The moral discourse of HIV providers within their organizational context: An ethnographic case study

Structural Equation Modeling of Stigma and HIV Prevention Clinical Services Among Transgender and Gender Diverse Adults: The Mediating Role of Substance Use and HIV Sexual Risk

BACKGROUND

Transgender and gender diverse (TGD) adults experience high levels of stigma that contributes to elevated substance use and HIV sexual risk behaviors. Despite higher burdens of substance use and HIV compared to cisgender adults, TGD individuals may be less likely to engage in health care to avoid further discrimination.

SETTING

This analysis included 529 TGD adults in Massachusetts and Rhode Island who were HIV negative or had an unknown HIV serostatus and were purposively sampled between March and August 2019.

METHODS

We used structural equation modeling to test whether substance use, HIV sexual risk behaviors (ie, condom use, sex work, and multiple partners), and receiving gender-affirming hormone therapy mediate any observed association between TGD-related stigma and utilization of HIV prevention clinical services (ie, HIV prevention programs, PrEP use, and HIV testing).

RESULTS

Substance use and HIV sexual risk mediated the relationship between TGD-related stigma and utilization of HIV prevention clinical services (β = 0.08; 95% CI = 0.05, 0.17; P = 0.03 and β = 0.26; 95% CI = 0.14 to 0.37; P < 0.001). Having a hormone therapy prescription was not a mediator between TGD-related stigma and HIV prevention clinical services.

CONCLUSIONS

Future interventions that aim to improve HIV prevention clinical services among TGD adults should consider the impact of TGD-related stigma on participants' substance use and sexual risk behaviors. These efforts require that health care organizations and community organizations make a deliberate investment in the reach and success of interventions and programs.

Direct Observation Methods: a Practical Guide for Health Researchers

OBJECTIVE

To provide health research teams with a practical, methodologically rigorous guide on how to conduct direct observation.

METHODS

Synthesis of authors' observation-based teaching and research experiences in social sciences and health services research.

RESULTS

This article serves as a guide for making key decisions in studies involving direct observation. Study development begins with determining if observation methods are warranted or feasible. Deciding what and how to observe entails reviewing literature and defining what abstract, theoretically informed concepts look like in practice. Data collection tools help systematically record phenomena of interest. Interdisciplinary teams--that include relevant community members-- increase relevance, rigor and reliability, distribute work, and facilitate scheduling. Piloting systematizes data collection across the team and proactively addresses issues.

CONCLUSION

Observation can elucidate phenomena germane to healthcare research questions by adding unique insights. Careful selection and sampling are critical to rigor. Phenomena like taboo behaviors or rare events are difficult to capture. A thoughtful protocol can preempt Institutional Review Board concerns.

INNOVATION

This novel guide provides a practical adaptation of traditional approaches to observation to meet contemporary healthcare research teams' needs.

Medication Adherence and Characteristics of Patients Who Spend Less on Basic Needs to Afford Medications

INTRODUCTION

Among individuals with low income, cost is a well-established barrier to medication adherence. Spending less on basic needs to pay for medication is a particularly concerning cost-coping strategy and may be associated with worse health outcomes. The aims of this study were (1) to describe the demographic and health status characteristics of those who report spending less on basic needs to pay for medication, and (2) to understand the associated psychosocial and financial challenges of these individuals.

METHODS

We administered a survey to primarily low-income adults (n = 270) in St. Louis, MO, as part of a larger study from 2016 to 2018. Logistic regression was used to model odds of reporting spending less on basic needs to pay for medication.

RESULTS

Spending less on basic needs to pay for medication was significantly more likely in individuals with fair or poor health status, greater number of chronic conditions, greater medication expenditure, and difficulty paying bills. Individuals who spent less on basic needs were less likely to be fully adherent to their medication regimen.

CONCLUSIONS

Screening for unmet basic needs and offering referrals to social safety net programs in the primary care setting may help patients achieve sustainable medication adherence.

The temporal nature of social context: Insights from the daily lives of patients with HIV

Background

Patients’ life contexts are increasingly recognized as important, as evidenced by growing attention to the Social Determinants of Health (SDoH). This attention may be particularly valuable for patients with complex needs, like those with HIV, who are more likely to experience age-related comorbidities, mental health or substance use issues. Understanding patient perceptions of their life context can advance SDoH approaches.

Objectives

We sought to understand how aging patients with HIV think about their life context and explored if and how their reported context was documented in their electronic medical records (EMRs).

Design

We combined life story interviews and EMR data to understand the health-related daily life experiences of patients with HIV. Patients over 50 were recruited from two US Department of Veterans Affairs HIV clinics. Narrative analysis was used to organize data by life events and health-related metrics.

Key results

EMRs of 15 participants documented an average of 19 diagnoses and 10 medications but generally failed to include social contexts salient to patients. In interviews, HIV was discussed primarily in response to direct interviewer questions. Instead, participants raised past trauma, current social engagement, and concern about future health with varying salience. This led us to organize the narratives temporally according to past-, present-, or future-orientation. “Past-focused” narratives dwelled on unresolved experiences with social institutions like the school system, military or marriage. “Present-focused” narratives emphasized daily life challenges, like social isolation. “Future-focused” narratives were dominated by concerns that aging would limit activities.

Conclusions

A temporally informed understanding of patients’ life circumstances that are the foundation of their individualized SDoH could better focus care plans by addressing contextual concerns salient to patients. Trust-building may be a critical first step in caring for past-focused patients. Present-focused patients may benefit from support groups. Future-focused patients may desire discussing long term care options.

Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis

BACKGROUND

Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV; however, its uptake remains modest. Given that there are fewer cost barriers to receiving PrEP within VHA than via commercial insurance, VHA represents an ideal setting in which to study other barriers that may impact patients seeking PrEP.

OBJECTIVE

We sought to understand potential barriers to obtaining PrEP within the Veterans Health Administration (VHA) through examination of documentation in electronic medical records.

DESIGN

Retrospective structured chart review, including chart abstractions of notes, referrals, and communications; content analysis of charts from a subsample of patients receiving PrEP in VHA.

PARTICIPANTS

One hundred sixty-one patients prescribed PrEP at 90 sites varying in PrEP prescribing rates.

APPROACH

We extracted descriptive information and conducted a qualitative analysis of all PrEP-relevant free-text notes including who initiated the PrEP conversation (patient vs. provider), time interval between request and prescription, reasons for denying PrEP, and patient responses to barriers.

KEY RESULTS

Patients initiated 94% of PrEP conversations and 35% of patients experienced delays receiving PrEP ranging from six weeks to 16 months. Over 70% of cases evidenced barriers to access. Barriers included provider knowledge gaps about PrEP, provider knowledge gaps about VHA systems related to PrEP, confusion or disagreement over clinic purview for PrEP, and provider attitudes or stigma associated with patients seeking PrEP.

CONCLUSIONS

Although PrEP is recommended for HIV prevention in high-risk persons, many PrEP-eligible individuals faced barriers to obtaining a prescription. Current practices place substantial responsibility on patients to request and advocate for this service, in contrast to many other preventive services. Understanding the prevalence and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission.

Between knowing and doing person-centredness: A qualitative examination of health professionals’ perceptions of roles in self-management support

Self-management is a contemporary model of chronic condition care that places expectations on, and roles for, both patients and health professionals. Health professionals are expected to form partnerships with their patients, and patients are expected to be active participants in their own care. In these new roles, control and responsibility for self-management are shared between people with chronic conditions and their health professionals. We still have limited knowledge about how these new roles are enacted in self-management support. In this article, we examine how health professionals perceive the roles of patients and professionals in chronic condition self-management, drawing on Bourdieu’s concepts of field, doxa and capital. In this qualitative study, 32 in-depth interviews were conducted with 11 health professionals in Sydney, Australia. Data were analysed thematically. Three themes were derived. First, there was incongruence between how participants characterised and enacted their roles. Second, participants compartmentalised clinical and non-clinical aspects of self-management support. Finally, the roles of health professionals entwined with emotions and judgements of patienthood revealed that the provision of self-management support was linked to a fit between individuals’ cultural health capital and the expectations governing the field. We argue that ‘taken for granted’ assumptions about self-management and self-management support must be challenged to mitigate negative social representations and unrealistic expectations placed on patients and health professionals, particularly those patients with less capital, who are more marginalised within clinical interactions.