Characteristics and Outcomes of Women and Infants Who Received Prenatal Care While Incarcerated in Arkansas State Prison System, 2014-2019.

BACKGROUND: Prisons face challenges in meeting the unique health care needs of women, especially those who are pregnant. This retrospective chart review sought to describe the maternal and infant health outcomes of incarcerated women who received prenatal care while in an Arkansas prison. METHODS: Using a hospital-based electronic medical records (EMR) system, we examined the maternal health history and current pregnancy characteristics of 219 pregnant women who received prenatal care while incarcerated from June 2014 to May 2019. We also examined labor and delivery characteristics and postpartum and infant birth outcomes for the 146 women from this cohort who delivered a living child while still incarcerated. RESULTS: Most records indicated complex health histories with several chronic illnesses, mental health diagnoses, history of substance use, and lifetime medical complications. Despite comorbid illness, substance use disorder (SUD), trauma-history, and post-traumatic stress disorder (PTSD) prevalence was lower than expected. Previous and current obstetrical complications were common. Although the Neonatal Intensive Care Unit (NICU) admission rate (41%) was high, few infants required extensive treatment intervention. Postpartum complications were rare; however, a small portion of women who gave birth in custody experienced severe complications and were re-admitted to the hospital post-discharge. CONCLUSIONS: Incarcerated pregnant women and their infants are a marginalized population in great need of health care advocacy. To optimize maternal-infant outcomes, carceral agencies must recognize the health needs of incarcerated pregnant women and provide appropriate prenatal care. Expansion of carceral perinatal care to include screening for SUD and psychiatric symptoms (e.g., PTSD) and referral to appropriate care is highly encouraged. Policies related to NICU admission for non-medical reasons should be further examined.

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

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

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

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

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

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

Conducting Health Research in Carceral Systems: Considerations and Recommendations.

Although the number of people incarcerated in the United States has grown dramatically, research on how incarceration affects individuals and the communities they return to has lagged behind. This may be because of the unique challenges of doing research within carceral systems and the relatively small number of investigators who are competent to undertake these efforts.We provide a primer for investigators with limited experience conducting research in carceral settings and highlight considerations and recommendations that may aid those conducting health research with incarcerated persons. We follow this with an illustrative case example exemplifying how the considerations apply to recent health research that our team conducted on mental illness prevalence in a large regional jail.Understanding how to effectively conduct research with criminal justice populations and systems is the first step in beginning to understand the effects of mass incarceration as a driver of health disparities and health inequity.

A short-term longitudinal examination of the relations between depression, anhedonia, and self-injurious thoughts and behaviors in adults with a history of self-injury.

BACKGROUND: Limited research has addressed the role of anhedonia in predicting suicidality and/or nonsuicidal self-injury (NSSI) in adults, despite evidence suggesting that loss of interest or pleasure may increase vulnerability for self-inflicted harm, even beyond other depressive symptoms. METHODS: In the current study, we explored the role of symptoms of depression and recent changes in anhedonia in predicting suicidality, NSSI ideation, and perceptions of NSSI helpfulness among individuals with a history of NSSI or suicide attempts (N=187). RESULTS: We found that changes in anhedonia partially mediated the effect of depression on suicidality, and fully mediated the effect of depression on perceptions of NSSI helpfulness. Anhedonia did not predict NSSI ideation above and beyond depression symptoms, and did not significantly predict NSSI frequency when accounting for suicidality. Compared to individuals with a history of NSSI only or suicide attempt only, people with a history of both NSSI and suicide attempt evidenced greater risk and symptomatology. CONCLUSIONS: Results confirm the relation between anhedonia and suicidality evidenced in past research, but suggest a complex relationship between anhedonia, depression, and facets of non-suicidal self-injury.

Custodial and perinatal care patterns of women who received prenatal care while incarcerated in the Arkansas state prison system, 2014-2019.

BACKGROUND: The extraordinary growth in women's incarceration over the past several decades has resulted in calls for expansion of research into their unique needs and experiences, including those related to pregnancy and perinatal care. However, while research into the health outcomes of women who are incarcerated while pregnant has grown, research on women's custodial and perinatal care patterns has remained nearly non-existent. Here, we sought to describe (1) the characteristics of the population of women who came to be incarcerated in a state prison system during pregnancy and (2) the characteristics of women's custodial and perinatal care patterns during and after incarceration. METHODS: We conducted a retrospective chart review of the population of women who received perinatal care while incarcerated in the Arkansas state prison system over a 5-year period from June 2014 to May 2019. Electronic medical records and state prison records were merged to form our study population. Data were from 212 women (Mage = 28.4 years; 75.0% non-Latina White) with a singleton pregnancy who received at least one obstetric care visit while incarcerated. RESULTS: Drug-related convictions were the most common crimes leading to women's incarceration while pregnant, and violent crime convictions were rare. Nearly half (43.4%) of women who gave birth in custody did so within 90 days of admission and the great majority (80.4%) released within 1-year of giving birth, including 13.3% who released within 30 days. DISCUSSION: The frequency with which women who became incarcerated while pregnant released from prison either prior to or shortly after giving birth was a striking, novel finding of this study given the implications for perinatal care disruption among a high-risk population and the harms of forced separation from infants within hours of birth. CONCLUSIONS: Diversionary programs for pregnant women convicted of crimes, particularly in states without current access, are urgently needed and should be a priority for future policy work.

Mental Health, Drug Use, and Programming: Applying a Needs Assessment Framework in Arkansas' Largest Jail.

Jail programming is rarely informed by site-specific health needs, diagnostic-specific screening tools that are validated, or the input of incarcerated individuals. Using the community needs assessment (CNA) framework, we aimed to fill these gaps among people incarcerated in the Pulaski County Regional Detention Facility (PCRDF), Arkansas' largest jail. Participants were 179 adults at the PCRDF who completed surveys and open-ended questions focused on (a) their mental and behavioral health and (b) programming needs at the facility. Using a concurrent transformative mixed-methods design, we descriptively analyzed surveys and conducted content analysis of the open-ended questions. Over half of participants reported clinically significant anxiety (62.6%), post-traumatic stress disorder (53.1%), and/or depression (50.3%) symptoms; positive substance use disorder screening was especially common (91.7%). Nearly all (97%) individuals queried desired more programming, with the most desired being mental health and substance use programs. Other desired programs included physical health, education, community reintegration, family support, recreation, nutrition, religious/spiritual services, and meditation. Our CNA ensured the input of those directly impacted during program-focused decision making and identified strategies to effectively implement and sustain jail-based programs. Such assessments can be a potential mechanism for addressing the burden of mental and behavioral health problems in jail populations.

To SHARE or not to SHARE: Exploring incarcerated women's decisions about enrolling in exposure-based group therapy.

Exposure therapies effectively treat traumatic stress sequelae, including that which follows sexual violence victimization (SVV). Carceral facilities house women with significantly higher rates of SVV than community samples, yet they rarely implement this form of treatment. In this study, women with histories of SVV (n = 63) completed semistructured qualitative interviews about their decision to enroll or not enroll in an exposure-based group therapy called Survivors Healing from Abuse: Recovery through Exposure while incarcerated. All study participants were previously incarcerated in a prison, where they were offered the opportunity to enroll in Survivors Healing from Abuse: Recovery through Exposure. We used the theory of planned behavior to analyze factors that affected enrollment decisions. Results revealed that enrollment decisions among incarcerated women can be categorized within the theory of planned behavior framework. Interview responses indicated that recognizing current problems as related to experiences of SVV, holding positive attitudes about mental health treatment, observing peers engaging in help-seeking behaviors, and perceiving treatment as accessible were linked with enrollment. Negative perceptions of treatment, fear of judgment, and negative peer influence (e.g., distrust of peers) were linked to decisions not to enroll. While certain beliefs were influenced by contextual features of incarceration (e.g., peer interactions outside of group therapy), many overlapped with factors found to influence help-seeking among nonincarcerated populations. Findings have implications for how to engage members of underserved populations in resource-deprived contexts who have a great need for treatment of traumatic symptoms secondary to sexual violence. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Arkansas crisis stabilization unit guests: Baseline characteristics from a longitudinal cohort study.

Crisis Stabilization Units (CSUs) are short-term residential facilities that provide care to people experiencing mental health crises, seeking to reduce reliance on local emergency departments and avoid unnecessary jail detention. Despite these intentions, there is little foundational literature to support research on CSU efficacy and a dearth of research on the sociodemographic characteristics and specific needs of CSU patients. Here, we recruited and surveyed 208 participants admitted to one of two focal Arkansas CSUs on their sociodemographic characteristics, justice-involvement, mental health, substance use, and health care utilization. Results revealed that participants were mostly unemployed (68.16%), low-income (72.34%), and experiencing insecure housing (33.33%). They reported extensive justice-involvement (85.57%), high rates of clinically significant mental illness symptom severity (77.00% for anxious symptoms; 78.33% for depressive symptoms; 79.40% for traumatic stress symptoms), and recent substance use (73.34%). Recent engagement with other medical services was common, though more participants reported visiting an emergency department (42.23%) than did receiving outpatient medical care (26.73%). While research on CSU patient outcomes is needed, our results indicate that CSUs have the potential to be an essential part of the health care continuum by serving a population with multiple, intersecting needs and addressing a deficit in community-based crisis care. Continued investigation of community-based crisis intervention services is critical to bridging the gap between vital behavioral health resources and the populations in need of them. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

An integrative literature review of substance use treatment service need and provision to pregnant and postpartum populations in carceral settings.

Pregnancy is a critical time to provide access to substance use treatment; this is especially true among incarcerated populations, who are known to be at particularly high risk of poor health outcomes. In this integrated literature review, we (1) report what is known about the prevalence of substance use among incarcerated pregnant and postpartum populations; (2) describe substance use treatment programs and current care practices of pregnant and postpartum populations in carceral settings; and (3) explore recommendations and strategies for increasing access to substance use treatment for incarcerated pregnant and postpartum populations. A comprehensive search of seven electronic databases yielded in the retrieval of 139 articles that were assessed for inclusion. Of the retrieved articles, 33 articles met criteria for inclusion in this review. A review of the literature revealed that the understanding of substance use prevalence among pregnant incarcerated women is limited. We also found that treatment of substance use disorders among pregnant and postpartum populations is not routinely available, enhanced perinatal services are sorely needed, and substance use treatment programs are feasible with the help of community partnerships. More research is required to understand current substance use treatment initiatives and outcomes for pregnant women in prison. In addition, strategies for integrating evidence-based, substance use treatment in carceral settings is also needed. Future directions are discussed.

A longitudinal analysis of PTSD and other mental health symptoms among people sentenced to drug treatment court.

OBJECTIVE: Drug treatment courts offer an alternative to incarceration for people who are facing criminal charges related to addiction. Because addiction commonly co-occurs with trauma exposure and associated mental illnesses, drug treatment courts likely serve people with these difficulties. Yet whether or how mental health symptoms change over drug treatment court participation has not been studied. METHOD: We sought to (1) describe the mental health symptom profiles, including PTSD, of recent drug court enrollees, (2) examine the course of these symptom profiles at baseline, 6-month follow-up, and 12-month follow-up, and (3) test posttraumatic stress symptoms (PTSS) and gender as potential moderators of any identified time effects. Participants were 983 adults sentenced to drug treatment court between 2009 and 2017. RESULTS: Generalized linear mixed models revealed a significant effect of time on PTSS as measured by the PTSD Checklist and on summary indices of mental health measured by the Brief Symptom Inventory (p < .05 for all the outcomes). Gender did not moderate the effect of time on either outcome. However, those with PTSS above the clinical cut-off at baseline experienced less improvement in mental health over time. CONCLUSION: Our findings suggest that drug treatment court participants' mental health, including PTSS, improved over time. However, the presence of elevated PTSS interfered with improvements in other facets of mental health. Additional work is needed to identify specific program components that may exert causal effects and to examine interventions for PTSS that can be readily integrated in drug treatment courts. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Perceived emotion invalidation predicts daily affect and stressors.

BACKGROUND AND OBJECTIVES: Perceived emotion invalidation is linked to the development or worsening of a variety of emotional and physical health conditions. However, prior studies are largely cross-sectional and whether there are day-to-day effects of generally feeling invalidated is unknown. DESIGN: We examined the relations between perceived emotion invalidation and momentary affect, average daily affect, and the experience of daily stressors among a sample of young adults using ecological momentary assessment (EMA). METHODS: Participants (n = 86) completed measures of perceived emotion invalidation and emotional reactivity at baseline then completed one week of EMA including: (1) 7x/day reports of current affect and social context and (2) 1x/day index of experienced stressors and their intensity. RESULTS: Higher perceived emotion invalidation predicted lower momentary positive affect. Perceived invalidation also interacted with social context such that higher emotion invalidation predicted greater negative affect when participants were with non-close others (i.e., co-workers, acquaintances). Only participants with high perceived emotional invalidation experienced increased stress alongside heightened daily negative affect. CONCLUSIONS: These results provide preliminary evidence that feeling emotionally invalidated may predict affective experiences, including how emotions are momentarily experienced and how life stressors are interpreted when they are later reflected on.

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

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

Characteristics of recently incarcerated primary care patients with and without a positive posttraumatic stress disorder screening upon clinic intake.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is prevalent among people who have been incarcerated. Here, we examined whether screening positive for PTSD was associated with other indicators of poor health, acute healthcare utilization, and poverty among primary care patients upon release from incarceration. METHOD: We conducted a cross-sectional survey in a national network of primary care clinics serving people recently released from incarceration. Participants were 416 patients who completed the Primary Care PTSD screen (PC-PTSD) and other questions about mental and physical health, acute healthcare utilization, and economic status within 6 months of release. RESULTS: Screening positive for PTSD was associated with worse status across nearly all variables examined, including being more likely to report: poor/fair health (61.6% vs. 41.7%), current depressive symptoms (89.7% vs. 50.8%), lifetime depression diagnosis (63.3% vs. 35.3%), cannabis use since release (20.7% vs. 9.6%), homelessness (31.9% vs. 18.5%), having no cash on hand (56.3% vs. 39.0%) and severe food insecurity (29.3% vs. 18.2%; all ps < .01). Reporting recent suicidality (14.3% vs. 7.0%), alcohol use since release (30.2% vs. 20.0%), and emergency department utilization (20.4% vs. 12.2%) was also more likely (all ps ≤ .03). These trends were largely upheld when controlling for demographic characteristics and chronic physical health conditions using linear probability regression. CONCLUSIONS: Primary care patients recently released from incarceration have a need for wrap-around services that address health challenges and poverty. Patients with significant PTSD symptoms face even greater challenges. Identification and treatment of PTSD both during and after incarceration is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Justice-Involved, Sexually Victimized Women's Perspectives on the Acceptability of Receiving Trauma-Focused Therapy in Prison.

Incarcerated women report high rates of sexual victimization. Interviews with 63 previously incarcerated women survivors of sexual violence explored perceptions toward receiving trauma-focused therapy while incarcerated and postrelease trauma-focused therapy utilization. Nearly all participants (97%) recommended that trauma-focused therapy be available to incarcerated women. Most believed that prisons are acceptable places to receive trauma-focused therapy, without qualification (65%); some reported mixed feelings or indicated acceptability but identified factors that would increase acceptability (33%). Notably, most were currently experiencing trauma-related symptoms, but few had attended trauma-focused therapy following release. Findings indicate that access to prison-based trauma-focused therapy is necessary and acceptable.

The application of implementation science methods in correctional health intervention research: a systematic review.

BACKGROUND: Improving access to high-quality healthcare for individuals in correctional settings is critical to advancing health equity in the United States. Compared to the general population, criminal-legal involved individuals experience higher rates of chronic health conditions and poorer health outcomes. Implementation science frameworks and strategies offer useful tools to integrate health interventions into criminal-legal settings and to improve care. A review of implementation science in criminal-legal settings to date is necessary to advance future applications. This systematic review summarizes research that has harnessed implementation science to promote the uptake of effective health interventions in adult criminal-legal settings. METHODS: A systematic review of seven databases (Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Social Work Abstracts, ProQuest Criminal Justice Database, ProQuest Sociological Abstracts, MEDLINE/PubMed) was conducted. Eligible studies used an implementation science framework to assess implementation outcomes, determinants, and/or implementation strategies in adult criminal-legal settings. Qualitative synthesis was used to extract and summarize settings, study designs, sample characteristics, methods, and application of implementation science methods. Implementation strategies were further analyzed using the Pragmatic Implementation Reporting Tool. RESULTS: Twenty-four studies met inclusion criteria. Studies implemented interventions to address infectious diseases (n=9), substance use (n=6), mental health (n=5), co-occurring substance use and mental health (n=2), or other health conditions (n=2). Studies varied in their operationalization and description of guiding implementation frameworks/taxonomies. Sixteen studies reported implementation determinants and 12 studies measured implementation outcomes, with acceptability (n=5), feasibility (n=3), and reach (n=2) commonly assessed. Six studies tested implementation strategies. Systematic review results were used to generate recommendations for improving implementation success in criminal-legal contexts. CONCLUSIONS: The focus on implementation determinants in correctional health studies reflects the need to tailor implementation efforts to complex organizational and inter-agency contexts. Future studies should investigate policy factors that influence implementation success, design, and test implementation strategies tailored to determinants, and investigate a wider array of implementation outcomes relevant to criminal-legal settings, health interventions relevant to adult and juvenile populations, and health equity outcomes. TRIAL REGISTRATION: A study protocol (CRD42020114111) was registered with Prospero.

State Laws on Substance Use Treatment for Incarcerated Pregnant and Postpartum People.

Background: Incarcerated perinatal populations report high rates of substance use in the United States (US). Despite this, substance use disorder (SUD) treatment is not routinely available in carceral settings and state policies related to the provision of substance use screening and treatment are unknown. Methods: We conducted a systematic search in WestLaw through the end of the 2020 legislative session combining the terms "pregnant" and "postpartum" with terms for incarceration and related terms. The search returned 453 statutes from 43 states. A deductive codebook of various maternal health topics was developed. Legislative texts related to SUD screening and treatment were extracted for textual analysis. Results: Of the 43 states identified as having at least 1 state statute pertaining to pregnant or postpartum incarcerated people, 7 states had statutes relevant to SUD screening and treatment. Statutes related to substance use screening, education, treatment and diversion programs, program eligibility, aftercare and release planning, and funding appropriations. Conclusions: The majority of states across the U.S. lack legislation that address SUD screening and treatment among incarcerated perinatal populations. Given the known limited access to SUD treatment for perinatal populations in custody, increasing legislative statutes could increase access to essential care.

Evidence-Based Quality Improvement (EBQI) in the pre-implementation phase: key steps and activities.

Background: Evidence-Based Quality Improvement (EBQI) involves researchers and local partners working collaboratively to support the uptake of an evidence-based intervention (EBI). To date, EBQI has not been consistently included in community-engaged dissemination and implementation literature. The purpose of this paper is to illustrate the steps, activities, and outputs of EBQI in the pre-implementation phase. Methods: The research team applied comparative case study methods to describe key steps, activities, and outputs of EBQI across seven projects. Our approach included: (1) specification of research questions, (2) selection of cases, (3) construction of a case codebook, (4) coding of cases using the codebook, and (5) comparison of cases. Results: The cases selected included five distinct settings (e.g., correction facilities, community pharmacies), seven EBIs (e.g., nutrition promotion curriculum, cognitive processing therapy) and five unique lead authors. Case examples include both community-embedded and clinically-oriented projects. Key steps in the EBQI process included: (1) forming a local team of partners and experts, (2) prioritizing implementation determinants based on existing literature/data, (3) selecting strategies and/or adaptations in the context of key determinants, (4) specifying selected strategies/adaptations, and (5) refining strategies/adaptations. Examples of activities are included to illustrate how each step was achieved. Outputs included prioritized determinants, EBI adaptations, and implementation strategies. Conclusions: A primary contribution of our comparative case study is the delineation of various steps and activities of EBQI, which may contribute to the replicability of the EBQI process across other implementation research projects.