reasons for contraception nonuse. A content analysis of open-text responses systematically recoded data to mitigate survey bias and ensure consistency, resulting in adjusted prevalence calculations and identification of other nonuse themes. Recoded contraception nonuse slightly differed from original reports (21.5% versus 19.4%). Both calculations showed that many respondents reporting nonuse may be at a low risk for pregnancy due to factors like tubal ligation or abstinence. Most frequent nonuse reasons were not wanting to use birth control (27.1%) and side effect concerns (25.0%). Other open-text responses showed common themes of infertility, and breastfeeding as contraception. Comparing quantitative and qualitative responses revealed contradicting information, suggesting respondent misinterpretation and confusion surrounding the term "pregnancy prevention." Though this analysis may be limited by manual coding error and researcher biases, we avoided coding exhaustion via 1-hour coding periods and validated reliability through intercoder kappa scores. CONCLUSIONS: In this study, we observed that respondents reporting contraception nonuse often described other methods of pregnancy prevention and contraception barriers that were not included in categorical response options. Open-text responses shed light on a more comprehensive list of pregnancy prevention methods and nonuse options. Our findings contribute to survey questions that can lead to more accurate depiction of postpartum contraceptive behavior. Additionally, future use of these qualitative methods may be used to improve other health behavior survey development and resulting data.

Team-based suicide prevention: lessons learned from early adopters of collaborative care.

Suicide prevention in clinical settings requires coordination among multiple clinicians with expertise in different disciplines. We aimed to understand the benefits and challenges of a team approach to suicide prevention in primary care, with a particular focus on Veterans. The Veterans Health Administration has both a vested interest in preventing suicide and it has rapidly and systematically adopted team-based approaches for primary care interventions, including suicide prevention. We conducted eight focus groups and eight in-depth interviews with primary care providers (PCPs), behavioral health providers and nurses located in six regions within one Veterans Administration Catchment Area in the northeast of the US. Transcripts were analyzed using simultaneous deductive and inductive content analysis. Findings revealed that different clinicians were thought to have particular expertise and roles. Nurses were recognized as being well positioned to identify subtle changes in patient behavior that could put patients at risk for suicide; behavioral health providers were recognized for their skill in suicide risk assessment; and PCPs were felt to be an integral conduit between needed services and treatment. Our findings suggest that clinician role-differentiation may be an important by-product of team-based suicide prevention efforts in VHA settings. We contextualize our findings within both a processual and relational interprofessional framework and discuss implications for the implementation of team-based suicide prevention.

Attitudes, practices, and priority of HIV screening and testing among clinical providers in Transylvania and Moldavia, Romania.

Screening and linkage to care are core, foundational strategies for HIV transmission prevention and for identifying People Living with HIV (PLHIV). In Romania - with an atypical experience in the HIV/AIDS epidemic - providing care for HIV+ patients identified early is a priority, though screening and testing can pose a challenge in some areas. METHODS: A survey of 125 clinical providers to explore important dimensions of HIV/ AIDS clinical care was conducted in Transylvania and Moldavia, where clinicians identified poor/ latent screening as a major problem in providing timely care and in preventing the spread of disease. We analyzed determinants of offering HIV screening/testing to patients using Pearson Chi-square analysis and logistic regression. Logistic regression generated Odds Ratios (OR) to reflect the magnitude of association between the relevant variables, with 95% confidence interval (95% CI) indicating statistical range. RESULTS: In total, 40.8% of providers did not provide HIV screening/testing to at least one segment of the population. Hospital-based providers were significantly more likely to offer HIV screening/testing to all segments than were non-hospital-based providers (58.1% v. 35.5%, respectively; p < .05). Providers located within institutions with screening/testing policies were more likely to offer such services to their patients (p < .05). Overall, 94.4% of providers indicated interest in more training around HIV screening/testing. DISCUSSION: Reaching Romanian and global goals for reducing HIV require more timely screening and action based on positive status. Romanian clinicians are interested in expanding HIV screening/testing and are interested in participating in training that helps them feel more prepared to undertake this work.

Unsafe abortion in Kenya: a cross-sectional study of abortion complication severity and associated factors.

BACKGROUND: Complications due to unsafe abortion cause high maternal morbidity and mortality, especially in developing countries. This study describes post-abortion complication severity and associated factors in Kenya. METHODS: A nationally representative sample of 326 health facilities was included in the survey. All regional and national referral hospitals and a random sample of lower level facilities were selected. Data were collected from 2,625 women presenting with abortion complications. A complication severity indicator was developed as the main outcome variable for this paper and described by women's socio-demographic characteristics and other variables. Ordered logistic regression models were used for multivariable analyses. RESULTS: Over three quarters of abortions clients presented with moderate or severe complications. About 65% of abortion complications were managed by manual or electronic vacuum aspiration, 8% by dilation and curettage, 8% misoprostol and 19% by forceps and fingers. The odds of having moderate or severe complications for mistimed pregnancies were 43% higher than for wanted pregnancies (OR, 1.43; CI 1.01-2.03). For those who never wanted any more children the odds for having a severe complication was 2 times (CI 1.36-3.01) higher compared to those who wanted the pregnancy then. Women who reported inducing the abortion had 2.4 times higher odds of having a severe complication compared to those who reported that it was spontaneous (OR, 2.39; CI 1.72-3.34). Women who had a delay of more than 6 hours to get to a health facility had at least 2 times higher odds of having a moderate/severe complication compared to those who sought care within 6 hours from onset of complications. A delay of 7-48 hours was associated with OR, 2.12 (CI 1.42-3.17); a delay of 3-7 days OR, 2.01 (CI 1.34-2.99) and a delay of more than 7 days, OR 2.35 (CI 1.45-3.79). CONCLUSIONS: Moderate and severe post-abortion complications are common in Kenya and a sizeable proportion of these are not properly managed. Factors such as delay in seeking care, interference with pregnancy, and unwanted pregnancies are important determinants of complication severity and fortunately these are amenable to targeted interventions.

Costs of postabortion care in public sector health facilities in Malawi: a cross-sectional survey.

BACKGROUND: Health systems could obtain substantial cost savings by providing safe abortion care rather than providing expensive treatment for complications of unsafely performed abortions. This study estimates current health system costs of treating unsafe abortion complications and compares these findings with newly-projected costs for providing safe abortion in Malawi. METHODS: We conducted in-depth surveys of medications, supplies, and time spent by clinical personnel dedicated to postabortion care (PAC) for three treatment categories (simple, severe non-surgical, and severe surgical complications) and three uterine evacuation (UE) procedure types (manual vacuum aspiration (MVA), dilation and curettage (D&C) and misoprostol-alone) at 15 purposively-selected public health facilities. Per-case treatment costs were calculated and applied to national, annual PAC caseload data. RESULTS: The median cost per D&C case ($63) was 29% higher than MVA treatment ($49). Costs to treat severe non-surgical complications ($63) were almost five times higher than those of a simple PAC case ($13). Severe surgical complications were especially costly to treat at $128. PAC treatment in public facilities cost an estimated $314,000 annually. Transition to safe, legal abortion would yield an estimated cost reduction of 20%-30%. CONCLUSIONS: The method of UE and severity of complications have a large impact on overall costs. With a liberalized abortion law and implementation of induced abortion services with WHO-recommended UE methods, current PAC costs to the health system could markedly decrease.

Developing a scale to measure stigmatizing attitudes and beliefs about women who have abortions: results from Ghana and Zambia.

The objective of this research was to explore the context of abortion stigma in Ghana and Zambia through qualitative research, and develop a quantitative instrument to measure stigmatizing attitudes and beliefs about abortion. Ultimately, we aimed to develop a scale to measure abortion stigma at the individual and community level that can also be used in the evaluation of stigma reduction interventions. Focus group discussions were conducted in both countries to provide information around attitudes and beliefs about abortion. A 57-item instrument was created from these data, pre-tested, and then administered to 531 individuals (n = 250 in Ghana and n = 281 in Zambia). Exploratory factor analyses were conducted on 33 of the original 57 items to identify a statistically and conceptually relevant scale. Items with factor loadings > 0.39 were retained. All analyses were completed using Stata IC/11.2. Exploratory factor analysis resulted in a three-factor solution that explained 53% of the variance in an 18-item instrument. The three identified subscales are: (i) negative stereotypes (eight items), (ii) discrimination and exclusion (seven items), and (iii) potential contagion (three items). Coefficient alphas of 0.85, 0.80, and 0.80 for the three subscales, and 0.90 for the full 18-item instrument provide evidence of internal consistency reliability. Our Stigmatizing Attitudes, Beliefs, and Actions scale captures three important dimensions of abortion stigma: negative stereotypes about men and women who are associated with abortion, discrimination/exclusion of women who have abortions, and fear of contagion as a result of coming in contact with a woman who has had an abortion. The development of this scale provides a validated tool for measuring stigmatizing attitudes and beliefs about abortion in Ghana and Zambia. Additionally, the scale has the potential to be applicable in other country settings. It represents an important contribution to the fields of reproductive health, abortion, and stigma.

We are complex beings: comparison of statistical methods to capture and account for intersectionality.

OBJECTIVES: Intersectionality conceptualises how different parts of our identity compound, creating unique and multifaceted experiences of oppression. Our objective was to explore and compare several quantitative analytical approaches to measure interactions among four sociodemographic variables and interpret the relative impact of axes of marginalisation on self-reported health, to visualise the potential elevated impact of intersectionality on health outcomes. DESIGN: Secondary analysis of National Epidemiologic Survey on Alcohol and Related Conditions-III, a nationally representative cross-sectional study of 36 309 non-institutionalised US citizens aged 18 years or older. PRIMARY OUTCOME MEASURES: We assessed the effect of interactions among race/ethnicity, disability status, sexual orientation and income level on a self-reported health outcome with three approaches: non-intersectional multivariate regression, intersectional multivariate regression with a single multicategorical predictor variable and intersectional multivariate regression with two-way interactions. RESULTS: Multivariate regression with a single multicategorical predictor variable allows for more flexibility in a logistic regression problem. In the fully fitted model, compared with individuals who were white, above the poverty level, had no disability and were heterosexual (referent), only those who were white, above the poverty level, had no disability and were gay/lesbian/bisexual/not sure (LGBQ+) demonstrated no significant difference in the odds of reporting excellent/very good health (aOR=0.90, 95% CI=0.71 to 1.13, p=0.36). Multivariate regression with two-way interactions modelled the extent that the relationship between each predictor and outcome depended on the value of a third predictor variable, allowing social position variation at several intersections. For example, compared with heterosexual individuals, LGBQ+ individuals had lower odds of reporting better health among whites (aOR=0.94, 95% CI=0.93 to 0.95) but higher odds of reporting better health among Black Indigenous People of Color (BIPOC) individuals (aOR=1.13, 95% CI=1.11 to 1.15). CONCLUSION: These quantitative approaches help us to understand compounding intersectional experiences within healthcare, to plan interventions and policies that address multiple needs simultaneously.

Ending the Epidemic: Building Health Care Capacity Through HIV and HCV Preceptorship Programs.

Since 2015, Mount Sinai HIV/HCV Center of Excellence has implemented two-day HIV and HCV preceptorships for New York State health care. Participants assessed their knowledge of and confidence to perform 13 HIV or 10 HCV prevention- and treatment-related skills, measured on a 4-point Likert scale from "not at all" to "very" knowledgeable/confident at baseline, exit survey, and a recent evaluation. Wilcoxon signed rank sum tests determined mean differences at all three time points. Between baseline to exit assessment and baseline to evaluation assessment, HIV and HCV preceptorship attendees reported significant increases in knowledge for five HIV and three HCV components and confidence for two HIV and three HCV tasks (p < .05), respectively. The preceptorship significantly and positively impacted short-term and long-term knowledge and confidence around HCV and HIV clinical skills. The implementation of HIV and HCV preceptorship programs may increase HIV and HCV treatment and prevention service efficacy within key population areas.

Sharing the Details: Implementing and Evaluating the Integration of New York State AIDS Institute Health Equity Competencies for Health Care Providers into Clinical Training Activities.

Background: The New York State (NYS) Department of Health (DOH) AIDS Institute (AI) Clinical Education Initiative (CEI) trains the NYS health care workforce to improve health outcomes related to HIV, sexual health, hepatitis C, and for people who use drugs. Methods: In 2019, CEI began consistently integrating health equity into CEI activities through a working group that mapped NYS DOH AI health equity competencies for providers onto planned clinical education. We conducted a convergent mixed methods study on qualitative and quantitative participant feedback form (PFF) data to evaluate these competencies between April 1, 2021, and September 30, 2022, and conducted an annual survey of NYS clinician needs in 2021 and 2022. Results: The CEI Health Equity Working Group analyzed 25 measures within 4 health equity competencies that were grouped into 4 interventions: resources, internal tools, activity creation, and evaluation. Eighty-nine percent of PFF respondents (n=20,166) strongly agreed/agreed that CEI activities included multiple viewpoints; qualitative comments described informative and helpful activities. When asked how they address patient-identified social determinants of health (SDOH) needs, 84% and 71% of annual survey respondents reported they made the highest number of referrals for health insurance coverage assistance in 2021 and 2022, respectively. Discussion: CEI continues to address participant feedback and seamless incorporation of health equity components into their work. Health Equity Implications: Health equity in clinical practice and trainings is crucial in acknowledging and addressing SDOH that continue to impact NYS clinicians and their patients.

Reproductive health characteristics of young Malawian women seeking post-abortion care.

Abortion is illegal in Malawi except when the pregnancy endangers the mother's life, yet complications of abortion account for the majority of admissions to gynecological wards. This study collected data on all post-abortion care (PAC) cases reporting to all PAC-providing health facilities in Malawi over a 30-day period. Of a total of 2,028 PAC clients, 20.9% were adolescents (age 10-19) and 29.6% were young adults (age 20-24). More than half of adolescents and almost 80% of young adults were married. Less than 5% of adolescents and 22.5% of young adults reported using contraception when they became pregnant. Being unmarried was associated with previous abortion and contraceptive use among young adults. These statistics indicate a high proportion of unwanted pregnancy and lack of access to modern contraception among young women. Programs to increase access to pregnancy prevention services and protect young women from unsafe abortions are greatly needed.

An Exploration of Barriers to Suicide Prevention Messaging With US Veterans.

Background: Communication campaigns offer a portable intervention to effectively reach and engage target populations at risk for suicide including US veterans. Few studies have evaluated such efforts, and still fewer have examined factors that contribute to failed suicide prevention messaging. Aims: We aimed to examine characteristics of suicide prevention messages and persuasive processes that may underlie failed communicative intervention with US veterans. Method: Telephone interviews were completed with veterans (N = 33) from June to September 2016 using a semi-structured interview guide. Interview transcripts were coded by the authors with NVivo using a constant comparison analytic strategy. Results: Several reasons emerged for why suicide prevention messaging may fail to produce intended responses among veterans. Participants identified message features (e.g., language, images, messenger) and communication strategies that may diminish campaign effects. Limitations: Findings are not generalizable, are limited to participants who used VA healthcare and were not suicidal, and are subject to several biases. Conclusion: This work provides initial insights into barriers to effective message use with veterans.

Description and Evaluation of an Evidence-Based Residency Curriculum Using the Evidence-Based Medicine Environment Survey.

BACKGROUND AND OBJECTIVES: Teaching medical trainees evidence-based medicine (EBM) is required by the Accreditation Council for Graduate Medical Education. Most published graduate EBM curricula focus on critical appraisal over point-of-care information mastery. Faculty at the University of Rochester Family Medicine Residency implemented a clinically integrated, cyclical EBM curriculum juxtaposing information mastery with expert-level skills such as critical appraisal. We administered the Evidence-Based Medicine Environment Survey (EBMES) to learners before and after the yearlong curriculum. METHODS: Two cohorts of participating third-year residents completed the EBMES before and after an EBM curriculum. RESULTS: Over 2 years, 21 residents completed pre- and postevaluations. Resident perception of the EBM educational and practice environment was high at baseline and improved for 15 of 36 survey items (P<.05). CONCLUSIONS: Resident perception of the EBM learning environment improved after participation in a yearlong curriculum. Nearly all of the content covered in the "Science of Family Medicine" curriculum and measured by EBMES improved in a statistically significant manner. We propose that EBM curricula should combine traditional literature search and critical appraisal skills with information mastery to maximize effectiveness. Our curriculum can be modified to fit other graduate family medicine contexts.

Piling it on: Perceived stress and lack of access to resources among US-based LGBTQ+ community members during the COVID-19 pandemic.

OBJECTIVES: While the LGBTQ+ community has been disproportionally impacted by COVID-19 medical complications, little research has considered non-medical impact. METHODS: We conducted a secondary analyses of USA-based respondents from a global cross-sectional online mixed-methods survey collecting sexual orientation, gender identity, and the perceived stress scale (PSS). Bivariate and multivariate ordinal regression statistics were performed. RESULTS: Fourteen percent (n = 193,14.2%) identified as LGBTQ+. Variables significantly associated with LGBTQ+ included: COVID testing/treatment affordability, canceled activities, stocking food/medications, quitting job, lost income, and inability to procure groceries/cleaning supplies/medications. Adjusting for Hispanic ethnicity and income, BIPOC LGBTQ+ individuals had twice the odds (OR:2.02;95%CI:1.16-3.53) of moderate compared to low PSS scores, and high compared to moderate PSS scores, compared to white non-LGBTQ+ individuals. Adjusting for Hispanic ethnicity, income, age, and education, deaf LGBTQ+ individuals had twice the odds (OR:2.00;95%CI:1.12-3.61) of moderate compared to low PSS scores, and high compared to moderate PSS scores, compared to hearing non-LGBTQ+ individuals. CONCLUSION: The LBGTQ+ community has increased stress due to COVID-19. Public health interventions must mitigate stress in BIPOC and deaf LGBTQ+ communities, addressing their intersectional experiences.

Evaluation of Syracuse Healthy Start's program for abnormal flora management to reduce preterm birth among pregnant women.

UNLABELLED: Randomized trials of bacterial vaginosis (BV) treatment among pregnant women to reduce preterm birth have had mixed results. Among non-pregnant women, BV recurs frequently after treatment. Randomized trials of early BV treatment for pregnant women in which recurrence was retreated have shown promise in reducing preterm birth. Syracuse's Healthy Start (SHS) program began in 1997; in 1998 prenatal care providers for pregnant women living in high infant mortality zip codes were encouraged to screen for abnormal vaginal flora at the first prenatal visit. Vaginal swabs were sent to a referral hospital laboratory for Gram staining and interpretation. SHS encouraged providers to treat and rescreen women with bacterial vaginosis or abnormal flora (BV). We abstracted prenatal and hospital charts of live births between January 2000 and March 2002 for maternal conditions and treatments. We merged abstracted data with local electronic data. We evaluated the effect of BV screening before 22 weeks gestation, treatment, and rescreening using a retrospective cohort study design. Among 838 women first screened before 22 weeks, 346 (41%) had normal flora and 492 (59%) women had BV at a mean of 13 weeks gestation; 202 (24%) did not have treatment documented and 290 (35%) received treatment at a mean of 15 weeks gestation; 267 (92%) of those treated were re-screened. Among pregnant women with early BV, 42 (21%) untreated women and 28 (10%) treated women delivered preterm (Odds Ratio [OR] 0.4, 95% confidence interval [CI] 0.2-0.7)). After adjustment for age, race, prior preterm birth and other possible confounders, treatment remained associated with a reduced risk of preterm birth compared to no treatment (aOR = 0.5, 95% CI 0.3-0.9); the aOR for women with normal flora was not significantly different. CONCLUSION: Screening, treatment, and rescreening for BV/abnormal flora between the first prenatal visit and 22 weeks gestation showed promise in reducing preterm births and deserves further study.

Team communication within integrated primary care in the context of suicide prevention: A mixed methods preliminary examination.

Direct and indirect communication through the electronic medical record play a vital role in helping medical home primary care teams implement suicide prevention efforts. The purpose of this study is to examine how communication related to suicide prevention occurs among primary care team members working within a group of clinics in the Veterans Health Administration that has embedded integrated behavioral health providers (BHPs) and uses a shared electronic medical record. Using sequential exploratory mixed methods design, eight focus groups and 11 in-depth interviews with primary care providers (PCPs), nurses, and BHPs comprised the qualitative portion of the study, which was used to help develop an online questionnaire distributed to all primary care teams. Participants (n = 86) of the online survey included 15 BHPs, 32 PCPs, and 39 registered nurses. Qualitative data included asking a series of questions concerning how suicide prevention is accomplished in primary care. Themes concerning how providers communicate both directly and indirectly arose from the data and were used to develop questions for the survey to help further understand the data. Overall, the data suggested good team communication was occurring. However, there were opportunities to enhance communication through the use of huddles and enhancing communication from PCPs to other team members when the patient's medical status changed. Direct communication was preferred, and finding ways to increase communication may be important to help decrease potential errors that may occur via diffusion of responsibility. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Young women's reproductive health conversations: Roles of maternal figures and clinical practices.

OBJECTIVE: To explore the role of clinical providers and mothers on young women's ability to have confidential, candid reproductive health conversations with their providers. METHODS: We conducted 14 focus groups with 48 women aged 15-28 years (n = 9), and 32 reproductive healthcare workers (n = 5). Focus groups were audio recorded and transcribed. Data were analyzed using inductive coding and thematic analyses. We examined findings through the lens of paternalism, a theory that illustrates adults' role in children's autonomy and wellbeing. RESULTS: Mothers have a substantial impact on young women's health values, knowledge, and empowerment. Young women reported bringing information from their mothers into patient-provider health discussions. Clinical best practices included intermingled components of office policies, state laws, and clinical guidelines, which supported health workers' actions to have confidential conversations. There were variations in how health workers engaged young women in a confidential conversation within the exam room. CONCLUSIONS: Both young women and health workers benefit from situations in which health workers firmly ask the parent to leave the exam room for a private conversation with the patient. Young women reported this improves their comfort in asking the questions they need to make the best decision for themselves. Clinic leadership needs to ensure that confidentiality surrounding young women's reproductive health is uniform throughout their practice and integrated into patient flow.

Intimate Partner Violence, Suicide, and Their Overlapping Risk in Women Veterans: A Review of the Literature.

INTRODUCTION: Suicidal thoughts and behaviors (STB) and intimate partner violence (IPV) are both serious and prevalent problems in the Veteran population that often occur in tandem, particularly among women Veterans. Women Veterans, the fastest growing segment of the Veteran population, may have unique overlapping risks that are worth exploring. Although the intersection of IPV and STB is well documented in the civilian population, it has not been thoroughly explored in women Veterans. MATERIALS AND METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, we conducted a systematic review of the STB and IPV literature specifically related to women Veterans. We only included articles that sampled women Veterans, rather than active duty/reservist/National Guard women; due to the small volume of STB research using samples of only women Veterans, we included studies that used mixed-gender samples. We extracted risk factors for STB and/or IPV involvement from 56 selected articles and placed them into tables for comparison to determine commonalities. RESULTS: Common risk factors fell into three categories: socio-demographic risk factors (young age, unemployment, and sexual minority status) were significant across both bodies of literature; mental health risk factors (general psychopathology, post-traumatic stress disorder (PTSD), depression, sleep disturbance, and substance use/abuse) also had significant overlap; and military service-related risk factors (military sexual trauma (MST) and deployment factors) were also relevant across both bodies of literature. Mental health risk factors, particularly PTSD, were the most common. CONCLUSION: Frequently, the risk factors for IPV and STB are shared and it is important to consider how research, screening and intervention efforts for these serious problems might be integrated. Our exploration of the literature may be used as a basis for future research with women Veterans on the intersection of STB and IPV. Further, Veterans Health Administration clinicians should be aware of these intersecting risk factors to enhance care and improve screening for both issues in women Veteran clients.