Clinic Readiness for Trauma-Informed Health Care Is Associated With Uptake of Screening for Adverse Childhood Experiences

INTRODUCTION

Adverse childhood experiences (ACEs) are strongly correlated with many of the most common causes of preventable illness, preventable death, and health disparities. In January 2020, California launched the first statewide initiative to integrate ACE screening throughout its Medicaid system. A key element of the initiative was the California ACEs Learning and Quality Improvement Collaborative, a 48-clinic, 16-month learning collaborative. This evaluation aimed to determine whether developing a trauma-informed environment of care was associated with uptake of ACE screening.

METHODS

Participants included 40 of 48 clinics that participated in the statewide learning collaborative. Clinics completed an assessment of progress in 5 essential components of trauma-informed health care at baseline and 1-year follow-up. Clinics tracked data on ACE screens completed on an ongoing basis and submitted data quarterly. A hierarchical linear model was used to examine the association between change in readiness for trauma-informed health care and change in quarterly screens.

RESULTS

Readiness for trauma-informed health care increased for all participating clinics over the course of the learning collaborative. The average number of quarterly screens also increased, with considerable variability among clinics. Clinics with larger increases in readiness for trauma-informed health care had larger increases in quarterly screens.

DISCUSSION

The findings align with long-standing recommendations for trauma screening to occur in the context of trauma-informed environments of care.

CONCLUSION

A trauma-informed clinic is the foundation for successful adoption of ACE screening. ACE screening initiatives should include education and sufficient support for clinics to embrace a trauma-informed systems change process.

The Association Between Interpersonal Violence and Unstable Housing Among Veterans

BACKGROUND

Despite programs to address housing for Veterans, they continue to be at high risk of unstable housing. Interpersonal violence is also highly prevalent among Veterans and may contribute to unstable housing. Our study aimed to determine whether interpersonal violence was associated with unstable housing among Veterans, and how this association was influenced by common co-occurring conditions such as substance use and mental illness.

METHODS

Veterans in the Mind Your Heart Study (N = 741) completed survey data on history of interpersonal violence and access to housing in the prior year. Interpersonal violence was defined as experiencing sexual violence, physical violence, or mugging/physical attack using the Brief Trauma Questionnaire. Multivariable models examined associations between interpersonal violence and unstable housing. Primary models were adjusted for age and sex. Potential explanatory factors were added in subsequent models, including marital status, education, income, substance use disorder, PTSD, and other mental illness.

RESULTS

Veterans who had experienced interpersonal violence had almost twice the odds of unstable housing after adjustment for age and sex (AOR 1.9, 95% CI 1.2-3.0). This association was attenuated in the fully adjusted model including substance use, PTSD, and other mental illness, illustrating the interdependence of these factors (AOR 1.5, 95% CI 0.91-2.5). Subtypes of interpersonal violence were individually associated with increased odds of unstable housing after adjustment for age and sex (physical abuse AOR 1.7, 95% CI 1.2-2.5; mugging/physical attack AOR 1.8, 95% CI 1.2-2.7; sexual violence AOR 1.4, 95% CI 0.89-2.2), but were no longer significant in the fully adjusted model.

CONCLUSIONS

Previous experiences of interpersonal violence were associated with unstable housing among Veterans. Substance use, PTSD, and other mental illness played an important role in this relationship-highlighting the potential to improve health outcomes through trauma informed approaches that address mental health, substance use, and housing concurrently.

The Association of Trauma with the Physical, Behavioral, and Social Health of Women Living with HIV: Pathways to Guide Trauma-informed Health Care Interventions

BACKGROUND

Trauma is increasingly recognized as a near-universal experience among women living with HIV (WLHIV) and a key contributor to HIV acquisition, morbidity, and mortality.

METHODS

We present data from the baseline analysis of a planned intervention trial of the impact of trauma-informed health care on physical, behavioral, and social health outcomes of WLHIV in one clinic, with a particular focus on quality of life and viral suppression. Data were collected through interviewer-administered surveys and electronic health record data abstraction.

RESULTS

Among 104 WLHIV, 97.1% of participants reported having experienced lifetime trauma, and participants had experienced on average 4.2 out of 10 Adverse Childhood Experiences. WLHIV with more lifetime trauma were significantly more likely to report post-traumatic stress disorder, depression, and anxiety symptoms; significantly more likely to report potentially harmful alcohol and drug use; and had a significantly poorer quality of life. In addition, women who had experienced more lifetime trauma were significantly less likely to report being on and adhering to HIV medications, although trauma was not significantly associated with having an undetectable HIV viral load.

CONCLUSIONS

These data suggest that trauma is associated with much of the morbidity and mortality experienced by WLHIV. The results of this study support the implementation and study of trauma-informed approaches to health care for WLHIV.

Providing Primary Care for HIV in the Context of Trauma: Experiences of the Health Care Team

BACKGROUND

Trauma-informed health care for women living with human immunodeficiency virus (HIV) attends not only to HIV treatment, but also to the many common physical and emotional health consequences of trauma. One principle of providing trauma-informed care is the acknowledgement that working with a population that has experienced extensive trauma affects the team members who care for them in the clinic, as well as the interactions between those team members.

METHODS

To understand the needs of one primary health care team, we conducted in-depth interviews with 21 providers, staff, and collaborators who provide care to patients within the clinic. We used symbolic interaction and grounded theory methods to examine how interactions unfold within the clinic and how they are influenced by trauma.

RESULTS

The clinic team serves a highly traumatized and vulnerable population. Within this context, interactions between clinic staff unfold and trauma surfaces, and power dynamics play out along the lines of professional hierarchy. Although power differences cause tension within the clinic, professional hierarchy also serves as an important division of labor in times of medical crises.

CONCLUSIONS

Clinic power dynamics may be influenced to improve the care environment for patients, and to realize a more effective and satisfying trauma-informed health care clinic for both patients and staff.

Gender differences in causes of death among persons with HIV/AIDS in San Francisco, California, 1996-2013

The objective was to examine gender differences in causes of death using the San Francisco HIV/AIDS and death registries. Data from San Francisco residents diagnosed with HIV/AIDS who died from 1996 to 2013 were analyzed. Age, race/ethnicity, year, and gender-adjusted standardized mortality ratios and Poisson 95% confidence intervals were calculated for underlying causes of death. Among the 6268 deaths, deaths attributed to drug use, mental disorders due to substance use, cerebrovascular disease, chronic obstructive pulmonary disease, renal disease, and septicemia were more likely among women than among men. Compared to the California population, women had elevated standardized mortality ratios for drug overdose (25.37), mental disorders due to substance abuse (27.21), cerebrovascular disease (2.83), chronic obstructive pulmonary disease (7.37), heart disease (2.37), and liver disease (5.54), and these were higher than the standardized mortality ratios for the men in our study. Men, but not women, had elevated standardized mortality ratios for suicide (2.70), undetermined intent (3.88), renal disease (2.29), and non-AIDS cancer (1.68) compared to population rates. Continued efforts to reduce HIV-related illnesses and an increased emphasis on diagnosing and treating preventable causes of death, including substance use, heart disease, and mental health disorders, are needed as part of comprehensive HIV care.

Seeking Safety Group Therapy for Co-Occurring Substance Use Disorder and PTSD among Transgender Women Living with HIV: A Pilot Study

Transgender women living with HIV experience high rates of substance use, violence, and post-traumatic stress disorder (PTSD). Seeking Safety is a manualized, present-focused, cognitive-behavioral therapy program designed to address co-occurring substance use and PTSD. Seeking Safety has evidence of efficacy in a variety of populations but had not been evaluated specifically with people living with HIV or transgender women. We pilot-tested a 12-session Seeking Safety program with a group of transgender women living with HIV who reported substance use and a history of violence. Seven transgender women living with HIV were recruited from two HIV primary care clinics in San Francisco and completed pre- and post-intervention assessments. Participants attended an average of 8 of the 12 sessions. Mean scores for all three outcome measures improved: PTSD symptom scores declined 17.5%, alcoholism screening scores declined 23.9%, and drug abuse screening scores declined 68.8%, on average. Despite the small sample, this pilot study showed Seeking Safety to be a promising intervention among transgender women living with HIV. The findings are encouraging and justify larger studies of Seeking Safety among transgender women and other people living with HIV who experience high rates of substance use and PTSD.

An expressive therapy group disclosure intervention for women living with HIV improves social support, self-efficacy, and the safety and quality of relationships: a qualitative analysis

Women living with HIV (WLHIV) face high rates of morbidity and mortality. HIV disclosure interventions have been identified as a promising but under-evaluated approach for WLHIV to improve their health and well-being. The Medea Project is an expressive therapy group intervention that was first developed to help incarcerated women develop the confidence and skills to tell their stories publicly in theatrical performances. The intervention was subsequently adapted as a community-based disclosure intervention for WLHIV. Our study describes an analysis of the impact of the Medea Project on the lives of the WLHIV who participated. All participating WLHIV publicly disclosed their HIV status during the performances. Five impact themes emerged from the data: sisterhood, catharsis, self-acceptance, safer and healthier relationships, and gaining a voice. Our study identifies a voluntary, effective, and broadly beneficial disclosure intervention for women living with HIV.

Recent trauma is associated with antiretroviral failure and HIV transmission risk behavior among HIV-positive women and female-identified transgenders

Trauma and posttraumatic stress disorder disproportionally affect HIV-positive women. Studies increasingly demonstrate that both conditions may predict poor HIV-related health outcomes and transmission-risk behaviors. This study analyzed data from a prevention-with-positives program to understand if socio-economic, behavioral, and health-related factors are associated with antiretroviral failure and HIV transmission-risk behaviors among 113 HIV-positive biological and transgender women. An affirmative answer to a simple screening question for recent trauma was significantly associated with both outcomes. Compared to participants without recent trauma, participants reporting recent trauma had over four-times the odds of antiretroviral failure (AOR 4.3; 95% CI 1.1-16.6; p = 0.04), and over three-times the odds of reporting sex with an HIV-negative or unknown serostatus partner (AOR 3.9; 95% CI 1.3-11.9; p = 0.02) and <100% condom use with these partners (AOR 4.5; 95% CI 1.5-13.3; p = 0.007). Screening for recent trauma in HIV-positive biological and transgender women identifies patients at high risk for poor health outcomes and HIV transmission-risk behavior.

Atraumatic splenic rupture: an unusual manifestation of acute HIV infection

A 27-year-old white male, who had sex with other men, presented to the emergency department with 3 days of left shoulder and abdominal pain. He reported no history of trauma to the abdomen. On abdominal imaging, he was found to have hemoperitoneum from a ruptured spleen; he underwent splenectomy. Causes of atraumatic splenic rupture can be divided into six main categories: infectious, neoplastic, inflammatory, congenital or structural, iatrogenic, and idiopathic. Work-up of the atraumatic splenic rupture revealed that his HIV antibody was newly positive. He had a documented negative HIV antibody 3 weeks prior to the current admission. CD4 cell count, obtained after splenectomy, was 904 cells per microliter and the HIV-1 plasma RNA level was 4657 copies per milliliter. Spleen pathology demonstrated an enlarged spleen with increase in the number of small to intermediate size lymphoid cells in the red pulp, and reactive follicular lymphoid hyperplasia, with numerous secondary lymphoid follicles and reactive germinal centers in the white pulp. T-cell receptor (TCR) gene rearrangement studies demonstrated a positive TCR beta gene rearrangement, without a TCR gamma gene rearrangement, consistent with a clonal CD8(+) T-cell population. The case gives rare insight into what happens in the spleen during acute HIV infection and encourages HIV testing in those presenting with atraumatic splenic rupture. Counseling patients with acute HIV to avoid potential trauma should also be considered.

Language, literacy, and characterization of stroke among patients taking warfarin for stroke prevention: Implications for health communication

OBJECTIVE

Warfarin is a medication commonly prescribed to prevent strokes associated with certain medical conditions such as atrial fibrillation; however, little is known about how people taking warfarin perceive the goal of therapy and how they describe strokes. We assessed the stroke-related health literacy of anticoagulated patients to inform ways in which to improve health communication among people taking warfarin.

METHODS

We conducted a mixed-methods study of an ethnically and linguistically diverse sample of people taking warfarin to prevent stroke (N=183) and measured literacy using the short-form Test of Functional Health Literacy in Adults. We asked participants to (1) describe their indication for warfarin, and (2) describe a stroke. Transcribed answers were coded as concordant or discordant with established indications for warfarin and definitions of stroke.

RESULTS

Forty-three percent of participants provided a discordant response when describing their indication for warfarin. Only 9.3% reported that the purpose of taking warfarin was to prevent stroke. Not speaking English [OR=2.4 (1.1-5.6)] and less than a college education [OR=3.3 (1.4-7.3)] were independently associated with discordant answers about warfarin. Nearly 40% of subjects had inaccurate perceptions of stroke, and only one-third of subjects described a symptom or sign of stroke. Among English and Spanish-speaking participants, inadequate literacy was strongly associated with discordant responses about stroke [OR=5.8 (2.1-15.6)].

CONCLUSION

Among high-risk people taking warfarin to prevent stroke, significant gaps in stroke-related health literacy exist. These gaps likely represent mismatches in the ways clinicians teach and patients learn.

PRACTICE IMPLICATIONS

Since stroke risk awareness and early recognition of the signs and symptoms of stroke are critical aspects of stroke prevention and treatment, clinicians should more strongly link warfarin therapy to stroke prevention and ensure that patients know the presenting symptoms and signs of stroke. Public health communication strategies regarding stroke prevention need to target individuals with limited literacy and limited English proficiency.

A visual medication schedule to improve anticoagulation control: a randomized, controlled trial

BACKGROUND

Misunderstanding between clinicians and patients may lead to medication-related errors and poor clinical outcomes, particularly in anticoagulant care.

METHODS

One hundred forty-seven chronic warfarin users were randomized to receive a visual medication schedule at each visit, along with brief counseling, versus standard care, and followed for 90 days. At baseline, patient and clinician reports of the prescribed warfarin regimen were recorded to identify patients as "discordant" versus "concordant" to determine whether the effect of the intervention varied with clinician-patient discordance.

RESULTS

At baseline, clinician-patient warfarin regimen discordance was common in intervention and control groups (38% versus 42%). Intervention subjects achieved anticoagulation control more rapidly than control subjects (median 28 versus 42 days; hazard ratio [HR], 1.43; confidence interval [CI], 1.00, 2.06). The benefit of the intervention was significant among subjects with baseline regimen discordance (median, 28 versus 49 days; HR, 1.92; CI, 1.08, 3.39) but not among subjects with baseline concordance (median 28 versus 35 days; HR, 1.14; CI, 0.71,1.83).

DISCUSSION

Among patients in poor anticoagulant control whose understanding of their warfarin regimen is discordant with their providers', a visual medication schedule, combined with brief counseling, reduced time to anticoagulation control. The study suggests a simple strategy to enhance medication safety and efficacy for at-risk patients.

Seven steps to better adherence: a practical approach to promoting adherence to antiretroviral therapy

The introduction of effective antiretroviral therapy has resulted in dramatic clinical benefits for those persons who have access to it. Adherence to such therapy has emerged as both the major determinant and the Achilles' heel of this success. Many patients have levels of adherence too low for durable virologic control. Virologic failure from suboptimal adherence diminishes the potential for long-term clinical success, leads to the emergence of drug-resistant virus, and may undermine the dramatic benefits in health parameters seen in resource-rich countries and expected in developing countries as effective antiretroviral therapy becomes more widely available. While adherence to antiretroviral therapy is regarded as the most important determinant of clinical outcomes in HIV-positive persons, most clinicians receive little guidance on practical steps to support and improve adherence. A structured, evidence-based, 7-step approach to supporting and improving antiretroviral adherence is described here. These steps can serve as a starting point or review for care providers working to support HIV-positive patients to successfully adhere to antiretroviral therapy.

Language, literacy, and communication regarding medication in an anticoagulation clinic: a comparison of verbal vs. visual assessment

Despite the importance of clinician-patient communication, little is known about rates and predictors of medication miscommunication. Measuring rates of miscommunication, as well as differences between verbal and visual modes of assessment, can inform efforts to more effectively communicate about medications. We studied 220 diverse patients in an anticoagulation clinic to assess concordance between patient and clinician reports of warfarin regimens. Bilingual research assistants asked patients to (1) verbalize their prescribed weekly warfarin regimen and (2) identify this regimen from a digitized color menu of warfarin pills. We obtained clinician reports of patient regimens from chart review. Patients were categorized as having regimen concordance if there were no patient-clinician discrepancies in total weekly dosage. We then examined whether verbal and visual concordance rates varied with patient's language and health literacy. Fifty percent of patients achieved verbal concordance and 66% achieved visual concordance with clinicians regarding the weekly warfarin regimen (P < .001). Being a Cantonese speaker and having inadequate health literacy were associated with a lower odds of verbal concordance compared with English speakers and subjects with adequate health literacy (AOR 0.44, 0.21-0.93, AOR 0.50, 0.26-0.99, respectively). Neither language nor health literacy was associated with visual discordance. Shifting from verbal to visual modes was associated with greater patient-provider concordance across all patient subgroups, but especially for those with communication barriers.Clinician-patient discordance regarding patients' warfarin regimen was common but occurred less frequently when patients used a visual aid. Visual aids may improve the accuracy of medication assessment, especially for patients with communication barriers.

The importance of establishing regimen concordance in preventing medication errors in anticoagulant care

Miscommunication between patients and providers can have serious consequences, especially where medications are concerned. We examined whether regimen discordance between patient and provider, a possible result of miscommunication, contributes to unsafe medication management. We studied 220 patients taking warfarin in an anticoagulation clinic to characterize two medication assessment methods. We measured (1) adherence by asking patients to report any missed doses and (2) concordance between patients' and providers' reports of warfarin regimens. We categorized patients as having regimen adherence if they missed no doses, and concordance if there was patient-provider agreement in weekly dosage. We characterized anticoagulant outcomes as unsafe if international normalized ratio (INR) values were <2.0 (at risk for thrombosis) or >4.0 (at risk for hemorrhage), and explored relationships among adherence, concordance, and anticoagulant outcomes. One hundred fifty-five patients (71%) reported no missed doses during the prior 30 days. Poor adherence was associated with underanticoagulation (AOR 2.33, 1.56-3.45), but not overanticoagulation (AOR 1.36, 0.69-2.66). One hundred ten patients (50%) reported regimens discordant with clinicians' report. There was no relationship between patients' reports of adherence and concordance. Among adherent patients, discordance was associated with underanticoagulation (AOR 1.67, 1.00-2.78) and overanticoagulation (AOR 3.44, 1.32-9.09). Discordance regarding warfarin regimens is common and places patients at risk for adverse events. To promote safe and effective care, clinicians should separately determine adherence and regimen concordance during routine medication assessments. Systems need to be developed to ensure concordance in medication regimens.

Health literacy and anticoagulation-related outcomes among patients taking warfarin

BACKGROUND

Little is known about whether health literacy affects anticoagulation-related outcomes.

OBJECTIVE

To assess how health literacy is associated with warfarin knowledge, adherence, and warfarin control (measured by the international normalized ratio [INR]).

DESIGN

Survey.

PARTICIPANTS

Patients taking warfarin through an anticoagulation clinic.

MEASUREMENTS

Health literacy was measured using the short-form Test of Functional Health Literacy in Adults (s-TOFHLA), dichotomized as "limited" (score 0 to 22) and "adequate" (score 23 to 36). We asked patients to answer questions relating to their warfarin therapy and used multivariable logistic regression to assess whether health literacy was associated with incorrect answers. We also assessed whether health literacy was associated with nonadherence to warfarin as well as time in therapeutic INR range.

RESULTS

Bilingual research assistants administered the survey and s-TOFHLA to 179 anticoagulated English- or Spanish-speaking patients. Limited health literacy was associated with incorrect answers to questions on warfarin's mechanism (adjusted odds ratio [OR] 4.8 [1.3 to 17.6]), side-effects (OR 6.4 [2.3 to 18.0]), medication interactions (OR 2.5 [1.1 to 5.5]), and frequency of monitoring (OR 2.7 [1.1 to 6.7]), after adjusting for age, sex, race/ethnicity, education, cognitive impairment, and years on warfarin. However, limited health literacy was not significantly associated with missing warfarin doses in 3 months (OR 0.9 [0.4 to 2.0]) nor with the proportion of person-time in therapeutic INR range (OR 1.0 [0.7 to 1.4]).

CONCLUSIONS

Limited health literacy is associated with deficits in warfarin-related knowledge but not with self-reported adherence to warfarin or INR control. Efforts should concentrate on investigating alternative means of educating patients on the management and potential risks of anticoagulation.

Etiology of pruritic papular eruption with HIV infection in Uganda

CONTEXT

A frequent cause of human immunodeficiency virus (HIV)-related morbidity in sub-Saharan Africa is a commonly occurring, intensely pruritic skin rash. The resulting scars are disfiguring and stigmatizing. Despite the substantial prevalence of pruritic papular eruption (PPE) among HIV-infected Africans, the cause has been elusive.

OBJECTIVE

To determine the etiology of PPE occurring in HIV-infected individuals.

DESIGN, SETTING, AND PATIENTS

Cross-sectional study of HIV-infected patients with active PPE from clinics in Uganda conducted from May 19 through June 6, 2003. Enrollment occurred in the month preceding May 19. Each participant was clinically examined by 2 dermatologists, had laboratory studies performed, was administered an epidemiologic questionnaire, and had a skin biopsy of a new lesion evaluated by a dermatopathologist.

MAIN OUTCOME MEASURES

Histological characteristics of new pruritic lesions. Other assessments included CD4 cell count, eosinophil count, and physician-assessed rash severity.

RESULTS

Of 109 patients meeting inclusion criteria, 102 (93.6%) completed the study. The CD4 cell counts in this study population were generally low (median, 46/microL) and inversely related to increasing rash severity (median CD4 cell counts: 122 for mild, 41 for moderate, and 9 for severe; P<.001 for trend). Eighty-six patients (84%; 95% confidence interval, 77%-91%) had biopsy findings characteristic of arthropod bites. Patients with arthropod bites on biopsy had significantly higher peripheral eosinophil counts (median, 330 vs 180/microL; P = .02) and had a trend toward lower CD4 cell counts (median, 40 vs 99/microL; P = .07) than those without histological evidence of arthropod bites.

CONCLUSIONS

Pruritic papular eruption occurring in HIV-infected individuals may be a reaction to arthropod bites. We hypothesize that this condition reflects an altered and exaggerated immune response to arthropod antigens in a subset of susceptible HIV-infected patients.