Engagement In Care Research Articles

Characterizing syndemic HIV risk profiles and mHealth intervention acceptability among patients in the emergency department

ABSTRACT Syndemic theory proposes that co-occurring, mutually reinforcing psychosocial challenges (mental health, substance use, minority stress [discrimination/stigma], abuse, unmet basic needs) drive HIV risk behavior and create barriers to care for marginalized populations. It is thus necessary to address this holistic, complex picture in HIV prevention. Emergency department (ED) visits are a prime opportunity to engage key risk groups, given their low engagement in regular clinic-based care and high utilization of drop-in care via EDs. Yet, EDs are overburdened and under-resourced; mHealth may be a vehicle for intervention delivery in this context. This study aimed to 1) characterize demographics, syndemic profiles, and HIV risk behavior among ED patients and 2) assess the acceptability of addressing syndemic issues, particularly via an mHealth approach, in the ED. A sample of N = 198 ED patients with an indication of HIV risk completed a cross-sectional psychosocial assessment. Descriptive statistics and bivariate correlations between syndemic issues were examined. Patients presenting to the ED reported marginalized identities and complex syndemic profiles including mental health issues (77%), at risk substance use (30%), childhood abuse (35%), adult abuse (31%), minority stress (63%), and unmet basic needs (37%). Over half the sample reported at least three syndemic issues (54%). All syndemic issues were significantly correlated with each other, supporting a synergistic nature. The sample reported indicators of HIV risk including lack of PrEP awareness (33%)/uptake (94%), condomless sex (37%), and not testing for HIV (41%). Majority reported syndemic profiles have never been addressed in the ED (71%), think it would be helpful (88%), and willing to utilize mHealth during an ED visit (76%). The current study provides information to guide next steps for ED-based point-of-care HIV prevention, and more broadly, working towards equitable HIV prevention services reaching those missed by existing interventions.

Facets of mindfulness are associated with inflammation biomarkers in a sample of sexual minority men with HIV

ABSTRACT Sexual minority men (SMM) are disproportionately impacted by HIV and thus, HIV related-health complications. HIV has been linked to earlier onset of multi-morbid chronic diseases and declines in physical and cognitive functioning attributable to chronic HIV immune activation and resulting inflammation. Inflammation has been targeted with mindfulness-based interventions (MBIs); however, hypothesized negative associations between mindfulness and inflammation need to be confirmed in SMM with HIV. This is a secondary data analysis of baseline data from a randomized clinical trial (RCT) of SMM living with HIV with biologically confirmed recent methamphetamine use (ARTEMIS). Mindfulness was assessed with the Five Factor Mindfulness Questionnaire (FFMQ). Inflammation was assessed via cytokines interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Separate adjusted (for age, viral load, CD4 count, and methamphetamine use) regression models evaluated associations between four facets of mindfulness (description, awareness, non-judgement, and non-reactivity) with IL-6 and TNF-α. The average age of the participants was 43.86 (SD = 8.95). Both description (b = .54, se = .24) and awareness (b = .50, se=.23) were positively associated with IL-6. All other associations between mindfulness and inflammation were non-significant in adjusted models. There was also some evidence to suggest that engagement in care moderated associations between description and non-reactivity with IL-6 (ΔR 2 = .03, F = 3.64), such that description and non-reactivity were each positively associated with inflammation among those who attended <100% of primary care appointments (b = 1.04, se=.34 and b = 1.23, se=.39, respectively), but was not associated with inflammation among those who attended 100% of appointments (b =.16, se=.32 and b=-.17, se=.40, respectively). There was also a significant interaction between 12-step program attendance and awareness with IL-6 (ΔR2= .03, F = 4.26), such that awareness was positively associated with inflammation among those who attended 12-step programming (b = 1.25, se = .41), but not associated with inflammation among those who did not (b = .22, se = .28). Further research is needed to understand how and under what circumstances mindfulness is associated with pro- versus anti-inflammatory processes.Trial Registration: NCT01926184.

General practice preconception care invitations: a qualitative study of women’s acceptability and preferences

BackgroundIn general practice, primary care providers can potentially use electronic medical records (EMRs) to identify and invite reproductive-aged women with preconception health risk factors to increase their engagement in preconception...

Prevention of adverse HIV treatment outcomes: machine learning to enable proactive support of people at risk of HIV care disengagement in Tanzania

ObjectivesThis study aimed to develop a machine learning (ML) model to predict disengagement from HIV care, high viral load or death among people living with HIV (PLHIV) with the goal...

Heart Failure Care Facilitators and Barriers in Rural Haiti: A Qualitative Study

Background: Heart failure (HF) is a leading cause of hospitalizations in Haiti. However, few patients return for outpatient care. The factors contributing to chronic HF care access are poorly understood. Objective: The purpose of this study is to investigate the facilitators and barriers to accessing care for chronic HF from the patients’ perspectives. Methods: We conducted a qualitative descriptive study of 13 patients with HF participating in three group interviews and one individual interview. We recruited patients after discharge from a nongovernmental organization-supported academic hospital in rural Haiti. We employed thematic analysis using emergent coding and categorized themes using the socioecological model. Findings: Facilitators of chronic care included participants’ knowledge about the importance of treatment for HF and engagement with health systems to manage symptoms. Social support networks helped participants access clinics. Participants reported low cost of care at this subsidized hospital, good medication accessibility, and trust in the healthcare system. Participants expressedstrong spiritual beliefs, with the view that the healthcare system is an extension of God’s influence. Barriers to chronic care included misconceptions about the importance of adherence to medications when symptoms improve and remembering follow-up appointments. Unexpectedly, participants believed they should take their HF medications with food and that food insecurity resulted in missed doses. Lack of social support networks limited clinic access. The nonhealthcare costs associated with clinic visits were prohibitive for many participants. Participants expressed low satisfaction regarding the clinic experience. A barrier to healthcare was the belief that heart disease caused by mystical and supernatural spirits is incurable. Conclusions: We identified several facilitators and barriers to chronic HF care with meaningful implications for HF management in rural Haiti. Future interventions to improve chronic HF care should emphasize addressing misconceptions about HF management and fostering patient support systems for visit and medication adherence. Leveraging local spiritual beliefs may also promote care engagement.

Financial incentives to increase engagement across the hepatitis C care cascade among people at risk of or diagnosed with hepatitis C: A systematic review

BackgroundReversing declining rates of people initiating and completing hepatitis C (HCV) treatment, observed in many countries, is needed to achieve global HCV elimination goals. Providing financial incentives to increase HCV testing and treatment uptake among people at-risk of or living with HCV infection could be an effective intervention. We conducted a systematic review to assess evidence regarding the effectiveness of financial incentives to improve engagement and progression through the HCV care cascade. MethodsWe searched MEDLINE, PubMed and EMBASE for studies published from January 2013 to January 2023 that evaluated financial incentives offered to people living with and at-risk of HCV to increase HCV antibody and or RNA testing, linkage to care, treatment initiation, treatment adherence, treatment completion, and sustained viral load (SVR) testing. Open-label randomised controlled trials (RCTs), controlled non-randomised studies, cohort or observation studies and mixed-methods studies were included, whereas literature reviews, case series and studies which did not report data were excluded. ResultsWe identified 1,278 studies, with 21 included after full-text screening (14,913 participants); three randomised controlled trials and 18 non-randomised studies. Studies evaluated incentives aimed at improving test uptake (n = 11), engagement in care (n = 13), treatment initiation (n = 8), adherence (n = 3), completion (n = 3) and attainment of SVR (n = 5). Findings provided inconclusive evidence for the effectiveness of incentives in improving engagement in the HCV cascade of care. Determining incentive effectiveness to improve care cascade engagement was limited by low quality study designs, heterogeneity in type (cash or voucher), value (US$5 to $600) and cascade stage being incentivised. No randomised controlled trials assessed the effectiveness of incentives to promote HCV testing, and none showed an impact on treatment uptake. In non-randomised studies (observational comparative), some evidence suggested that incentives promoted HCV testing, but evidence of their role in promoting linkage to care, HCV treatment adherence and treatment completion were mixed. ConclusionCurrently, there lacks high-quality evidence evaluating whether financial incentives improve HCV testing and treatment outcomes. Future research should seek to standardise methodologies, compare incentive types and values to enhance engagement in HCV care, and determine factors that support incentives effectiveness.

Increasing engagement with liver disease management across the UK: follow-up cross-sectional survey.

Liver disease is an increasing cause of premature mortality. Early detection of liver disease in primary care gives opportunity to intervene and change outcomes. Engagement in liver disease care by NHS bodies responsible for primary care pathway development could drive improvements. The formation of integrated care systems (ICS) in England provides an opportunity to reassess engagement with liver disease nationally. To update the level of engagement with community chronic liver disease management amongst ICSs and health authorities across the UK. A cross-sectional follow up survey to ICS and UK Health Boards. Questions used for a previous survey in 2020 were adapted and sent electronically to NHS bodies responsible for health care across the UK using a Freedom of Information request. Quantitative analysis used Microsoft Excel. There were 67 responses from 68 possible ICS and Health Board areas representing 99% UK coverage. 27% had a named individual responsible for liver disease. Monitoring of local liver disease health statistics happened in 34% of all UK areas. Comprehensive care pathways were available in 24/67 (36%) of areas, an increase from 26% in the 2020 survey. Areas with no liver pathways in place fell from 58% to 36% between the two surveys. Regional variations persist, with Wales and Scotland moving towards comprehensive coverage. Almost double the number of areas were making use of transient elastography within community pathways of care, up from 25% to 46%. The results of this re-survey highlight improvements, but emphasise the need to build on regional success to further reduce inequality in care commissioning.

Predicting Mental Health Care Enrollment and Treatment Uptake among Newly Arrived Refugees in U.S. Resettlement Programs.

This article examines variables that predict mental health care enrollment and engagement among refugees. The authors explore a mental health care model designed to identify mental health needs early among refugee arrivals that may interfere with adjustment and overall health outcomes using data from a Midwest refugee resettlement program. Using ecological models of mental distress and theories on help-seeking behaviors, the authors used logistic and count regressions to predict enrollment in mental health care services and utilization rates. Gender, nationality, and presenting problems were significant predictors of enrollment and length of engagement in services. The findings provide guidance to practitioners and resettlement agencies on refugee mental health and opportunities to increasing access and engagement in mental health care.

Outcomes that Matter to Youth and Families in Behavioral Health Services.

Patient-centered outcomes research helps youth and families using behavioral health services make informed decisions about treatments to help them achieve the outcomes most important to them. However, there are few efforts to identify the outcomes valued by youth and families systematically. This project aimed to support the development of behavioral health services that deliver outcomes valued by families by identifying the outcomes that youth and young adults with behavioral health needs and caregivers say matter most to them. We engaged 34 youth and young adults (YYA) with behavioral health needs, alongside 42 caregivers from six U.S. regions, in two rounds of one-hour virtual focus groups. The initial round involved participants identifying what they hoped to gain from using behavioral health services for personal, familial, and parental or child well-being and the attributes of positive service experiences. We coded responses using qualitative analytical software, culminating in synthesized reports. Subsequently, the second round entailed participants' review and refinement of initial findings. Across sessions, each group reported the top three outcomes deemed most important for children, YYA, parents, families, and their service experiences. YYA identified being understood by others, improving their interpersonal relationships, and feeling heard as the highest priority behavioral health service outcomes. Caregivers of children and youth with behavioral health needs identified having accessible services that meet their needs, having providers that collaborate effectively with parents and other service systems, and experiencing consistent and continuous behavioral health care for their child as the most important behavioral health service outcomes. Both YYA with behavioral health needs and caregivers of children and youth prioritized gaining the necessary knowledge, resources, and tools to support their or their child's behavioral health. Additionally, both participant groups emphasized the importance of effective communication with providers, within their families, and with peers. Minimizing judgment and stigma from society, providers, and other professionals also emerged as a critical outcome for these groups. It is essential for research and policy development to focus on and cater to the outcomes that are important and valued by YYA and their families to maximize family engagement in care.

Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Health Care System (Jabula Uzibone): Protocol for an Implementation Study.

Almost 60% of transgender people in South Africa are living with HIV. Ending the HIV epidemic will require that transgender people successfully access HIV prevention and treatment. However, transgender people often avoid health services due to facility-based stigma and lack of availability of gender-affirming care. Transgender-specific differentiated service delivery (TG-DSD) may improve engagement and facilitate progress toward HIV elimination. Wits RHI, a renowned South African research institute, established 4 TG-DSD demonstration sites in 2019, with funding from the US Agency for International Development. These sites offer unique opportunities to evaluate the implementation of TG-DSD and test their effectiveness. The Jabula Uzibone study seeks to assess the implementation, effectiveness, and cost of TG-DSD for viral suppression and prevention-effective adherence. The Jabula Uzibone study collects baseline and 12-month observation checklists at 8 sites and 6 (12.5%) key informant interviews per site at 4 TG-DSD and 4 standard sites (n=48). We seek to enroll ≥600 transgender clients, 50% at TG-DSD and 50% at standard sites: 67% clients with HIV and 33% clients without HIV per site type. Participants complete interviewer-administered surveys quarterly, and blood is drawn at baseline and 12 months for HIV RNA levels among participants with HIV and tenofovir levels among participants on pre-exposure prophylaxis. A subset of 30 participants per site type will complete in-depth interviews at baseline and 12 months: 15 participants will be living with HIV and 15 participants will be HIV negative. Qualitative analyses will explore aspects of implementation; regression models will compare viral suppression and prevention-effective adherence by site type. Structural equation modeling will test for mediation by stigma and gender affirmation. Microcosting approaches will estimate the cost per service user served and per service user successfully treated at TG-DSD sites relative to standard sites, as well as the budget needed for a broader implementation of TG-DSD. Funded by the US National Institutes of Mental Health in April 2022, the study was approved by the Human Research Ethics Committee at University of Witwatersrand in June 2022 and the Duke University Health System Institutional Review Board in June 2023. Enrollment began in January 2024. As of July 31, 2024, a total of 593 transgender participants have been enrolled: 348 are living with HIV and 245 are HIV negative. We anticipate baseline enrollment will be complete by August 31, 2024, and the final study visit will take place no later than August 2025. Jabula Uzibone will provide data to inform HIV policies and practices in South Africa and generate the first evidence for implementation of TG-DSD in sub-Saharan Africa. Study findings may inform the use of TG-DSD strategies to increase care engagement and advance global progress toward HIV elimination goals. DERR1-10.2196/64373.

Development and validation of the mpox stigma scale (MSS) and mpox knowledge scale (MKS)

BackgroundFew validated brief scales are available to measure constructs that may hinder mpox-related prevention and care engagement, such as knowledge and stigma. Both are highly salient barriers to infectious disease care and disease understanding, precursors to evaluating one’s risk and need to, for example, accept vaccination. To address this gap, we developed and validated the Mpox Stigma Scale (MSS) and Mpox Knowledge Scale (MKS).MethodsAs part of a full-scale clinical trial, we offered an optional mpox survey to participants who self-identified as African American or Black, were 18–29 years old, and lived in Alabama, Georgia, or North Carolina (2023, N = 330). We calculated psychometric properties through confirmatory factor analyses (CFA) and applied Comparative Fit Index (CFI), Goodness of Fit Index (GFI), and Tucker-Lewis Index (TLI) values equal to or exceeding 0.90 and Root Mean Square Error of Approximation (RMSEA) and Standardized Root Mean Square Residual (SRMR) values less than 0.08 to determine adequate model fit. We computed internal reliability using Cronbach’s alpha and calculated Pearson or Spearman correlation coefficients between the MSS and MKS and related variables.ResultsFor the MSS, CFA results showed that the one-factor model fit the data well (χ2(df = 5, N = 330) = 34.962, CFI = 0.97, GFI = 0.99, TLI = 0.94, RMSEA = 0.13, SRMR = 0.03). For the MKS, the one-factor model provided a good fit to the data (χ2(df = 6, N = 330) = 8.44, CFI = 0.99, GFI = 0.99, TLI = 0.95, RMSEA = 0.15, SRMR = 0.02). Cronbach’s alphas were MSS = 0.91 and MKS = 0.83, suggesting good to excellent reliability. The MSS was correlated with the MKS (r = .55, p < .001), stigmatizing attitudes (r = .24, p < .001), attitudes towards mpox vaccination (r=-.12, p = .030), and worry about contracting mpox (r = .44, p < .001). The MKS was correlated with worry about contracting mpox (r = .30, p < .001) and mpox disclosure (r=-.16, p = .003).ConclusionsThe MSS and MKS are reliable and valid tools for public health practice, treatment and prevention research, and behavioral science. Further validation is warranted across populations and geographic locations.Trial RegistrationClinicalTrials.gov NCT05490329.

Establishing a linked administrative data sampling frame to recruit families into a new UK-wide birth cohort study: findings from the Early Life Cohort Feasibility (ELC-FS) Study

Objective and ApproachFunded by the Economic and Social Research Council (2021-2024), a core aim of the ELC-FS was to establish a sampling frame by linking birth registrations and maternity records in the four UK nations (England, Wales, Scotland and Northern Ireland) to facilitate recruitment of ~2000 families into a new birth cohort study. An opt-out recruitment approach was essential. Widespread public dialogue work was undertaken to glean the attitudes and perspectives of stakeholders including data controllers, data users, and parents of young children, as to the acceptability of this recruitment model. ResultsAchieving the sampling frame required nation-specific approaches due to differences in existing legislation governing secondary use of administrative data. Complex and protracted negotiations with data controller approval panels were necessary. Public dialogue work revealed that stakeholders were: (i) excited by the prospect of a new UK-wide birth cohort study to provide invaluable insights into the lives of a new generation; and (ii) broadly accepting of the proposed use of administrative data for generating a sampling frame, particularly in terms of ensuring that the ELC-FS study has diverse and inclusive representation of family life in the UK today. ConclusionsELC-FS fieldwork will be completed by mid-2024. Preliminary analyses to be presented at the conference will assess the suitability of the sampling frame for achieving the target ELC-FS sample. ImplicationsWith careful engagement with stakeholders at a national level, access to linked administrative data as a sampling frame for a UK-wide birth cohort study is achievable, but not straightforward.

Scoping review of the role of social support in women Veterans’ psychosocial and health outcomes

Women veterans are a steadily growing population and have unique military experiences (e.g., report high rates of sexual harassment and assault) that are impactful across the lifespan. High levels of positive social support have been linked to a range of positive outcomes in both civilian and military populations. However, research has not consistently explored social support and interpersonal functioning in women veterans, or as potential mechanisms of change within interventions for women veterans. This is a scoping review of peer-reviewed articles that evaluated social support. Articles with at least 10% women or formally evaluated sex or gender in reference to social support were included. A total of 69 studies evaluated social support in relation to women veterans’ health outcomes. From a biopsychosocial perspective, social support is an important construct to examine relative to health care engagement and response. Limited research considered aging women veterans needs or focused on the intersectional identities of women veterans. Positive social support can have major physical and mental health benefits, yet limited research and disparate methodological approaches minimize the ability to draw conclusions on how social support can best be leveraged to support women veterans. Women veterans’ roles and military experiences (e.g., increased likelihood of combat exposure) are changing and this population is aging. Research is needed to inform best practices for this growing segment of the veteran population.

Identifying Effective Strategies for Improving Engagement in HIV Prevention and Care Among Transgender Persons in the United States: A Systematic Review.

This systematic review synthesized published literature (2000 - 2023) to identify HIV interventions specifically designed for transgender persons in the United States (PROSPERO registration number: CRD42021256460). The review also summarized strategies for improving outcomes related to the four pillars of the Ending the HIV Epidemic (EHE) initiative in the United States: Diagnose, Treat, Prevent, and Respond. A comprehensive search was conducted using the Centers for Disease Control and Prevention's HIV Prevention Research Synthesis Project database, which included over 120,000 citations from routine systematic searches in CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts. Of 23 interventions that met inclusion criteria, 94% focused on transgender women of color and 22% focused on young transgender persons aged 15-29 years old. Most interventions focused on Treat or Prevent, few focused on Diagnosis, and none focused on Respond. Twenty interventions (87%) showed improvement in at least one EHE related outcome and a quarter of these effective interventions were tested with randomized controlled trials. Common strategies observed in effective interventions include the following: engaging the community in intervention development; pilot-testing with the focus population to ensure appropriateness and acceptability; addressing social determinants of health (e.g. stigma, discrimination, violence) through empowerment and gender-affirming approaches; increasing access to care, prevention, and services through co-location and one-stop shop models; and utilizing peer-led counseling, education, support, and navigation. Continuous effort is needed in addressing gaps, including more research for transgender men and rural settings and for how best to adopt and adapt best practices for subgroups of transgender population.

"How well do we know our patients?": Further validation of a complexity rating scale for HIV.

Despite advances in the management and treatment of HIV, identifying risks for disengagement are essential to maximize positive outcomes. The current study investigated the validity of the Clinical Complexity Rating Scale for HIV (CCRS-HIV), a risk-prediction tool, by assessing agreement between patient and clinician scores of patient complexity. 207 patients completed the patient version of the CCRS-HIV (CCRS-HIVP), and six Attending Medical Officers (AMOs) caring for those individuals completed the original clinician version (CCRS-HIVC). Kappa statistics, sensitivity and specificity were used to assess patient-clinician agreement. Patient-clinician agreement was highest for problematic crystal methamphetamine use (86%), polypharmacy (84%) and other physical health concerns (67%). Cut-offs of 40 and 45 for the total CCRS-HIV score were identified as most appropriate, with high sensitivity (79.31% and 76.0% respectively). Overall agreement between the clinician and patient complexity scores was high. These findings provide further evidence of the validity of the scale. The study demonstrates that the unique role of AMOs at the center contributes to them knowing their patients well, allowing them to manage and refer when required for interdisciplinary care which likely contributes to their ongoing engagement in care and may account for the high level of agreement.

Implementing and monitoring high-quality community health worker care in adult primary care at New York City Health + Hospitals

BackgroundThis study describes how New York City (NYC) Health + Hospitals implemented a large-scale Community Health Worker (CHW) program in adult primary care clinics between January 2022 and December 2023 and established metrics to monitor program implementation. This study is timely as healthcare systems consider how to scale high-quality CHW programs.MethodsWe collected metrics in the following areas: (1) Workforce demographics, team structure, and training; (2) Enrolled patient demographics; (3) Patient-centered metrics, such as patient counts (e.g. patients outreached and enrolled) and engagement (e.g. median time in program, caseloads per CHW), and goals (e.g. median number of goals identified and completed). Metrics are based on standard data elements captured through CHW documentation in the electronic health record collected during program implementation. Data cleaning is completed using SQL queries and R scripts.ResultsIn June 2023, there were a total of 97 CHW and 22 CHW Supervisor staff lines in adult primary care across 17 healthcare sites. There were 4.6 CHWs to 1 CHW supervisor on average though this ranged by facility from 1:1 to 1:6. Compared to the population that receives primary care at NYC H + H, CHWs served more African American/Black patients (40% vs. 32%) and an older patient population (35% older than 65 vs. 21% older than 65). From January 2022 to December 2023, 13,812 patients were outreached by CHWs. Of these, 9,069 (66%) were referred by clinicians, 7,331 (53%) were enrolled, and 5,044 (37%) successfully graduated. The median number of goals identified by patients was four, and the median number of goals completed with a CHW per patient was three. The top three goals were primary care engagement (47%), specialty care engagement (46%), and food insecurity (45%).ConclusionEstablishing clear implementation and process metrics helps to ensure that CHWs embedded in health systems can meaningfully engage adult patients in health care, address patient-centered goals, and connect patients to community and government services.

Psychosocial Syndemic Burden, Sexual Behaviors, and Engagement in HIV Prevention Care Among Sexual and Gender Minority Youths: United States, 2022.

Objectives. To examine linear and nonlinear associations between psychosocial syndemic factors and HIV risk and engagement in HIV prevention care among sexual and gender minority (SGM) youths. Methods. Between February and October 2022, we recruited 17 578 SGM youths aged 13 to 18 years in the United States for an online survey. We examined the relationship of syndemics (i.e., binge drinking, drug use, sexual victimization, and anti-lesbian, gay, bisexual, and transgender discrimination) with sexual behaviors (i.e., sexual initiation, condomless anal or vaginal sex, and number of sexual partners) and HIV prevention care (i.e., HIV testing, preexposure prophylaxis awareness and utilization) using regression. Results. Psychosocial syndemic burden (number of syndemic factors reported) was linearly and cubically associated with engagement in sexual behaviors. Psychosocial syndemic burden was linearly associated with higher HIV testing and preexposure prophylaxis awareness and cubically associated with higher preexposure prophylaxis utilization. Conclusions. Our findings are evidence of synergism across psychosocial syndemic factors regarding HIV risk and engagement in HIV prevention care among SGM youths in the United States. Public Health Implications. Multicomponent interventions may help reduce HIV risk and promote access to HIV prevention services among SGM individuals aged 13 to 18 years. (Am J Public Health. 2024;114(9):892-902. https://doi.org/10.2105/AJPH.2024.307753).

The impact of financial incentives on mental health among adults in HIV care in Lake Zone, Tanzania.

Depression and anxiety are prevalent among people with HIV (PWH), hindering retention in care. Though economic interventions can improve care engagement and mental health in the general population, this remains understudied among PWH. This study assessed whether financial incentives improve mental health among adult antiretroviral therapy (ART) initiates in Lake Zone, Tanzania. Two-arm randomized controlled trial. From 2021 to 2023, 32 clinics were randomized to offer patients monthly financial incentives (22 500 TSH/US$ 10) for ≤six months (conditional on visit attendance) or standard-of-care (SoC) services. We assessed changes in depression (PHQ-2 scores) and anxiety (GAD-2 scores) symptoms at baseline, six, and 12 months. Difference-in-differences effects were used to estimate changes over time by arm using inverse probability of censoring sample weights (IPCW). Participants ( n = 1990) were 57.3% female; median age was 35.0. Baseline prevalences of depression and anxiety symptoms were 66.2% and 60.4%, respectively, and endline prevalences were 7.8% and 7.6% in the intervention and SoC arms, respectively, with no differences by arm. Using IPCW, the differences in the prevalence of depression and anxiety symptoms in the intervention arm compared to the SoC arm were 2.5 percentage points [95% confidence interval (CI): -3.0, 8.0) and 2.3 percentage points (95% CI: -3.2, 7.9) respectively after six months, and 5.5 percentage points (95% CI: -0.20, 10.8) and 3.8 percentage points (95% CI: -1.5, 9.2) respectively after 12 months. Both study arms experienced substantial reductions in poor mental health, primarily within the first six months of care. Financial incentives provided in this study did not significantly augment these downward trends but may improve engagement in care, indirectly improving mental health.

Applying a trauma‐informed care framework to courtroom practice: An analysis of judges' perspectives

AbstractAnalysis of in‐depth interviews with eight district court judges in North Carolina revealed over 40 practices that judges can adopt to become more trauma‐informed in their work. These practices map onto SAMHSA's framework for a trauma‐informed approach, demonstrating that abstract principles can translate into concrete actions in the courtroom setting. Analysis revealed an additional core principle of trauma‐informed judicial practice—Rehabilitation and Healing—and several areas where judges can deepen their commitment to trauma‐informed care—engagement with peer support programming; greater attention to cultural, historical, and gender issues; and application of trauma‐informed practice in adult criminal court.

Evaluation of the integration of palliative care in a fragile setting amongst host and refugee communities: Using consecutive rapid participatory appraisals

Background: Palliative care is seldom integrated in healthcare in fragile, conflict affected and vulnerable settings with significant refugee populations. Aim: This study aimed to evaluate the integration of palliative care into a fragile, conflict affected and vulnerable community in Northern Uganda. Design: Consecutive Rapid Participatory Appraisals were conducted to evaluate the integration of palliative care in Adjumani District. The first established a baseline and the second, 4 years later, evaluated progress. Data collection included documentary review, key informant interviews and direct observation. Setting/participants: A rural district in Uganda with equal numbers of refugees and host populations living side-by-side. 104 key informants were interviewed, and practice observed in 11 health facilities. Results: At baseline, palliative care was not routinely integrated in the health system. Barriers included health system challenges, cultural beliefs, understanding and trust, mental health issues, gaps in palliative care provision, the role of the community and beliefs about illness impacted care with the village health teams being a trusted part of the health system. Following integration activities including training, mentorship and community sensitisation, the repeat rapid appraisal after 4 years showed a significant increase in palliative care delivery. New themes identified included increased provision of palliative care, the impact of training and community engagement and ownership of palliative care. Conclusion: Community engagement and participation, training interventions and referral pathways enabled the integration of palliative care. Rapid Participatory Appraisal provides a useful framework to evaluate activities aimed at integration of palliative care in a community.