Client Access Research Articles

Counseling Perinatal Clients with Substance Use Disorder: A Relational Approach

ABSTRACT Treatment for substance use disorder (SUD) is frequently accompanied by concurrent trauma counseling. However, the needs of perinatal clients with SUD remain unaddressed, despite their clinical and multicultural needs concerning trauma, gender, and perinatal status. Relational cultural theory (RCT), which aims to enhance clients’ capacities for relational resilience and growth-fostering relationship, may help augment client access to adaptive support networks. We present an overview of the clinical needs of perinatal clients with dual diagnoses and propose a creative and relational approach to this vital work.

The mobilization of nurse-client therapeutic relationships in injectable opioid agonist treatment: Autonomy, advocacy and action

IntroductionInjectable opioid agonist treatment (iOAT) is an evidence-based treatment that serves an important minority of people with opioid use disorder who require specialized care. Unique to iOAT care is the consistency with which clients access treatment (up to three times daily), a condition that creates repeated opportunities for health care engagement. To date, no study has examined therapeutic relationships in this life saving, nurse-led treatment that can have lasting implications in the equitable delivery of other forms of addictions care. MethodsThis study used grounded theory to generate a dynamic framework for therapeutic relationship building in iOAT. Researchers collected semi-structured interviews from registered nurses working in iOAT sites (n=24) form January 2020 through June 2022. The study analyzed collected data through a constant comparative analysis; explored through open, axial, and selective coding; and assessed in a conditional relationship matrix. The team reviewed key findings with stakeholders through formalized processes of engagement to confirm saturation of coding categories. Throughout data collection and analysis, researchers integrated feedback from additional knowledge users and member checking. Reported findings adhered to the COREQ1 standardized checklist. ResultsWe identified five interrelated categories that created a distinct culture of care for iOAT nurses: Ways of Knowing, Personal Investment, Leveraging Empathy, Finding Flexibility, and Collaborating to Overcome. Through creating a safe, nonjudgmental environment, nurses establish therapeutic relationships that build trust to identify client needs outside of medication administration. In turn, nurses participate in team-based problem solving to advocate for client needs. If nurses cannot find flexibility within and outside of the health care system to improve client engagement, tensions can arise and therapeutic relationships can be strained. ConclusionsTherapeutic relationships are an integral part of building and maintaining trust with a population that has been precariously involved with other forms of health care. Nurses make a substantial effort to create a safe and nonjudgmental environment to manifest a culture of care that bridges client needs and program access. Without the expansion of access to iOAT programs and their embedded services, nurses are limited in their ability to provide individualized care for clients with diverse needs.

Clinicians' perspectives on why young Aboriginal people are not testing for sexually transmissible infections in Western Sydney.

Incidence of sexually transmissible infections (STI) amongst young Aboriginal people in Australia are significantly higher compared to the wider population. Low levels of engagement with public sexual health services also exacerbates health inequity. This study sought to understand the access barriers facing Aboriginal People with local Sexual Health services from the perspective of local clinicians within Western Sydney. Six clinicians (six registered nurses, two medical practitioners) and two social workers, working in a Sexual Health service, were interviewed using a semi-structure questionnaire. Interviews were audio recorded and transcribed verbatim. Interview texts were analysed using NVIVO 12 and a thematic analysis undertaken. Thematic analysis revealed three broad themes: personal, practical, and programmatic. Clinicians believed the involvement of Aboriginal people in service delivery would contribute to greater inclusion and more culturally competent services. Clinicians also considered that young Aboriginal people were unaware of the risks of untreated STIs, and that greater STI-related education regarding risk and prevention may reduce STI incidence and improve participation in services. Clinicians believed that culturally-competent STI education would be more effective if co-designed with the local Aboriginal community. Clinicians identified that Aboriginal young people were concerned about their privacy when accessing services, and that barriers could be reduced by greater community engagement in service delivery design and quality improvement initiatives. The three themes identified in this study provide guidance for service providers about approaches that may enhance the access, participation, and cultural safety sexual health services for Aboriginal clients.

Engagement over telehealth: comparing attendance between dialectical behaviour therapy delivered face-to-face and via telehealth for programs in Australia and New Zealand during the Covid-19 pandemic

BackgroundWhile the COVID-19 crisis has had numerous global negative impacts, it has also presented an imperative for mental health care systems to make digital mental health interventions a part of routine care. Accordingly, through necessity, many Dialectical Behaviour Therapy (DBT) programs transitioned to telehealth, despite little information on clinical outcomes compared with face-to-face treatment delivery. This study examined differences in client engagement (i.e. attendance) of DBT: delivered face-to-face prior to the first COVID-19 lockdown in Australia and New Zealand; delivered via telehealth during the lockdown; and delivered post-lockdown. Our primary outcomes were to compare: [1] client attendance rates of DBT individual therapy delivered face-to-face with delivery via telehealth, and [2] client attendance rates of DBT skills training delivered face-to-face compared with delivery via telehealth.MethodsDBT programs across Australia and New Zealand provided de-identified data for a total of 143 individuals who received DBT treatment provided via telehealth or face-to-face over a six-month period in 2020. Data included attendance rates of DBT individual therapy sessions; attendance rates of DBT skills training sessions as well as drop-out rates and First Nations status of clients.ResultsA mixed effects logistic regression model revealed no significant differences between attendance rates for clients attending face-to-face sessions or telehealth sessions for either group therapy or individual therapy. This result was found for clients who identified as First Nations persons and those who didn’t identify as First Nations persons.ConclusionsClients were as likely to attend their DBT sessions over telehealth as they were face-to-face during the first year of the Covid-19 pandemic. These findings provide preliminary evidence that providing DBT over telehealth may be a viable option to increase access for clients, particularly in areas where face-to-face treatment is not available. Further, based on the data collected in this study, we can be less concerned that offering telehealth treatment will compromise attendance rates compared to face-to-face treatment. Further research is needed comparing clinical outcomes between treatments delivered face-to-face compared delivery via telehealth.

A comparative analysis of resource networks of intermediary support organizations for nonprofit development: Evidence from incubators for nonprofit organizations

AbstractIncubators for nonprofit organizations (NPOs) are agencies that provide diverse services to support the creation, survival, and early stage growth of NPOs. A primary task of such agencies is to provide NPO clients access to resources through networking. Drawing on the literature on intermediary support organizations (ISOs) and tie formation and a comparative case study of three incubators for NPOs in China, this study examines differences in their resource networks for supporting NPOs and the various factors associated with those different network characteristics. The analysis shows that the types of organizations that play a pivotal role in each case's resource network—business organizations, governmental organizations, and NPOs—are different. Each of these distinctive network characteristics is individually associated with organizational influence, resource dependence, and institutional design. These differences in resource networks and the mechanisms underlying network formation contribute to the literature on ISOs.

Promotion of physical activity by health professionals in a sample of six public hospitals: A cross sectional study.

Despite strong evidence of physical and mental health benefits from physical activity, participation is low. Physical activity promotion by health professionals can effectively increase physical activity participation. This study aimed to explore the frequency of physical activity promotion by health professionals in public hospitals with a focus on community-based structured exercise; and facilitators and barriers to such promotion. We surveyed health professionals (n = 100) from physiotherapy, rheumatology and rehabilitation departments at six public hospitals in Sydney, Australia. Most common respondent characteristics were physiotherapist (84%), female (68%), aged 25-34 years (45%) and treating older adults (45%). Almost all health professionals (94%) considered themselves physical activity role-models. Half (53%) reported promoting physical activity frequently/often to their clients. Those working with children with a physical disability (23%) were more likely to promote physical activity (Relative Risk 1.69, 95% CI 1.13-2.51, p = .03), than those working with adults or older adults. Half the physiotherapists (52%) reported providing tailored advice about increasing physical activity frequently/often, but only 20% provided advice about structured physical activity. Barriers reported by physiotherapists were lack of time (51%) and client's access to transport (61%). Only half the health professionals surveyed offered tailored physical activity advice to clients, and advice on structured physical activity was less common. SO WHAT?: Some promotion of physical activity by health professionals is occurring in hospital settings but more work is needed to embed this within clinical care.

International Music Therapists' Perceptions and Experiences in Telehealth Music Therapy Provision.

The use of telehealth within music therapy practice has increased through necessity in recent years. To contribute to the evolving evidence base, this current study on Telehealth Music Therapy (TMT) was undertaken to investigate the telehealth provision experiences of music therapists internationally. Participants completed an anonymous online cross-sectional survey covering demographics, clinical practice, telehealth provision, and telehealth perceptions. Descriptive and inferential statistics, in combination with thematic analysis, were used to analyze the data. A total of 572 music therapists from 29 countries experienced in providing TMT took part in this study. The results showed that the overall number of clinical hours (TMT and in-person hours combined) declined due to the pandemic. Participants also reported reduced perceived success rates in utilizing both live and pre-recorded music in TMT sessions when compared to in-person sessions. Although many music therapists rose to the challenges posed by the pandemic by incorporating TMT delivery modes, there was no clear agreement on whether TMT has more benefits than drawbacks; however, reported benefits included increased client access and caregiver involvement. Furthermore, a correlation analysis revealed moderate-to-strong positive associations between respondents who perceived TMT to have more benefits than drawbacks, proficiency at administering assessments over telehealth, and perceived likelihood of using telehealth in the future. Regarding the influence of primary theoretical orientation and work setting, respondents who selected music psychotherapy as a primary theoretical orientation had more experience providing TMT prior to the pandemic while those primarily working in private practice were most inclined to continue TMT services post-pandemic. Benefits and drawbacks are discussed and future recommendations for TMT are provided.

Older adults' experiences with using information and communication technology and tech support services in New York City: findings and recommendations for post-pandemic digital pedagogy for older adults.

Although Information and Communication Technology (ICT) has great potential to help older adults cope with challenges associated with aging, the intended benefits of ICT are not always realized in this population due to access barriers and low digital literacy. During the COVID-19 pandemic, numerous tech support initiatives for older adults got underway. However, evaluation of the effectiveness of these initiatives is less common. This research partnered with a large, multi-service organization in New York City that gave some groups of their clients ICT devices, unlimited broadband, and access to technology training in response to COVID-19 lockdowns. This study investigates older adults' experiences with ICT and ICT support services to better inform the existing and emerging tech support for older adults during and beyond the pandemic. Data were obtained from interviewer-administered surveys of 35 older adult recipients of ICT devices, connectivity, and training in New York City. The average age was 74 years (range = 55-90 years). The group was diverse regarding race/ethnicity (Black 29%, Latino 19%, White 43%). All had low incomes. Surveys consisted of multiple-choice items and open-ended responses. The study found that one size does not fit all when it comes to ICT training and support for older adults. While connection to devices and services and tech support led to a degree of ICT adoption, the newly learned skills did not always lead to expanded device usage. The readily available tech support training and support do not guarantee service utilization, as success with tech services is related to one's pre-existing ICT competence. The study concludes that customized training based on individuals' skills rather than age is needed. Tech support training should start by understanding an individual's interests and incorporate tech education to help users identify a wide range of existing and emerging online services that can meet their needs. Service organizations should consider including an assessment of ICT access, use, and skills into their standard intake protocols to ensure effective service delivery.

Seeking safety intervention for comorbid post-traumatic stress and substance use disorder: A meta-analysis.

Seeking Safety (SS) is a widely implemented cognitive-behavioral therapy for comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD). It is a present-focused coping skills model that is highly flexible, with varied methods of delivery, to maximize acceptability and client access. The purpose of this meta-analysis is to examine the effect of SS on comorbid PTSD and SUD across randomized control trials (RCTs). In addition, ours is the first meta-analysis to examine the dose-response of SS by comparing delivery of all 25 SS topics versus fewer. Articles published before January 2, 2023 (CINAHL n=16, PsycINFO n=31, MEDLINE n=27, Cochrane n=38, and Scopus n=618) were searched. Seven studies were included for meta-analysis and dose-response analysis. Based on effect sizes (ES), meta-analysis revealed that SS has a medium group, time (p=.04), and time by group effect on substance use per the Addiction Severity Index at 3 months and a small effect on Clinician-Administered PTSD Scale scores by group, a large effect by time, and a medium time by group (p=.002) effect at 6 months. Based on the pooled ES examining various measures across multiple timepoints, SS had small to medium effects on substance use by time, group, or time by group and medium to large effects on PTSD symptoms by time, group, or time by group (except for the group effect at 3-month follow-up). Significant effects were found for substance use by time at 3 and 6 months and for PTSD postintervention, at 6 months and 9 months by group, time, and time by group while only by time at 3 months. Meta-regression revealed that partial dose versions of SS generally function as well as the full dose version of SS when observing long-term effects (greater than 3 months). Findings suggest SS has merit in treating PTSD symptoms and SUD. Based on the summarized effect sizes, SS appears more effective in reducing PTSD than substance use, which converges with the larger treatment outcome literature that consistently finds this. We explore reasons that treatment of SUD is more challenging than treating PTSD and offer suggestions for practitioners. We emphasize the need for future studies to utilize common measures and provide full details of treatment delivery for optimal comparison across studies.

How the Oaklander Model sparked a Global Community of Therapists in a Pandemic, and enriched Training and Treatment

Social isolation caused by COVID threatened psychotherapist-client and instructor-learner contact especially in the child therapy field. In response, the author devised free online Oaklander Model interactive play therapy tools (Sandtray, Puppets, Dollhouse, Projective Cards, Mindfuldraw) which replace their hands-on originals with tabs of images clients choose, place, move, enlarge or shrink, and make act and speak to orchestrate scenes. The author also conducted teleconference training and supervision in their use. Both the digital interventions and instruction continue to attract therapists from some 30 countries, who collaborate to support children from afar. The technological recasting of play techniques and teaching proved to retain and even expand their powers along with their reach. Such expansion confirmed the universal, timeless efficacy of Oaklander’s interventions and approach, and their applicability to virtual platforms. It also increased client access to therapy and therapist access to clinical education, regardless of location and finances. Finally, it revealed advantages of remote play therapy and training: recording sessions or stages of client creations, including from separate devices; shot sharing of clients’ home, household members, pets and meaningful objects for assessment and exploration; environmental sustainability of foregoing transportation, office rental, physical art materials and storage; and construction of an international therapeutic community sharing their knowledge. Periodic polling, current website analytics and a recent formal survey show these techniques and gains have outlasted and outgrown lockdown despite distance, financial hardship and, sometimes, war. Digital therapy, learning and collaboration endure and expand both online and live as the foundation of this network’s dual achievement: a global community of healers and a global extension of healing.

Reviewing Record Keeping in Psychotherapy from Ethical Perspective

It is stated that the ethical framework of psychotherapy records is specified by applicable laws, the Ethic Code of the American Psychological Association (APA) and the Ethic Regulations of the Turkish Psychologists Association. Ethical standards, occupational limitations and legal obligations may in some cases contradict themselves or suggest acting in different ways. In situations that create ethical dilemmas like this, a guideline is needed that will facilitate the ethical decision-making processes of psychotherapists and help balance these requirements. This study, in which a decent case example is given at the end, has been made to address the stated need. This review aims to present a gradual and detailed presentation of the ethical framework regarding the psychotherapy records that start from the first session, continue throughout the process, and are kept after the therapy ends. It is thought that emphasizing the importance of keeping records in psychotherapy in terms of professional ethics will guide psychotherapists. While reviewing the subject; ethical principles and obligations regarding psychotherapy records, purposes of record keeping, characteristics and content of records, the confidentiality of records, client's access to records, sharing of records with third parties and destruction of records are included.

Access, retention, and effectiveness of Individual Placement and Support in the U.S.: Are there racial or ethnic differences?

BACKGROUND: Increased federal attention to advancing racial equity and support for underserved communities suggests the need for data on racial and ethnic differences in evidence-based employment services for people with serious mental illness. Individual Placement and Support (IPS) is an evidence-based model of supported employment for this population. OBJECTIVE: The objective was to identify differences based on race and ethnicity in IPS services. METHODS: This narrative review examined the empirical literature on IPS services in the U.S., assessing evidence of differences in access, retention, and effectiveness for Black and Hispanic IPS clients, relative to non-Hispanic Whites. RESULTS: We identified 12 studies examining racial and ethnic differences in access (4 studies), retention (3 studies), and effectiveness (6 studies). The findings for access to IPS were mixed, with two studies showing no differences, one finding less access for Blacks, and another finding greater access for Blacks but less access for Hispanics. Three studies found better retention rates for clients enrolled in IPS regardless of race or ethnicity. Compared to clients receiving usual vocational services, all studies found better employment outcomes for IPS clients regardless of race or ethnicity. CONCLUSION: Unlike for most of health care, few racial and ethnic differences have been found for IPS employment services in the U.S. Access to IPS is inadequate for all groups, with conflicting evidence whether Blacks and Hispanics have even less access. Based on the available evidence, Black and Hispanic clients have comparable retention and employment outcomes in IPS as non-Hispanic White clients. State and local mental health leaders responsible for monitoring IPS outcomes should routinely report statistics on race and ethnicity. They should also give active attention to client needs and equity. Research designs should answer multifaceted questions regarding disparities for historically underserved populations.

AWARENESS INTEGRATION THEORY CASE REPORT: THERAPUTIC INTERVENTION FOR ANXIETY AND DEPRESSION IN A TRANSEXUAL MALE COLLEGE STUDENT

One clinical psychotherapist's case report about a 19-year-old Caucasian transexual male college student with above-average intelligence is presented. Client had previously been diagnosed with generalized anxiety disorder, gender dysmorphia, and obsessive-compulsive disorder tendencies. The client sought therapeutic services due to low self-esteem that promoted feelings of awkwardness in social situations, worry that others are mad at him, and a desire for deeper relationships with friends. Therapist followed the six phases of Zeine's model of awareness integration therapy (AIT) based on AI theory. AIT has been found to successfully reduced anxiety symptoms in clients diagnosed with generalized anxiety and other disorders. AIT aims to enhance one's self-awareness about internal processes, increase self-esteem, release past traumas and psychological blocks, reduce anxiety symptoms, and regulate thoughts, emotions, attentions, intentions, and actions. Therapist's treatment plan and client's goals aligned with the six phases of AIT by: (a) increasing insight into the historical and current sources of low self-esteem; (b) decreasing the frequency of negative self-descriptive statements; (c) increasing the frequency of positive self-descriptive reports; (d) decreasing anxiety level while increasing the ability to function daily and learn; (e) implementing mindfulness exercises to reduce anxiety and worry; and (f) taking committed actions toward living a valued life. Therapist helped client access and gain awareness of the correlation between the way he perceives the world and how he relates to and behaves towards others. Client enhanced his abilities to incorporate new understanding of how he viewed the world following therapy, and made better decisions regarding himself and his personal identity. Client's scores on the posttraumatic stress disorder checklist (for DMS-5), the generalized anxiety disorder screen (GAD-7), and the patient health questionnaire (PHQ-9) decreased signicantly following 10 months of AIT. Client reported his anxiety had decreased, and he felt condent about initiating and participating in social interactions. (word count: 300)

Blockchain-Oriented Data Exchange Protocol With Traceability and Revocation for Smart Grid

<p>The smart energy system (SES) encourages data administration and information services developments, particularly smart grids. Presently, numerous SESs cloud environments are accessible to smart grids. Nonetheless, because of the semi-credible character of the SES cloud environments, achieving secured access, information storage, updates, deletion, tracing, and revocation of ill-disposed clients is a genuine concern. In this publication, an Ethereum blockchain-oriented secured access regulation design upholding traceability and revocability is offered for smart grids to resolve these problems. The blockchain implements unified identity verification and saves all public-keys, users’ attribute sets, and revocable lists. The system administrator creates system parameters and sends private-keys to users. The domain administrator prepares the domain’s security and privacy-preservation policies and executes encryption procedures. If the attributes correspond with the access policy and the user’s ID is unrevoked, they could acquire interim-decryption capabilities from the edge/cloud servers. Tracking malevolent users for revocation is applicable throughout all stages, ensuring the system is secured under Decisional-Bilinear-Diffie-Hellman (DBDH) complex theory and can withstand multi-attacks. Analysis revealed the size of the public/private keys to be shorter, contrary to relevant schemes. The overhead duration is less for generating the public-key, data encryption, and decryption phases. </p> <p> </p>

Dietitians' perceptions of identifying and managing malnutrition and frailty in the community: A mixed-methods study.

This study aimed to explore dietitians' perceptions of their current practice for identifying and managing malnutrition/frailty in the community, to fill an evidence gap. This mixed-methods study involved an online survey distributed to dietitians practising in Australia and New Zealand, and semi-structured interviews with a subset of survey participants. The 34-item survey and interviews explored dietitians' practices for identifying/managing malnutrition and frailty, focusing on the community setting. Survey data were analysed descriptively and some simple association tests were conducted using statistical software. Interview data were analysed thematically. Of the 186 survey respondents, 18 also participated in an interview. Screening and assessment for malnutrition varied in the community and occurred rarely for frailty. Dietitians reported practising person-centred care by involving clients/carers/family in setting goals and selecting nutrition interventions. Key barriers to providing nutrition care to community-dwelling adults included a lack of awareness/understanding of nutrition by clients and other health professionals (leading to them not participating in or valuing nutrition care), lack of time and resources in the community, and client access to foods/supplements. Enablers included engaging family members/carers and coordinating with other health professionals in nutrition care planning. Reported practices for identifying malnutrition and frailty vary in the community, suggesting guidance may be needed for health professionals in this setting. Dietitians reported using person-centred care with malnourished and frail clients but encountered barriers in community settings. Engaging family members/carers and multidisciplinary colleagues may help overcome some of these barriers.

Privacy-preserving authentication scheme based on zero trust architecture

Zero trust architecture is an end-to-end approach for server resources and data security which contains identity authentication, access control, dynamic evaluation, and so on. This work focuses on authentication technology in the zero trust network. In this paper, a Traceable Universal Designated Verifier Signature (TUDVS) is used to construct a privacy-preserving authentication scheme for zero trust architecture. Specifically, when a client requests access to server resources, we want to protect the client's access privacy which means that the server administrator cannot disclose the client's access behavior to any third party. In addition, the security of the proposed scheme is proved and its efficiency is analyzed. Finally, TUDVS is applied to the single packet authorization scenario of the zero trust architecture to prove the practicability of the proposed scheme.

Validating the integrity of Convolutional Neural Network predictions based on zero-knowledge proof

Machine Learning as a Service can provide outsourced deep learning model prediction services to clients that do not have computing resources. Meanwhile, the integrity of the prediction services cannot be guaranteed due to model theft attacks from the services provider aspect or fake services from client aspect. Therefore, when clients access such deep learning models, it is urgent to verify the integrity of the model prediction process to ensure trusted interaction. For such, we propose a deep learning integrity verification scheme for integrity verification of the model prediction process without leaking information about key or private parameters of the deep learning model. When conducting integrity verification, the zero-knowledge succinct non-interactive knowledge argument is strategically used to construct a zero-knowledge proof. Specifically, we take the basic structure of the common single-layer Convolutional Neural Networks in deep learning as an example, construct Rank-1 Constraint Satisfaction according to the computational logic of each hidden layer in the model prediction process, so then design the proof circuits. We conduct extensive experiments for different scale CNN model inputs to demonstrate the practicality and feasibility of proposed scheme.

The Role of Electronic Health Tools in Unwanted Pregnancy Prevention, Abortion and Post-Abortion Follow-Up: A Systematic Review.

More than 30% of women experience at least one abortion. To date, there has been no comprehensive mobile health project on the impact of technology on access to abortion, contraception, and post-abortion follow-up. The purpose of this study was to review published studies on the role of electronic health in the prevention of unwanted pregnancy, abortion, and post-abortion follow-up. The Web of Science, PubMed, ScienceDirect, and EMBASE databases were searched to find relevant articles published between 2008 and 2018. A systematic review study was conducted on 33 relevant articles. All studies related to the use and impact of electronic health on unwanted pregnancy prevention, abortion and post-abortion follow-up in English from January 2008 to December 2018 were included. The quality of the studies was evaluated using the PRISMA-S. Thirty-three studies met the inclusion criteria for the review. The Studies were divided into four main groups of women's experiences on the use of mobile health and telemedicine technologies for at-home medical abortion, unwanted pregnancy prevention, abortion, and post-abortion follow-up. The results showed the significant impact of using electronic health on unwanted pregnancy prevention, abortion, and post-abortion follow-up. Health technologies have the potential to be used as a low-cost and accessible method to replace abortion services. They can facilitate remote care and quick access to information to complete the gaps in access to abortion. Therefore, it is necessary for health service providers to be aware of the possibility of the client's access to electronic health tools.

Scale-up of the DMPA-SC in Nigeria: Why policy matters

BackgroundInjectable contraceptives have contributed substantially to Nigeria's rise in modern family planning methods usage. They are one of the most commonly used and preferred means of contraception among women in the country. Enabling policies are required to assure contraceptive access, security, and use. This study aimed to investigate the policy environment and how it supports or limits Nigeria's introduction and scale-up of subcutaneous depot-medroxyprogesterone acetate (DMPA-SC).MethodsThe design of this mixed-methods study was cross-sectional. Desk reviews of policy papers, key informant interviews, and in-depth interviews were used to obtain information from respondents about the introduction of DMPA-SC in Nigeria and how existing policies influenced its scale-up. Data on DMPA-SC and other injectables were gathered from Nigeria's national electronic logistics management information system.ResultsThe findings suggest that policies such as task-shifting and task-sharing, cost-free policies, reproductive health policies, and others created an enabling environment for the scale-up of DMPA-SC adoption in Nigeria. The inclusion of DMPA-SC on the essential medicines list and the approved patent medicines list facilitated the scale-up process by ensuring private sector participation, removing economic barriers to access, fostering greater collaboration among health worker cadres, improving intersectoral partnerships, and improving logistics and client access. Despite significant anomalies in some implementing policies, injectable contraceptive consumption data demonstrate a progressive increase in DMPA-SC use during the study period. The results also indicate that policy initiatives have a favorable impact on the use of DMPA-SC throughout the country.ConclusionThe existence of policies, the active participation of stakeholders, and the political will of the Nigerian health system's leadership have all aided in the scaling-up of the DMPA-SC. Understanding how to build an enabling policy climate is critical for providing women with family planning options. These lessons from Nigeria emphasize the importance of these levers, which should be considered by teams intending to introduce innovative health products, particularly in developing countries.

Utilization of Presence Awareness in Trauma Therapy

Trauma can result in many long-term symptoms including emotional dysregulation, depression, addiction, and PTSD. When triggered by trauma, patients typically experience the world through a myopic lens. Helping clients observe and sense their trauma sequelae in the broader sensory awareness of Presence appears to help clients more easily process and resolve traumatic experience. The Presence Psychotherapy Trauma Protocol (PPTP) provides specific open-ended questions in session to help clients orient to Presence Awareness which can then be utilized to resolve trauma. Options to help clients sense their traumatic experience in the expansive awareness of Grounded Presence, Spacious Presence, Relational Presence, or Transcendent Presence create multiple regulating, processing, and attachment healing opportunities. PPTP’s concept of Reflective View is introduced which provides the clinician with prompts to help the client identify who they are as Presence Awareness early in session. This paper demonstrates, through a case example, how Presence Awareness and specifically Reflective View help clients access, tolerate, and process trauma in a broader sense of Presence Awareness.