Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection

Perceptions of Care and Perceived Discrimination: A Qualitative Assessment of Adults Living with Sickle Cell Disease

Sickle cell disease (SCD) is a major public health concern with significant associated economic costs. Although the disease affects all ethnic groups, about 90% of individuals living with sickle cell disease in the USA are Black/African American. The purpose of this study was to assess the health care discrimination experiences of adults living with SCD and the quality of the relationship with their health care providers. We conducted six focus groups from October 2018 to March 2019 with individuals receiving care at a specialized adult sickle cell program outpatient clinic at a private, nonprofit tertiary medical center and teaching hospital in the northeastern USA. The sample of 18 participants consisted of groups divided by gender and current use, past use, or never having taken hydroxyurea. Ten (56%) participants were males; most were Black/African American (83%) and had an average age of 39.4 years. This study reports a qualitative, thematic analysis of two of 14 areas assessed by a larger study: experiences of discrimination and relationships with providers. Participants described experiences of bias related to their diagnosis of SCD as well as their race, and often felt stereotyped as "drug-seeking." They also identified lack of understanding about SCD and poor communication as problematic and leading to delays in care. Finally, participants provided recommendations on how to address issues of discrimination.

State-of-the-Art Review: Evaluation and Management of Delusional Infestation

Delusional infestation is a condition encountered frequently by healthcare professionals across a variety of specialties in which patients have a fixed, false belief that they are infested with living creatures, such as bugs, parasites, worms, or mites, or nonliving objects, such as fibers. Delusional infestation can be debilitating for patients, who not only present with intense psychological distress and physical discomfort but are also at risk of developing numerous dermatological and psychiatric complications. This condition poses unique diagnostic challenges, as these symptoms can occur secondary to many metabolic or infectious causes, as well as unique treatment challenges, with patients frequently refusing psychiatric care and consequently seeking evaluation by other healthcare professionals. In this review, we aim to use existing literature to provide clinicians in infectious diseases or other specialties with sufficient clinical context and treatment guidance for the appropriate management of delusional infestation.

A Moderated Mediation Analysis of HIV and Intersectional Stigmas and Antiretroviral Adherence in People Living with HIV in the Dominican Republic

Experiencing HIV and intersectional stigmas in healthcare settings may affect antiretroviral treatment (ART) adherence among people with HIV (PWH), given their need for frequent interactions with clinical settings and healthcare providers. Considering the importance of reducing stigmas to promote well-being and the need to elucidate how stigma influences health across various settings, we examined how experienced HIV stigma in Dominican Republic healthcare settings impacts ART adherence through internalized HIV stigma and whether race or sexual orientation stigma moderates this relationship. Participants were 471 PWH (aged 17-71) who were recruited from two HIV clinics in the Dominican Republic in 2021-2022. Results revealed a significant mediation effect (B=-0.10, SE = 0.05, CI [-0.234, - 0.014]) after adjusting for effect of age and time since HIV diagnosis, suggesting that experienced HIV stigma in healthcare settings was associated with more internalized HIV stigma (B = 0.39, SE = 0.11, p = .001), subsequently linked to lower ART adherence (B=-0.26, SE = 0.11, p = .016). The indirect effect was significant at low levels of race stigma (B=-0.16, SE = 0.09, CI [-0.369, - 0.001]) but not at high levels of race stigma (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). This indirect effect was also significant at low levels of sexual orientation stigma (B=-0.19, SE = 0.10, CI [-0.401, - 0.023]) but not at high levels of sexual orientation stigma (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). These findings suggest that addressing experienced HIV stigma in Dominican Republic healthcare settings, along with various dimensions of HIV-related stigma (e.g., internalized stigma) and intersecting stigmas (e.g., race, sexual orientation), is vital for improving health outcomes, such as optimal ART adherence.

Using Causal Bayesian Networks to Assess the Role of Patient-Centered Care and Psychosocial Factors on Durable HIV Viral Suppression

We assessed the role of patient-centered care on durable viral suppression (i.e., all viral load test results < 200 copies per ml during 2019) by conducting a retrospective cohort study of clients medically case managed by the Miami-Dade County Ryan White Program (RWP). Summary measures of patient-centered care practices of RWP-affiliated providers were obtained from a survey of 1352 clients. Bayesian network models analyzed the complex relationship between psychosocial and patient-centered care factors. Of 5037 clients, 4135 (82.1%) had durable viral suppression. Household income was the factor most strongly associated with durable viral suppression. Further, mean healthcare relationship score and mean "provider knows patient as a person" score were both associated with durable viral suppression. Healthcare relationship score moderated the association between low household income and lack of durable viral suppression. Although patient-centered care supports patient HIV care success, wrap around support is also needed for people with unmet psychosocial needs.

Empowering people living with HIV (PLHIV): unveiling care gaps and identifying opportunities for improving care for PLHIV in Singapore and Hong Kong

INTRODUCTION

This study explored the behaviours of people living with HIV in Singapore and Hong Kong in terms of achieving and maintaining their physical and psychological wellbeing in relation to HIV, to identify the challenges and support needed in HIV care.

METHODS

This qualitative study involved 90-minute interviews among Singapore and Hong Kong people living with HIV aged ≥18 years to explore health-related quality of life perceptions and gaps in patient empowerment in HIV care during February-May 2022. The COM-B (C: Capability; O: Opportunity; M: Motivation; B: Behaviour) framework was used during data analysis to identify behaviour facilitators and barriers for people living with HIV to achieve and maintain their wellbeing. Detailed accounts of respondents' experience of living with and managing HIV, that is what worked well, unmet needs and perceived significance of wellbeing indicators, were analysed qualitatively via a combination of inductive content and deductive frameworks.

RESULTS

A total of 30 and 28 respondents were recruited from Singapore (SG) and Hong Kong (HK), respectively. Most respondents were aged 20-49 years (SG: 83.3%; HK: 64.3%), males (SG: 96.7%; HK: 92.9%), men who have sex with men (SG: 93.3%; HK: 71.4%), had university or higher education (SG: 73.3%; HK: 50.0%) and were fully employed (SG: 73.3%; HK: 57.1%). In both Singapore and Hong Kong, physical health was considered a key focus of overall wellbeing, albeit attention to long-term health associated with cardiovascular and renal health was less salient. The impact of symptoms, side effects of treatment, mood and sleep were among the top wellbeing indicators of importance. Respondents felt that insufficient information was provided by physicians, citing consultation time and resource constraints impeding further expression of concerns to their physicians during consultation. Respondents prioritized functional wellness and delegated psychosocial health to supportive care professionals, patient groups, families and/or friends.

CONCLUSIONS

There is a need in Singapore and Hong Kong to empower people living with HIV to establish better communications with their physicians and be more involved in their treatment journey and equally prioritize their psychosocial wellbeing.

The relationship between relational continuity and family physician follow-up after an antidepressant prescription in older adults: a retrospective cohort study

BACKGROUND

Side effects can occur within hours to days of starting antidepressant medications, whereas full therapeutic benefit for mood typically takes up to four weeks. This mismatch between time to harm and lag to benefit often leads to premature discontinuation of antidepressants, a phenomenon that can be partially reversed through early doctor-patient communication and follow-up. We investigated the relationship between relational continuity of care - the number of years family physicians have cared for older adult patients - and early follow-up care for patients prescribed antidepressants.

METHODS

A retrospective cohort study was conducted on residents of Ontario, Canada aged 66 years or older who were dispensed their first antidepressant prescription through the provincial drug insurance program between April 1, 2016, and March 31, 2019. The study utilized multivariable regression to estimate the relationship between relational continuity and 30-day follow-up with the prescribing family physician. Separate estimates were generated for older adults living in urban, non-major urban, and rural communities.

RESULTS

The study found a small positive relationship between relational continuity of care and follow-up care by the prescribing family physician for patients dispensed a first antidepressant prescription (RRR = 1.005; 95% CI = 1.004, 1.006). The relationship was moderated by the patients' location of dwelling, where the effect was stronger for older adults residing in non-major urban (RRR = 1.009; 95% CI = 1.007, 1.012) and rural communities (RRR = 1.006; 95% CI = 1.002, 1.011).

CONCLUSIONS

Our findings do not provide strong evidence of a relationship between relational continuity of care and higher quality management of antidepressant prescriptions. However, the relationship is slightly more pronounced in rural communities where access to continuous primary care and specialized mental health services is more limited. This may support the ongoing need for the recruitment and retention of primary care providers in rural communities.

Bibliometric and visualization analysis of risk management in the doctor-patient relationship: A systematic quantitative literature review

OBJECTIVES

This paper analyzed the research on risk management in the doctor-patient relationship (DPR) based on a systematic quantitative literature review approach using bibliometric software. It aims to uncover potential information about current research and predict future research hotspots and trends.

METHODS

We conducted a comprehensive search for relevant publications in the Scopus database and the Web of Science Core Collection database from January 1, 2000 to December 31, 2023. We analyzed the data using CiteSpace 6.2.R2 and VOSviewer 1.6.19 software to examine the annual number of publications, countries/regions, journals, citations, authors, and keywords in the field.

RESULTS

A total of 553 articles and reviews that met the criteria were included in this study. There is an overall upward trend in the number of publications issued; in terms of countries/regions, the United States and the United Kingdom are the largest contributors; Patient Education and Counseling is the most productive journal (17); Physician communication and patient adherence to treatment: a meta-analysis is the most cited article (1637); the field has not yet to form a stable and obvious core team; the analysis of high-frequency keywords revealed four main research directions: the causes of DPR risks, coping strategies, measurement tools, and research related to people prone to doctor-patient risk characteristics; the causes of DPR risks, coping strategies, measurement tools, and research related to people prone to doctor-patient risk characteristics; the keyword burst analysis revealed several shifts in the research hotspots for risk management in the DPR, suggesting that chronic disease management, is a future research direction for the continued development of risk management in the DPR.

CONCLUSIONS

The visualization analysis of risk management literature in the DPR using CiteSpace and VOSviewer software provides insights into the current research status and highlights future research directions.

Project CHARIOT: study protocol for a hybrid type 1 effectiveness-implementation study of comprehensive tele-harm reduction for engagement of people who inject drugs in HIV prevention services

BACKGROUND

People who inject drugs (PWID) remain a high priority population under the federal Ending the HIV Epidemic initiative with 11% of new HIV infections attributable to injection drug use. There is a critical need for innovative, efficacious, scalable, and community-driven models of healthcare in non-stigmatizing settings for PWID. We seek to test a Comprehensive-TeleHarm Reduction (C-THR) intervention for HIV prevention services delivered via a syringe services program (SSP).

METHODS

The CHARIOT trial is a hybrid type I effectiveness-implementation study using a parallel two-arm randomized controlled trial design. Participants (i.e., PWID; n = 350) will be recruited from a syringe services program (SSP) in Miami, Florida. Participants will be randomized to receive either C-THR or non-SSP clinic referral and patient navigation. The objectives are: (1) to determine if the C-THR intervention increases engagement in HIV prevention (i.e., HIV pre-exposure prophylaxis; PrEP or medications for opioid use disorder; MOUD) compared to non-SSP clinic referral and patient navigation, (2) to examine the long-term effectiveness and cost-effectiveness of the C-THR intervention, and (3) to assess the barriers and facilitators to implementation and sustainment of the C-THR intervention. The co-primary outcomes are PrEP or MOUD engagement across follow-up at 3, 6, 9 and 12 months. For PrEP, engagement is confirmed by tenofovir on dried blood spot or cabotegravir injection within the previous 8 weeks. For MOUD, engagement is defined as screening positive for norbuprenorphine or methadone on urine drug screen; or naltrexone or buprenorphine injection within the previous 4 weeks. Secondary outcomes include PrEP adherence, engagement in HCV treatment and sustained virologic response, and treatment of sexually transmitted infections. The short and long term cost-effectiveness analyses and mixed-methods implementation evaluation will provide compelling data on the sustainability and possible impact of C-THR on comprehensive HIV prevention delivered via SSPs.

DISCUSSION

The CHARIOT trial will be the first to our knowledge to test the efficacy of an innovative, peer-led telehealth intervention with PWID at risk for HIV delivered via an SSP. This innovative healthcare model seeks to transform the way PWID access care by bypassing the traditional healthcare system, reducing multi-level barriers to care, and meeting PWID where they are.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05897099. Trial registry name: Comprehensive HIV and Harm Prevention Via Telehealth (CHARIOT). Registration date: 06/12/2023.

Unmet Needs for Ancillary Services and Associations with Clinical Outcomes Among Transgender Women with Diagnosed HIV: Medical Monitoring Project, United States, 2015-2020

Purpose: Access to ancillary services-including HIV support services, non-HIV clinical services, and subsistence services-can support care engagement and viral suppression and reduce disparities among people with HIV (PWH). We used representative U.S. data to assess differences in unmet needs for ancillary services between transgender women with HIV and other PWH. In addition, we examined associations between unmet needs and clinical outcomes among transgender women. Methods: We analyzed 2015-2020 Medical Monitoring Project data among transgender women (N = 362), cisgender men (N = 17,319), and cisgender women (N = 6016) with HIV. We reported weighted percentages for characteristics, and reported adjusted prevalence ratios (aPRs) controlling for race/ethnicity and age, and 95% confidence intervals (CI) using logistic regression with predicted marginal means to assess differences between groups. Results: Among transgender women, unmet needs were highest for dental care (24.9%), shelter or housing (13.9%), and transportation assistance (12.6%). Transgender women were more likely than cisgender men to have unmet subsistence needs. Among transgender women, unmet needs for ancillary services were negatively associated with many clinical outcomes after adjusting for age and race/ethnicity. Unmet needs for subsistence services were associated with higher levels of antiretroviral therapy nonadherence (aPR: 1.39; 95% CI: 1.13-1.70) and detectable viral loads (aPR: 1.47; 1.09-1.98), emergency room visits (aPR: 1.42; 1.06-1.90), and depression (aPR: 2.74; 1.83-4.10) or anxiety (aPR: 3.20; 2.05-5.00) symptoms. Conclusions: Transgender women with HIV were more likely than cisgender men with HIV to experience unmet needs for subsistence services-likely a reflection of substantial socioeconomic disadvantage. Addressing unmet needs is an essential step for improving care outcomes among transgender women with HIV.

The Provider's Role in Retaining Black Women With HIV in Care: A Scoping Review

Black/African American women represent 54% of new HIV cases among all women in the United States, face higher rates of morbidity and mortality, and are often understudied. The patient-provider relationship is an important motivator to keeping people who live with HIV retained in care and adherent to a medical regimen, thereby improving chances for viral suppression and maintaining overall better health. This scoping review sought to determine the extent of documented provider actions that encourage Black women with HIV to stay engaged in care. The review investigated five databases for peer-reviewed studies in the United States that included Black women from 2009 to 2023 and specifically described beneficial provider actions or behaviors. Of 526 records, 12 met the criteria. Studies revealed that women are motivated by providers who create a respectful, nonjudgmental emotionally supportive relationship with them rather than those who rely on an authoritative transactional exchange of information and orders.

The Association Between Racialized Discrimination in Health Care and Pain Among Black Patients With Mental Health Diagnoses

Chronic pain is a costly and debilitating problem in the United States, and its burdens are exacerbated among socially disadvantaged and stigmatized groups. In a cross-sectional study of Black Veterans with chronic pain at the Atlanta VA Health Care System (N = 380), we used path analysis to explore the roles of racialized discrimination in health care settings, pain self-efficacy, and pain-related fear avoidance beliefs as potential mediators of pain outcomes among Black Veterans with and without an electronic health record-documented mental health diagnosis. In unadjusted bivariate analyses, Black Veterans with a mental health diagnosis (n = 175) reported marginally higher levels of pain-related disability and significantly higher levels of pain interference compared to those without a mental health diagnosis (n = 205). Path analyses revealed that pain-related disability, pain intensity, and pain interference were mediated by higher levels of racialized discrimination in health care and lower pain self-efficacy among Black Veterans with a mental health diagnosis. Pain-related fear avoidance beliefs did not mediate pain outcomes. These findings highlight the need to improve the quality and effectiveness of health care for Black patients with chronic pain through the implementation of antiracism interventions within health care systems. Results further suggest that Black patients with chronic pain who have a mental health diagnosis may benefit from targeted pain management strategies that focus on building self-efficacy for managing pain. PERSPECTIVE: Racialized health care discrimination and pain self-efficacy mediated differences in pain-related disability, pain intensity, and pain interference among Black Veterans with and without a mental health diagnosis. Findings highlight the need for antiracism interventions within health care systems in order to improve the quality of care for Black patients with chronic pain. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01983228.

Patients' perceived quality of the care provided during the management of HIV/AIDS in a tertiary care setting in Nigeria

Background

The provision of patient-centred care by clinicians is believed to improve patient satisfaction with care as well as the outcome of treatment.

Objective

To assess the quality of personalized care provided to people living with HIV/AIDS in a typical Nigerian health care setting and its association with patients' knowledge and attitude towards HIV/AIDS and patients' knowledge and attitude towards antiretroviral therapy.

Methods

The study was a cross sectional study carried out in the HIV/AIDS clinic of the University of Uyo Teaching Hospital, Nigeria. Data on the demographic and clinical details of the patients were obtained from patients' case notes using a suitably designed, pre-piloted data collection instrument. Furthermore, data on the quality of patient-centred care, patients' knowledge and attitude towards HIV/AIDS, and patients' knowledge and attitude towards antiretroviral therapy was obtained using 'Patient Assessment of Quality of Individualized care for Chronic Illness Scale', 'Patient knowledge and attitude towards HIV/AIDS questionnaire; and 'Patient knowledge and attitude towards antiretroviral therapy questionnaire', respectively.Quantitative data were analysed using Statistical Program and Service Solutions (SPSS) version 25.0 computer package. Descriptive statistics were used to summarize data, while inferential statistics were used where applicable with statistical significance set at p<0.05.

Results

The overall mean patients' satisfaction with individualized care score was 3.54 (SD = ±0.86; Max. = 5). The mean scores of the patients' knowledge and attitude towards HIV/AIDS were 6.80 (SD = ± 1.079; Max. = 8) and 5.5 (SD = ± 0.924; Max. = 7) respectively, while the mean scores of the patients' knowledge and attitude toward antiretroviral therapy were 5.7 (SD = ± 1.103; Max. = 10) and 4.2 (SD = ± 0.874; Max. = 6). Multivariate linear regression revealed that the quality of patient centred care was a predictor of knowledge and attitude towards antiretroviral therapy (B=0.511; CI = 95%, p = 0.024).

Conclusion

The quality of patient-centred care provided to persons living with HIV/AIDS in the facility is satisfactory. Patients perceived quality of care appear to be a predictor of knowledge and attitude towards antiretroviral therapy.

"Messengers matter": Assessing the impact of racially concordant care on vaccine hesitation

With the rise in COVID-related deaths among the unvaccinated, understanding coronavirus vaccine hesitancy is critical to maintaining public health. Previous research has shown that sociodemographic factors, such as race, are essential for understanding vaccine hesitancy; yet, the specific factors driving racial disparities in vaccination continue to be a matter of intense debate. This study uses a novel survey experiment to uncover the linkages between race, physician trust, and vaccine hesitancy. Using a standard prompt on the release of the COVID-19 vaccine, it tests whether patient-physician race concordance affects the likelihood of vaccine uptake among US citizens. Analyses reveal that racially concordant care has a negligible effect on vaccine hesitancy, but does ameliorate other harmful beliefs regarding one's likelihood of experiencing discrimination and racism in healthcare more generally. These findings suggest that increasing diversity in the medical field should be paired with efforts to address systemic inequalities to promote increased vaccination.

Complementary and alternative medicine use among people living with HIV in Shiraz, Southern Iran

Background

Living with HIV requires lifelong care to support engagement with and adherence to antiretroviral therapy. The Middle East and North Africa region provides access to ART, but research is lacking on the lived-experiences of people living with HIV. Globally, complementary and alternative medicine (CAM) is increasingly used by patients who need support alongside receiving medical treatment for chronic conditions. This study aims to examine the frequency and reasons behind the use of CAM, as well as identify its associated factors among people living with HIV in Shiraz, Iran.

Methods

In this cross-sectional study, a total of 320 patients (aged 18-70 years) with a confirmed diagnosis of HIV residing in Fars province and diagnosed between 1999 and 2019 were recruited randomly through their clinical record numbers from five HIV treatment centers. They were surveyed on their quality of life and CAM use via the Short-Form Health Survey questionnaire (SF-36) and a semi-structured survey of "CAM use." The data analysis for this study involved the use of Chi-squared test, independent t-test, and multiple logistic regression model.

Results

Of 287 patients, 89.22% reported using CAM in the previous year. CAM use was more prevalent among those with a family history of CAM use (94.3% vs. 81.8%, p = 0.023). Frequent reasons for using CAM were reported to be sexual dysfunction (32.4%), depression (28.3%), thirstiness (23.3%), and nausea (17.5%). Quality of life, as measured via the SF-36 questionnaire in all its 8 sub-domains, did not differ among those who used CAM versus those who did not (61.5 ± 27.6 vs. 58.1 ± 30.9, p = 0.626).

Conclusion

CAM was used among a majority of people living with HIV in Shiraz, Iran. People who used CAM appeared to experience a similar quality of life relative to those who did not use CAM. Future studies on the modalities of engagement with CAM can improve patient-physician shared decision-making and increase lifelong care options for people living with HIV.

Developing a male-specific counselling curriculum for HIV treatment in Malawi

Men living with HIV in sub-Saharan Africa have sub-optimal engagement in antiretroviral therapy (ART) Programs. Generic ART counselling curriculum in Malawi does not meet men's needs and should be tailored to men. We developed a male-specific ART counselling curriculum, adapted from the Malawi Ministry of Health (MOH) curriculum based on literature review of men's needs and motivations for treatment. The curriculum was piloted through group counselling with men in 6 communities in Malawi, with focus group discussion (FGD) conducted immediately afterward (n=85 men) to assess knowledge of ART, motivators and barriers to care, and perceptions of the male-specific curriculum. Data were analysed in Atlas.ti using grounded theory. We conducted a half-day meeting with MOH and partner stakeholders to finalize the curriculum (n=5). The male-specific curriculum adapted three existing topics from generic counselling curriculum (status disclosure, treatment as prevention, and ART side effects) and added four new topics (how treatment contributes to men's goals, feeling healthy on treatment, navigating health systems, and self-compassion for the cyclical nature of lifelong treatment. Key motivators for men were embedded throughout the curriculum and included: family wellbeing, having additional children, financially stability, and earning/keeping respect. During the pilot, men reported having little understanding of how ART contributed to their personal goals prior to the male-specific counselling. Men were most interested in additional information about treatment as prevention, benefits of disclosure/social support beyond their sexual partner, how to navigate health systems, and side effects with new regimens. Respondents stated that the male-specific counselling challenged the idea that men were incapable of overcoming treatment barriers and lifelong medication. Male-specific ART counselling curriculum is needed to address men's specific needs. In Malawi context, topics should include: how treatment contributes to men's goals, navigating health systems, self-compassion/patience for lifelong treatment, and taking treatment while healthy.

A scoping review to explore patient trust in dentistry: the definition, assessment and dental professionals' perception

Background A trusting dentist-patient relationship is pivotal in providing person-centred care. This scoping review aims to identify how trust is defined, measured and perceived by dental professionals.Methods The Joanna Briggs Institute framework was adopted. A search strategy was developed using MeSH (Medical Subject Headings) terms and key words. Medline/PubMed, Embase, PsycINFO and CINAHL were searched. Data were synthesised using thematic analysis.Findings In total, 16 studies were included that frequently used quantitative research methodology. Only four studies provided definition of trust. Many studies employed either Dental Trust Scale or Dental Beliefs Survey to measure dentist-patient trust, although others developed their own items. Limited research suggested that the dental professionals appreciated communication was paramount to building a trusting relationship with patients.Conclusion No consensus was found on the definition of trust, nor on a preferred assessment tool to measure dentist-patient trust. The limited evidence intimated that dental professionals acknowledged the importance of effective communication in building a trusting alliance with patients. The scarcity of relevant research highlights the need for more robust investigations of trust in dental care.

Patient-provider relationships: Opioid use disorder and HIV treatment in Vietnam

Background

The provider-patient relationship has been implicated as a positive force in health outcomes. This study examined the provider-patient relationship in the setting of integrated, partially-integrated, and non-integrated opioid use disorder (OUD) and HIV care models in Vietnam.

Objective

To examine the provider-patient relationship in the setting of integrated, partially integrated, and non-integrated OUD and HIV treatment in North Vietnam.

Methods

Between 2013 and 2018, we conducted face-to-face qualitative interviews with 44 patients living with HIV and OUD and 43 providers in northern Vietnam. These were analyzed using a semantic, inductive approach to qualitative thematic analysis.

Results

Several themes were identified. 1) Trust was important to the patient-provider relationship and sensitive to provider attitudes and competence. 2) Patients perceived greater provider competence and understanding of patient health problems in integrated treatment. 3) Patient-provider relationships were initially superficial but deepened over time, facilitated by continuity of care.

Conclusions

Patient perceptions of competence and respect were important to feeling cared for. Providers felt empathy and competence came with more experience caring for patients with OUD and HIV.

Perceived Mistreatment in Health Care Settings and its Relationship with HIV Clinical Outcomes in HIV-positive People who Use Drugs in Vancouver, Canada

People living with HIV (PLWH) often experience stigma and discrimination by health care professionals. We investigated the prevalence of perceived mistreatment in health care settings and its associations with HIV clinical outcomes and health care-seeking behaviour using data from a long-running prospective cohort of PLWH who use drugs. Of the 857 participants included, 19% reported at least one instance of perceived mistreatment during the study period. In adjusted longitudinal analyses, perceived mistreatment was positively associated with not being on ART in the same follow-up period, and participants who reported perceived mistreatment were less likely to report seeing a physician in the subsequent follow-up period. Daily use of injection drugs was positively associated with reporting perceived mistreatment. These findings demonstrate the implications of negative health care interactions in a population that must consistently engage with the health care system, and the need for stigma-reducing educational interventions for health care professionals.

The effect of using internet hospitals on the physician-patient relationship: Patient perspective

BACKGROUND

Internet hospitals are rapidly developing in China. Despite many studies regarding internet hospitals, there has been little further research that evaluates the impact of using internet hospitals on the physician-patient relationship during outpatient visits.

METHODS

We developed a questionnaire based on the patient-doctor relationship questionnaire (PDRQ-9) to survey the physician-patient relationship. A sample of 505 patients who sought medical services from offline physical or internet hospitals was selected by convenience sampling. Multiple linear regression analysis was performed to determine whether the use of internet hospitals during outpatient visits was associated with the physician-patient relationship.

RESULTS

Internet hospital users gave significantly lower scores than nonusers in total physician-patient relationship scores (P =.01) and in the 5 items of "My physician helps me" (P <.001), "I trust my physician" (P =.001), "My physician understands me" (P =.002), "My physician and I agree on the nature of my medical symptoms" (P =.01), and "I can talk to (communicate with) my physician freely" (P =.005). Multiple linear regression results showed that the use of internet hospitals during outpatient visits influenced the physician-patient relationship. And after controlling for other patient characteristics, the use of internet hospitals decreased the physician-patient relationship scores by 11.9%.

CONCLUSIONS

Our findings suggest that the current use of internet hospitals could not significantly enhance the physician-patient relationship during outpatient visits. Therefore, we should work on improving physicians' online communication skills and strengthening the level of trust between physicians and their patients. Policymakers should also pay close attention to the gap of the physician-patient relationship between internet hospitals and offline physical hospitals.

Primary Care Ethics is Just Medical Ethics: A Philosophical Argument for the Feasibility of Transitioning Acute Care Ethics to the Primary Care Setting

Whether practiced by ethics committees or clinical ethicists, medical ethics enjoys a solid foundation in acute care hospitals. However, medical ethics fails to have a strong presence in the primary care setting. Recently, some ethicists have argued that the reason for this disparity between ethics in the acute and primary care setting is that primary care ethics is distinct from acute care ethics: the failure to translate ethics to the primary care setting stems from the incorrect belief that acute care ethics can be applied to the primary care setting. In this paper, I argue that primary care ethics and acute care ethics are species of the same ethical genus, and that the ethical differences are not ones of kind but of circumstance. I do this by appealing to the role obligations that underlie acute care and primary care clinicians' medical ethical obligations and the shared institutions that ground those obligations.

Project T-SHARP: study protocol for a multi-site randomized controlled trial of tele-harm reduction for people with HIV who inject drugs

BACKGROUND

The resurgence of HIV outbreaks and rising prevalence among people who inject drugs (PWID) remain exigent obstacles to Ending the HIV Epidemic in the USA. Adapting a low threshold, comprehensive treatment model for PWID with HIV can leverage syringe services programs (SSPs) to increase availability and accessibility of antiretrovirals (ART), medications for opioid use disorder (MOUD), and hepatitis C cure. We developed Tele-Harm Reduction, a telehealth-enhanced, harm reduction intervention delivered within an SSP venue.

METHODS

The T-SHARP trial is an open-label, multi-site, randomized controlled superiority trial with two parallel treatment arms. Participants (n=240) recruited from SSPs in Miami, Ft. Lauderdale, and Tampa, Florida, who are PWID with uncontrolled HIV (i.e., HIV RNA>200) will be randomized to Tele-Harm Reduction or off-site linkage to HIV care. The primary objective is to compare the efficacy of Tele-Harm Reduction for initiation of ART at SSPs vs. off-site linkage to an HIV clinic with respect to viral suppression across follow-up (suppression at 3, 6, and 12 months post randomization). Participants with HIV RNA<200 copies/ml will be considered virally suppressed. The primary trial outcome is time-averaged HIV viral suppression (HIV RNA <200 copies/ml) over 3-, 6-, and 12-month follow-up. Secondary outcomes include initiation of MOUD measured by urine drug screen and HCV cure, defined as achieving 12-week sustained virologic response (negative HCV RNA at 12 weeks post treatment completion). A cost-effectiveness analysis will be performed.

DISCUSSION

The T-SHARP Trial will be the first to our knowledge to test the efficacy of an innovative telehealth intervention with PWID with uncontrolled HIV delivered via an SSP to support HIV viral suppression. Tele-Harm Reduction is further facilitated by a peer to support adherence and bridge the digital divide. This innovative, flipped healthcare model sets aside the traditional healthcare system, reduces multi-level barriers to care, and meets PWID where they are. The T-SHARP trial is a pragmatic clinical trial that seeks to transform the way that PWID access HIV care and improve HIV clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05208697. Trial registry name: Tele-Harm Reduction. Registration date: January 26, 2022.

Patient perceptions of facilitators and barriers to reducing hazardous alcohol use among people living with HIV in East Africa

BACKGROUND

Hazardous alcohol use among people living with HIV is associated with poor outcomes and increased morbidity and mortality. Understanding the hazardous drinking experiences of people living with HIV is needed to reduce their alcohol use.

METHODS

We conducted 60 interviews among people living with HIV in East Africa with hazardous drinking histories. Interviews and Alcohol Use Disorder Identification Test (AUDIT) scores were conducted 41 - 60 months after their baseline assessment of alcohol use to identify facilitators and barriers to reduced alcohol use over time.

RESULTS

People living with HIV who stopped or reduced hazardous drinking were primarily motivated by their HIV condition and desire for longevity. Facilitators of reduced drinking included health care workers' recommendations to reduce drinking (despite little counseling and no referrals) and social support. In those continuing to drink at hazardous levels, barriers to reduced drinking were stress, social environment, alcohol accessibility and alcohol dependency.

CONCLUSIONS

Interventions that capacity-build professional and lay health care workers with the skills and resources to decrease problematic alcohol use, along with alcohol cessation in peer support structures, should be explored.

Contingency Management and Pre-Exposure Prophylaxis Adherence Support Services (CoMPASS): A hybrid type 1 effectiveness-implementation study to promote HIV risk reduction among people who inject drugs

BACKGROUND

HIV disproportionally affects persons who inject drugs (PWID), but engagement with HIV pre-exposure prophylaxis (PrEP) is low. We describe the rationale and study design for a new study, "Contingency Management and Pre-Exposure Prophylaxis (PrEP) Adherence Support Services (CoMPASS)," a hybrid type 1 effectiveness-implementation trial to promote HIV risk reduction among PWID.

METHODS

In four community-based programs in the northeastern United States, PrEP-eligible PWID (target n = 526) are randomized to treatment as usual or Contingency Management (CM) and, as indicated, stepped up to PrEP Adherence Support Services (CoMPASS) over 24 weeks. During CM sessions, participants receive timely tangible rewards for verifiable activities demonstrating 1) PrEP initiation and adherence, and 2) engagement with medications for opioid use disorder (MOUD) and other OUD-related care. Participants who do not have high levels of biomarker-confirmed PrEP adherence at week 12 will be stepped up to receive PrEP Adherence Support Services (PASS) consisting of strengths-based case management over 12 weeks. Interventions are delivered by trained PrEP navigators, staff embedded within the respective sites. The primary outcome is sustained PrEP adherence by dried blood spot testing at 24 weeks. To inform future implementation, we are conducting implementation-focused process evaluations throughout the clinical trial.

CONCLUSIONS

Results from this protocol are anticipated to yield novel findings regarding the impact and scalability of CoMPASS to promote HIV prevention among PWID in partnership with community-based organizations. http://ClinicalTrials.gov identifier: NCT04738825.

Prosthesis preferences for those with upper limb loss: Discrete choice study of PULLTY® for use in regulatory decisions

Introduction

The patient's voice in shared decision-making has progressed from physician's office to regulatory decision-making for medical devices with FDA's Patient Preference Initiative. A discrete-choice preference measure for upper limb prosthetic devices was developed to investigate patient's risk/benefit preference choices for regulatory decision making.

Methods

Rapid ethnographic procedures were used to design a discrete-choice measure describing risk and benefits of osseointegration with myoelectric control and test in a pilot preference study in adults with upper limb loss. Primary outcome is utility of each choice based conjoint (CBC) attribute using mixed-effects regression. Utilities with and without video, and between genders were compared.

Results

Strongest negative preference was for avoiding infection risk (B = -1.77, p < 0.001) and chance of daily pain (B = -1.22, p, 0.001). Strongest positive preference was for attaining complete independence when cooking dinner (B = 1.62, p < 0.001) and smooth grip patterns at all levels (B = 1.62, B = 1.28, B = 1.26, p < 0.001). Trade-offs showed a 1% increase in risk of serious/treatable infection resulted in a 1.77 decrease in relative preference. There were gender differences, and where video was used, preferences were stronger.

Conclusions

Strongest preferences were for attributes of functionality and independence versus connectedness and sensation but showed willingness to make risk-benefit trade-offs. Findings provide valuable information for regulatory benefit-risk decisions for prosthetic device innovations.

Trial Registration

This study is not a clinical trial reporting results of a health care intervention so is not registered.

Virtual voices: examining social support exchanged through participant-generated and unmoderated content in a mobile intervention to improve HIV antiretroviral therapy adherence among GBMSM

Antiretroviral therapy (ART) adherence is suboptimal among gay, bisexual, and other men who have sex with men (GBMSM). Online interventions that incorporate social support represent new opportunities to improve adherence. This study focused on how social support was provided and sought within a technology-based ART adherence intervention. We coded and analyzed 1,751 messages. Within the social support messages, half of the time participants sought social support and half of the time they provided social support. Emotional and informational support were the most frequently exchanged forms. The most frequent topic that participants sought support around was interpersonal relationships (29%), followed by HIV care and treatment (28%). Similarly, 31% and 27% of messages in which participants provided support was related to HIV treatment and care and interpersonal relationships, respectively. HIV treatment and care issues most salient were ART adherence, lab results and upcoming tests, ART side effects, changes in ART regimens, and relationships with healthcare providers. Participants used the messaging feature in this intervention to spontaneously discuss and exchange support around HIV treatment and care. This analysis provided an opportunity to understand how participants informally interact with one another, how they seek and provide social support online, and their salient personal issues.

The effect of Augmented-Reality media-based health education on healthy lifestyle knowledge, attitude, and healthy lifestyle behaviors among pregnant women during COVID-19 pandemic in Jakarta, Indonesia

Pregnancy is a critical period. Pregnant women need to perform healthy lifestyle behavior in order to ensure good fetal development. During COVID-19 pandemic, Augmented-Reality (AR) media may be used in pregnant women health education. However, there is a lack of research that investigated the effect of AR media use in pregnant women health education. Therefore, this research aimed to investigate the impact of AR media use on healthy lifestyle knowledge, attitude, and behaviors among pregnant women during COVID-19 pandemic. This cohort-longitudinal study involved 86 pregnant women aged 18-45 years. The subjects who participated in this research received health education interventions using AR media for 5 months. The data collection was performed at the pre-post-intervention through a survey with questionnaire. Changes in subjects' healthy lifestyle knowledge, attitude, and behaviors were analyzed by using t-test. The research results show that the AR media use in health education significantly improved the subjects' scores for healthy lifestyle knowledge (5.0 ± 10.9; p < .05) and behaviors (9.7 ± 17.5; p < .05). However, the subject score for attitude was not significantly improved (0.3 ± 7.1; p ≥ .05). This research results provide evidence of the importance of using AR media in health education for pregnant women during COVID-19 pandemic.

Protocol for the pilot quasi-experimental controlled trial of a gender-responsive implementation strategy with providers to improve HIV outcomes in Uganda

BACKGROUND

Antiretroviral treatment (ART) is the most effective clinical intervention for reducing morbidity and mortality among persons living with HIV. However, in Uganda, there are disparities between men and women in viral load suppression and related HIV care engagement outcomes, which suggests problems with the implementation of ART. Gender norms are a known driver of HIV disparities in sub-Saharan Africa, and patient-provider relationships are a key factor in HIV care engagement; therefore, the role of gender norms is important to consider in interventions to achieve the equitable provision of treatment and the quality of ART counseling.

METHODS

The overall research objective of this study is to pilot test an implementation strategy (i.e., methods to improve the implementation of an evidence-based intervention) to increase providers' capacity to provide gender-responsive treatment and counseling to men and women on HIV treatment in Uganda. Delivered to HIV providers, this group training adapts evidence-based strategies to reduce gender biases and increase skills to deliver gender-specific and transformative HIV counseling to patients. The implementation strategy will be piloted through a quasi-experimental controlled trial. Clinics will be randomly assigned to either the intervention or control conditions. The trial will assess feasibility and acceptability and explore barriers and facilitators to implementation and future adoption while gathering preliminary evidence on the implementation strategy's effectiveness by comparing changes in patient (N = 240) and provider (N = 80-140) outcomes across intervention and control clinics through 12-month follow-up. Quantitative data will be descriptively analyzed, qualitative data will be analyzed through thematic analysis, and these data will be mixed during the presentation and interpretation of results where appropriate.

DISCUSSION

This pilot intervention trial will gather preliminary evidence on the acceptability, feasibility, and potential effect of a novel implementation strategy to improve men and women's HIV care engagement, with the potential to reduce gender disparities in HIV outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05178979 , retrospectively registered on January 5, 2022.

Integrating ART adherence support technologies in the care of pregnant and postpartum people with HIV: a qualitative study

Background

We have a limited understanding on how to best integrate technologies to support antiretroviral therapy (ART) adherence in routine HIV care.

Methods

We conducted semi-structured interviews with multidisciplinary providers caring for pregnant and postpartum people with HIV and asked providers about their perspectives on utilizing adherence support technologies such as text messages, video check-ins with providers or automated with facial recognition for directly-observed-therapy, signaling pill bottle, and signaling pill to support ART adherence. Each approach generated an adherence report. The interview instrument was guided by the Consolidated Framework for Implementation Research and included questions on the implementation climate, barriers, and facilitators to the clinical integration of the adherence approach and strategies that could be used to maximize this integration. The order of adherence support technologies was randomized to minimize bias. We used a modified grounded theory to develop the coding structure and two coders applied the codebook to the transcripts after establishing strong inter-rater reliability with 20% of interviews (kappa = 0.82).

Results

Between March and December 2020, we conducted 26 in-depth, semi-structured interviews with providers who weighed several factors when considering each approach, including the approach’s effect on patient-provider interaction in and outside of the clinic visit, timing for and duration of the approach’s utility, threat of disclosing status, and added burden to providers (e.g., needing to act on generated information) or to patients (e.g., needing to hide the signaling pills, responding to text messages). Providers’ most preferred approach was text-messages, and the least preferred was the signaling pill. Barriers to acceptability varied by approach and included perceived surveillance, violation of privacy, added time demand for providers, potential inaccuracy of the adherence data generated, and negative impact on the patient-provider relationship, particularly if the approach was perceived as coercive. Payers anticipated regulatory hurdles with unfamiliar approaches, particularly the signaling pill and signaling pill bottle. Facilitators included strengthened therapeutic alliance, predictable reminder mechanisms, and options for customization according to patient preference.

Conclusions

Our study elucidates barriers and facilitators to integrating technology-based adherence support approaches in clinical care to support adherence of pregnant and postpartum people with HIV.

Improving HIV medication adherence among forced migrants living with HIV: a qualitative study of refugees and asylum seekers in Malaysia

INTRODUCTION

Adherence to medication regimens is essential to decrease morbidity/mortality and increase life expectancy among HIV positive persons on Highly Active Anti-retroviral Therapy (HAART). This study was born in response to the absence of information regarding access and adherence to HAART among refugee and asylum seekers in urban, irregular, transit country settings.

OBJECTIVES

The purpose was to understand the barriers and facilitators to HIV medication adherence among refugees and asylum seekers living with HIV and to generate novel recommendations to facilitate adherence.

METHODS

Individual in-depth interviews were conducted with 34 refugees and asylum seeks to explore their lived experiences. Interviews were structured around the social ecological model to capture influences of multiple levels. Thematic analysis was conducted on transcripts.

RESULTS

Stigma, lack of knowledge and language barriers were among the main barriers noted by refugees and asylum-seekers in relation to HIV medication adherence, whereas interpersonal relationships, improved health, and strong patient-physician relationships were seen as facilitators. Participants noted their desire for community-support groups, education, and increased use of interpreters in order to combat some of the social barriers preventing full HIV medication adherence.

CONCLUSION

A regular status shapes participants' adherence to HIV medications. Group-based interventions to support refugees are needed.

Involvement, Perception, and Understanding as Determinants for Patient-Physician Relationship and Their Association with Adherence: A Questionnaire Survey among People Living with HIV and Antiretroviral Therapy in Austria

BACKGROUND

The relationship between patients and healthcare professionals (physicians) is the cornerstone of successful long-term antiretroviral therapy for people living with human immunodeficiency virus (HIV).

PURPOSE

This study aimed to investigate the connection between involvement, perception, and understanding as the basis for the patient-physician relationship and drug adherence, measured as the probability of non-adherence.

METHODS

In an online survey, people with HIV were asked about their relationship with their physicians and the extent to which they felt involved in treatment-related decisions. A statistical analysis was conducted to determine whether a better patient-physician relationship was associated with higher adherence to therapy. This was performed by univariate group comparison (Mann-Whitney-U, Fishers Exact Test) and logistic regression.

RESULTS

A total of 303 persons living with HIV participated in the survey, and 257 patients were included in the analysis. Overall, 27.6% were classified as non-adherent and self-reporting based on whether an antiretroviral therapy (ART) was taken in the past or how often the ART was interrupted. This proportion was significantly higher among patients aged 50-74 years (39.7%) and those with a longer therapy duration (9-15 years: 46.6%; from 15 years on: 55.8%). Therapy-non-adherent patients showed significantly lower scores in the relationship aspects understanding (2.68 vs. 3.03), participation (2.63 vs. 3.07), and perception (3.00 vs. 3.24) compared to adherent patients. Logistic regression analysis confirms that higher scores for understanding, involvement, and perception are strongly associated with a reduction in the risk of becoming non-adherent. This was true for all examined regression models, regardless of whether they were adjusted for the length of therapy and socio-demographic characteristics.

CONCLUSION

The results reinforce the need for awareness among health care professionals (HCP) regarding understanding, involvement, and perception as important aspects to improve the quality of the patient-physician relationship for high adherence levels with maximized non-adherence in ART management by PLWH.

HIV Related Stigma among Healthcare Providers: Opportunities for Education and Training

Background: HIV-stigma can influence engagement in care and viral suppression rates among persons living with HIV (PLWH). Understanding HIV-provider level stigma and its associated factors may aid in development of interventions to improve engagement in care. Methods: We assessed HIV-related stigma, provider knowledge, and practices and beliefs among healthcare providers using an online survey tool. Generalized linear modeling was used to determine factors associated with HIV-stigma score. Results: Among 436 participants, the mean age was 42.3 (SD 12.3), 70% female, 62% white, 65% physicians, and 44% worked at an academic center. The mean HIV Health Care Provider Stigma Scale (HPASS) score was 150.5 (SD 18.9, total = 180 [higher score = less stigma]) with factor subscale scores of 67.1 (SD 8.2, total = 78) prejudice, 51.3 (SD 9.7, total = 66) stereotyping, and 32.1 (SD 5, total = 36) discrimination. Female sex and comfort with talking about sex and drug use had 4.97 (95% CI 0.61, 9.32) and 1.99 (95% CI 0.88, 3.10) estimated higher HPASS scores. Disagreement/strong disagreement versus strong agreement with the statement that PLWH should be allowed to have babies and feeling responsible for talking about HIV prevention associated with -17.05 (95% CI -25.96, -8.15) and -2.16 (95% CI -3.43, -0.88) estimated lower HPASS scores. Conclusions: The modifiable factors we identified as associated with higher HIV related stigma may provide opportunities for education that may ameliorate these negative associations.

An EMR-based alert with brief provider-led ART adherence counseling in Haiti: effects on information, motivation, and behavioral skills (IMB) and patient-provider communication (PPC)

We examined the secondary effects of an antiretroviral therapy (ART) adherence intervention on information, motivation, and behavioral skills (IMB) and patient-provider communication (PPC). Data were from a sample of 116 patients enrolled in a quasi-experimental mixed-methods study at two large ART clinics in Haiti. We examined changes in IMB and PPC scores after the intervention and the association between baseline PPC and endline IMB.The intervention was associated with increased scores in information (ß = 0.89, 95% CI [0.07, 1.70]) and motivation (ß = 2.55, 95% CI [0.38, 4.72]) but a decreased score in behavioral skills (ß = -2.39, 95% CI [-4.29, -0.49]), after controlling for demographic and clinical variables. Baseline PPC was associated with higher endline IMB total scores (ß = 0.17, 95% CI [0.02, 0.31]), controlling for demographic variables, clinical variables, and baseline IMB score. At the subscale level, baseline PPC was associated with higher endline motivation score (ß = 0.09, 95% CI [0.01, 0.17]), marginally associated with higher endline information score (ß = 0.04, 95% CI [0.00, 0.08]), after controlling for demographic and clinical variables.The intervention was beneficial to patients' adherence related motivation. Favorable patient-provider communication is associated with more motivation to adhere to ART.

Nonadherence to Ledipasvir/Sofosbuvir Did Not Predict Sustained Virologic Response in a Randomized Controlled Trial of Human Immunodeficiency Virus/Hepatitis C Virus Coinfected Persons Who Use Drugs

BACKGROUND

Eliminating hepatitis C virus (HCV) will require effective treatment delivery to persons with substance use disorders (SUDs). We evaluated the relationship between ledipasvir/sofosbuvir treatment persistence (receiving 84 tablets), adherence, and sustained virologic response (SVR) in persons with human immunodeficiency virus (HIV)/HCV coinfection.

METHODS

Of the 144 participants with HIV/HCV and SUDs, 110 initiated a 12-week treatment course under 1 of 3 conditions (usual care, peer mentors, and cash incentives). We used self-report, pharmacy pill counts, and expected date of refill to examine adherence. Persistent participants were categorized as high adherence (taking ≥90% of doses) or low adherence (taking <90% of doses).

RESULTS

Most participants persisted on treatment after initiation (n = 105), with 95% (n = 100) achieving SVR. One third (34%) of participants had moderate/heavy alcohol use by the biomarker phosphatidylethanol ([Peth] ≥50 ng/mL), and 44% had urine toxicology positive for cocaine or heroin at enrollment. The proportion of persons with high adherence was 72% (n = 76), and the proportion of persons with low adherence was 28%. Although low adherence was associated with moderate/heavy alcohol use by PEth (relative risk = 2.77; 95% confidence interval, 1.50-5.12), SVR did not vary according to adherence (P = .702), and most participants (97%) with low adherence achieved SVR.

CONCLUSIONS

Treatment persistence led to high SVR rates among persons with HIV/HCV, despite imperfect adherence and SUDs.

Prenatal electrocardiogram testing and postpartum depression: A population-based cohort study

Background

Cardiovascular symptoms in pregnancy may be a clue to psychological distress. We examined whether electrocardiogram testing in pregnant women is associated with an increased risk of subsequent postpartum depression.

Methods

We conducted a population-based cohort study of pregnant women who delivered in Ontario, Canada comparing women who received a prenatal ECG to women who did not.

Results

In total, 3,238,218 women gave birth during the 25-year study period of whom 157,352 (5%) received an electrocardiogram during prenatal care. Receiving an electrocardiogram test was associated with a one-third relative increase in the odds of postpartum depression (odds ratio 1.34; 95% confidence interval 1.29-1.39, p < 0.001).

Conclusion

The association between prenatal electrocardiogram testing and postpartum depression suggests a possible link of organic disease with mental illness, and emphasizes that cardiovascular symptoms may be a clinical clue to the presence of an underlying mood disorder.

Tool to improve patient-provider interactions in adult primary care: Randomized controlled pilot study

OBJECTIVE

To assess whether an intervention to help patients prioritize goals for their visit would improve patient-provider communication and clinical outcomes.

DESIGN

Randomized controlled pilot study.

SETTING

Primary care clinic.

PARTICIPANTS

There were 120 adult hypertensive patients enrolled.

INTERVENTION

Patients were randomized to receive either usual care or a previsit patient activation card developed through a series of focus groups that prompted patients to articulate their needs and set priorities for their clinic visit. Encounters were audiorecorded, transcribed, and assessed using duplicate ratings of patient activation and decision making.

MAIN OUTCOME MEASURES

The primary outcome was change in medication adherence as measured by pill count at 4 and 12 weeks after the initial visit. Secondary outcomes evaluated patient-provider interaction quality (patient satisfaction, patient activation, shared decision making, patient trust, and physicians' perceived difficulty of the encounter), functional status, and blood pressure control.

RESULTS

Of the 120 enrolled patients, 106 completed the baseline visit (mean age of 66 years, 53% women, 57% Black, 36% White). Participants had multiple comorbidities (median number of medications = 8). During the visit, there was greater patient activation in the intervention arm than in the control arm (4.4 vs 3.8, P = .047; ratings were based on a scale from 1 to 10). However, after the visit there were no differences in medication adherence (4 weeks: 45.8% vs 49.5%; 12 weeks: 49.4% vs 51.1%), blood pressure control (4 weeks: 133/78 mm Hg vs 131/77 mm Hg; 12 weeks: 129/77 mm Hg vs 129/76 mm Hg), or encounter satisfaction (78.6% vs 73.8% fully satisfied; P = .63). There were also no differences in shared decision making, patients' trust, or perceived difficulty of the encounter.

CONCLUSION

A single previsit tool designed to prompt patients to set a prioritized agenda improved patient activation during the visit, but did not affect the quality of the interaction or postvisit patient-centred outcomes.

Partnership status and time to viral suppression and sustained viral suppression among newly diagnosed heterosexual people with HIV

BACKGROUND

Previous studies examining the role of partnership on HIV care outcomes have primarily focused on the men who have sex with men population in the United States, leaving a gap in the literature on this phenomenon among the heterosexual persons with HIV (PWH). This study examined association between partnership around diagnosis (married, unmarried-partnered, and un-partnered) with time to viral suppression (TVS) and sustained viral suppression (SVS) in newly diagnosed heterosexual PWH from a HIV clinic in Birmingham, Alabama.

METHODS

TVS [time to first viral load (VL) <200 copies/ml] was measured using VLs from 12 months following diagnosis using Kaplan-Meier and proportional hazard model for interval censoring (n=153) to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). SVS was measured using VLs for 12 months after first VS using logistic regression model (n=137) to calculate odds ratios (ORs) and 95% CIs. Models were adjusted for confounding demographics and clinical characteristics.

RESULTS

The study population comprised of 77% Black, 57% male, and 46% aged 31-49 years; 24% were married, 35% unmarried-partnered, and 41% un-partnered. The median TVS (days) was 57 for married, 73 for unmarried-partnered, and 75 for un-partnered. Compared to un-partnered individuals, unmarried-partnered had similar, whereas married had 69% higher [HR (95% CI): 1.69 (1.02, 2.78)] hazard of TVS. Compared to un-partnered, unmarried-partnered and married individuals had similar odds of achieving SVS.

CONCLUSION

Married, newly diagnosed, heterosexual PWH had faster TVS than un-partnered individuals suggesting that intimate partners may help achieve HIV care goals.

How does overall hospital satisfaction relate to patient experience with nursing care? a cross-sectional study in China

OBJECTIVE

To determine how patient experience with nursing care influence patient satisfaction with overall hospital services.

DESIGN

This was a cross-sectional study.

SETTING

Inpatients were consecutively recruited at the national hospital (with 2000 beds) in Shanghai, China.

PARTICIPANTS

The inclusion criteria were as follows: (1) hospitalised for 2 days or more; (2) able to read and understand Chinese; and (3) aged 18 years old or above. Patients with mental health problems were excluded. 756 patient surveys distributed among 36 wards were analysed. The mean age of participants in the study was 57.7 (SD=14.5) and ranged from 18 to 80 years. Most participants were men (61.5%) and ever married (94.6%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient experience with nursing care, meaning the sum of all interactions between patients and nurses, was measured using the self-designed questionnaire, which was developed by patient interviews, literature analysis and expert consultation. The overall patient satisfaction question was measured with a 10-point response option ranging from 1 to 10.

RESULTS

A linear relationship between the patient experience with nursing care and overall patient satisfaction was observed. The patient experience with nursing care was significantly associated with overall satisfaction in the crude model and in the adjusted models. Even after adjusting for six sociodemographic and three disease-related factors, the patient experience with nursing care explained 34.9% of the variation in overall patient satisfaction.

CONCLUSIONS

This study showed that patient experience with nursing care was an important predictor for overall patient satisfaction.

High Provider Trust Associates with High HIV Antiretroviral Adherence Among Women Living with HIV in a Metropolitan Washington, DC Cohort

Trust in providers and health care systems (HCSs) has been associated with higher HIV antiretroviral (ART) adherence; however, most previous studies enrolled primarily men and did not concurrently assess provider trust, HCS distrust, and clinical/biological outcomes. We enrolled 239 Washington, DC Women's Interagency HIV Study (WIHS) women: 167 with HIV (WWH) and 72 without HIV. In 2006 and 2017-2018, women completed surveys on provider trust and HCS distrust. Clinical, social, and demographic covariates were obtained during the 2017-2018 WIHS study visit. Descriptive analyses included chi-squared and Mann-Whitney tests. Wilcoxon signed-rank tests assessed trust measure change over time. Logistic (provider trust) and linear (HCS distrust) models were constructed in R. The majority of women were African American/Black (76.9%) with a median age of 52 (interquartile range 48, 58) and currently insured (99.6%). In multi-variable analyses, women with HIV (WWH) had higher odds of high provider trust [adjusted odds ratio (aOR) 2.90, 95% confidence interval (CI) 1.34, 6.45], with ≥95% ART adherence associated with high provider trust among only WWH (aOR 4.13, 95% CI 1.14, 15.92). Multi-variable models also showed 3.40-point higher HCS distrust scores among WWH who reported ≥95% ART adherence (p = 0.03). CD4 count and HIV viral load were not associated with provider trust or HCS distrust. Provider (p = 0.67) and HCS (p = 0.65) trust did not significantly change in this population at two time points for 10 years. Self-reported antiretroviral therapy adherence significantly associated with high provider trust, yet also with high HCS distrust, revealing a nuanced relationship to providers and the HCS among WWH.

Soft Skills: The Case for Compassionate Approaches or How Behavior Analysis Keeps Finding Its Heart

As the field of behavior analysis expands, our need to develop ourselves as more effective collaborators, particularly with families who may be the primary consumers of our science, becomes paramount. As scientists, our training lies primarily in the behavior analytic technologies that we study and apply. But our ability to disseminate our science, collaborate with non-behavior analysts, and ultimately grow our field hinges on our ability to navigate interpersonal situations in a way that puts forth compassion and humanity. We have the opportunity and capability to use our empirical procedures to implement and assess the effectiveness of interventions that target the soft skills of our field. The current article discusses the benefits of empathic and collaborative approaches in fields related to behavior analysis and provides suggestions for current behavior analysts to incorporate compassionate care into their practices. We provide a checklist for compassionate interactions accompanied by possibilities for its use as a tool for self-evaluation, procedural fidelity, and comprehensive training in the area of collaboration with families. Finally, we discuss areas for future research with respect to assessing and improving behavior analysts' compassionate approaches to treatment.

Patient Co-Participation in Narrative Medicine Curricula as a Means of Engaging Patients as Partners in Healthcare: A Pilot Study Involving Medical Students and Patients Living with HIV

This paper describes a pilot study of a new model for narrative medicine training, "community-based participatory narrative medicine" (CBPNM), which centers on shared narrative work between healthcare trainees and patients. Nine medical students and eight patients participated in one of two, five-week-long pilot workshop series. A case study of participants' experiences of the workshop series identified three major themes: (1) the reciprocal and collaborative nature of participants' relationships; (2) the interplay between self-reflection and receiving feedback from others; and (3) the clinical and pedagogical implications of the CBPNM model. Principles and proposed outcomes of the CBPNM model are presented.

Randomized Prospective Trial Exploring the Impact of Structured Journaling in Patients With Sarcoma on the Management of Treatment-Related Adverse Events

Treatment-related adverse events associated with systemic anticancer therapy (SACT) can deter patients with sarcoma from completing treatment. With self-monitoring, patients may be better empowered to self-advocate for improved symptom management. We hypothesized that by incorporating journaling, a structured form of self-monitoring, care team communication, and symptom management would improve. We thus designed a prospective randomized trial exploring journaling as a therapeutic adjuvant for symptom management (NCT03258892).

The Weight of Words: Indian Physicians' Perspectives on Patient Communication to Promote Diabetes Adherence

BACKGROUND

Effective communication by physicians can lead to improved patient adherence, resulting in better patient outcomes and increased patient satisfaction. This study: (i) examined communication with patients when they were non-adherent, (ii) examined attitudes toward common communication cues, and (iii) explored communication approaches to encourage diabetes adherence used by Indian physicians.

METHODS

Using a concurrent mixed methods approach, Indian physicians, specialized in diabetes and/or endocrinology were recruited, to complete a survey containing quantitative (n = 834) and qualitative (n = 648) questions. The questions included (i) whether physicians expressed disappointment and used scare tactics for non-adherent patients, (ii) to rate the importance of common communication cues when promoting adherence, and (iii) nested, qualitative questions to understand their communication approach to promote adherence. The data were analyzed using descriptive statistics and qualitative content analysis, respectively.

RESULTS

The quantitative study reported that the majority of the physicians sometimes showed their disappointment in their patient's progress (44.4%), sometimes used scare tactics to convey disease severity due to non-adherence (34.3%), and rated all communication cues as most important. The qualitative findings revealed that physicians used paternalistic (authoritative, educational, authoritarian) or collaborative (multistakeholder, patient-centered) approaches and the language cues of fear, blame, and threats to promote patient adherence.

CONCLUSION

These findings highlight the need for communication skill training programs for Indian physicians focused on empathic, non-verbal, supportive, and inclusive techniques so as to promote patient adherence. Further, these trainings need to use role-playing, video recording, and peer feedback methods to show physicians how to implement these skills during patient interactions.

Patient-Oncologist Therapeutic Alliance Among Young Adults with Cancer: Relationships with Meaning and Peace of Mind

Cancer diagnosis and subsequent treatment can impact how young adults make sense of their worlds and disrupt peace of mind. The patient-oncologist therapeutic alliance, built upon mutual care, respect, and trust, may foster a deeper understanding of one's illness and promote peace of mind. The study examined relationships between a comprehensive cancer-specific measure of therapeutic alliance and meaning and peace of mind among young adults with cancer (N = 56). Results indicated that a stronger therapeutic alliance was positively associated with meaning and peace of mind. Findings highlight the importance of the patient-oncologist therapeutic alliance in facilitating positive psychological outcomes among young adults with cancer.

Measuring the multiple domains of medication nonadherence: findings from a Delphi survey of adherence experts

Consensus on a gold-standard measure of patient medication nonadherence has been elusive, in part because medication nonadherence involves multiple, distinct behaviors across three phases (initiation, implementation, and persistence). To assess these behaviors, multiple measurement approaches may be needed. The purpose of this study was to identify expert-recommended approaches to measuring nonadherence behaviors. Thirty medication nonadherence experts were e-mailed two consecutive surveys. In both, respondents rated their agreement with definitions of nonadherence behaviors and measurement approaches. In the second survey, respondents rated the suitability of each measurement approach for assessing each behavior and identified the optimal measurement approach for each behavior. Consensus was achieved for eight patient medication nonadherence behaviors: not filling initial prescription and not taking first dose (noninitiation); refilling prescription late, missing doses, taking extra doses, taking doses at wrong time, and improperly administering medication (incorrect implementation); and discontinuing medication early (nonpersistence). Consensus was achieved for seven measurement approaches: self-report, prescription fill data, pill count, drug levels, electronic drug monitoring (EDM), smart technology, and direct observation. Self-report questionnaires were most commonly rated "at least somewhat suitable" for measuring behaviors. EDM was rated as optimal for measuring missing doses, taking extra doses, and taking doses at the wrong time. Prescription fill data were rated as optimal for not filling initial prescription, refilling late, and discontinuing. Direct observation was rated as optimal for measuring improper administration. Suitable and optimal measurement approaches varied across nonadherence behaviors. Researchers should select the measurement approach best suited to assessing the behavior(s) targeted in their research.

Patient-Provider Communication and Information, Motivation, and Behavioral Skills in HIV-Positive Adults Initiating Antiretroviral Therapy in Haiti

While Haiti has scaled up use of antiretroviral therapy (ART), current studies suggest sub-optimal adherence threatens long-term viral suppression in this understudied setting. Patient-provider communication (PPC) and information, motivation, and behavioral skills (IMB) have been implicated in ART adherence globally. However, no studies have examined their relevance in Haiti. The present mixed-methods study utilized cross-sectional survey data from 128 ART-initiating patients at 2 large HIV treatment sites in Haiti, as well as observational data from 12 clinic visits, to document associations between adherence-related PPC and IMB. Multivariate regression analyses suggested that PPC is associated with IMB constructs. At the bivariate level, more effective PPC was associated with higher levels of adherence-related information and motivation, but not behavioral skills. Observational findings indicate infrequent and non-collaborative adherence support. Taken together, findings lay the groundwork for additional research in the area of PPC, IMB, and ART adherence in Haiti.

Perceived characteristics of outpatient appointment scheduling association with patient satisfaction and treatment adherence: An innovation theory application

BACKGROUND

Despite the growing interest in Appointment scheduling (APS) in hospitals of developing countries, empirical assessment of their effectiveness in improving patients' experiences and adherence to treatment remains limited. We drew on the attributes of an innovation theory to hypothesize and test the extent to which perceived attributes of APS: relative advantage, compatibility, and complexity influences patient satisfaction and treatment adherence in a neurology clinic of a large Teaching Hospital in Ghana.

METHODS

A structured questionnaire was used to collect cross-sectional data from a sample of 295 scheduled patients visiting the clinic for follow-up care. Partial Least Squares Structural Equation Modeling (PLS-SEM) was used to analyze the hypothesized direct relationships of the APS attributes with patient satisfaction and treatment adherence, and the moderating effect of cordial doctor-patient communication in the relationships.

RESULTS

While the compatibility of APS with patient preference was positively associated with patient satisfaction (p < 0.01) and adherence to treatment (p < 0.01), the reverse was observed for complexity of the APS system (p < 0.01). We also found statistically significant relationship of patient satisfaction with treatment adherence (p < 0.01) which was positively moderated by cordial doctor-patient communication.

CONCLUSION

Findings suggest that making the APS system more compatible with patient preference can greatly improve upon patient experience satisfaction and adherence to medical treatment for effective therapeutic outcomes.

PRACTICE IMPLICATION

In the light of its benefits to patient care and outcomes, APS should be given priority over walk-in services in specialty clinics of developing countries.

Socioeconomic Factors Influence Health Information Seeking and Trust Over Time: Evidence From a Cross-Sectional, Pooled Analyses of HINTS Data

PURPOSE

Assessed socioeconomic factors in health information seeking behavior and trust of information sources from 2007 to 2017.

DESIGN

Pooled cross-sectional survey data.

SETTING

Health Information National Trends Survey.

PARTICIPATION

Data included 6 iterations of U.S. adults (Pooled: N = 19,496; 2007: N = 3,593; 2011: N = 3,959; 2013: N = 3,185; FDA 2015: N = 3,738; 2017: N = 3,285; and FDA 2017: N = 1,736).

MEASURES

Outcome variables were health information seeking, high confidence, and high trust of health information from several sources. Independent variables were education and income group, controlling for other sociodemographic variables.

ANALYSIS

Weighted descriptive and multivariate logistic regression for the pooled sample assessed associations by education and income. Fully interacted models with education/income-survey year interactions compared differences in outcomes between years.

RESULTS

We found information seeking, confidence, and trust were associated with income and education, which supported previously reported findings. Additionally, our findings indicated low-and medium-income groups had significantly lower odds of seeking health information compared to those in a high-income group. Regarding trust of information, a high school education was associated with higher odds of trust in family and friends. We also found that, over time, information seeking, confidence, and trust behavior differed by income and education, with some differences persisting.

CONCLUSION

Disparities by income and education in trust of information sources remained across time. Understanding optimal information sources, their reach, and their credibility among groups could enable more targeted interventions and health messaging. We also describe the implications for our findings in the context of COVID-19.