BackgroundRetention in HIV care improves survival and reduces the risk of HIV transmission to others. Multiple quantitative studies have described demographic and clinical characteristics associated with retention in HIV care. However, qualitative studies are needed to better understand barriers and facilitators.MethodsSemi-structured interviews were conducted with 51 HIV-infected individuals, 25 who were retained in care and 26 not retained in care, from 3 urban clinics. Interview data were analyzed for themes using a modified grounded theory approach. Identified themes were compared between the two groups of interest: patients retained in care and those not retained in care.ResultsOverall, participants identified 12 barriers and 5 facilitators to retention in HIV care. On average, retained individuals provided 3 barriers, while persons not retained in care provided 5 barriers. Both groups commonly discussed depression/mental illness, feeling sick, and competing life activities as barriers. In addition, individuals not retained in care commonly reported expensive and unreliable transportation, stigma, and insufficient insurance as barriers. On average, participants in both groups referenced 2 facilitators, including the presence of social support, patient-friendly clinic services (transportation, co-location of services, scheduling/reminders), and positive relationships with providers and clinic staff.ConclusionsIn our study, patients not retained in care faced more barriers, particularly social and structural barriers, than those retained in care. Developing care models where social and financial barriers are addressed, mental health and substance abuse treatment is integrated, and patient-friendly services are offered is important to keeping HIV-infected individuals engaged in care.

Andersen's Behavioral Model (ABM) provides a framework for understanding how patient and environmental factors impact health behaviors and outcomes. We compared patient-identified barriers/facilitators to retention in care and antiretroviral therapy (ART) adherence, and evaluated how they mapped to ABM. Qualitative semi-structured interviews with 51 HIV-infected adults at HIV clinics in Philadelphia, PA in 2013 were used to explore patients’ experiences with HIV care and treatment. Interview data were analyzed for themes using a grounded theory approach. Among those interviewed, 53% were male and 88% were non-white; 49% were retained in care, 96% were on ART, and 57% were virally suppressed. Patients discussed 18 barriers/facilitators to retention in care and ART adherence: 11 common to both behaviors (stigma, mental illness, substance abuse, social support, reminder strategies, housing, insurance, symptoms, competing life activities, colocation of services, provider factors), 3 distinct to retention (transportation, clinic experiences, appointment scheduling), and 4 distinct to adherence (medication characteristics, pharmacy services, health literacy, health beliefs). Identified barriers/facilitators mapped to all ABM domains. These data support the use of ABM as a framework for classifying factors influencing HIV-specific health behaviors, and have the potential to inform the design of interventions to improve retention in care and ART adherence.

In its report Global Health 2035, the Commission on Investing in Health proposed that health investments can reduce mortality in nearly all low- and middle-income countries to very low levels, thereby averting 10 million deaths per year from 2035 onward. Many of these gains could be achieved through scale-up of existing technologies and health services. A key instrument to close this gap is policy and implementation research (PIR) that aims to produce generalizable evidence on what works to implement successful interventions at scale. Rigorously designed PIR promotes global learning and local accountability. Much greater national and global investments in PIR capacity will be required to enable the scaling of effective approaches and to prevent the recycling of failed ideas. Sample questions for the PIR research agenda include how to close the gap in the delivery of essential services to the poor, which population interventions for non-communicable diseases are most applicable in different contexts, and how to engage non-state actors in equitable provision of health services in the context of universal health coverage.

BackgroundCommunity pharmacists are autonomous, regulated health care professionals located in urban and rural communities in Canada. The accessibility, knowledge, and skills of community pharmacists can be leveraged to increase mental illness and addictions care in communities.MethodsThe Bloom Program was designed, developed, and implemented based on the Behaviour Change Wheel and a program of research in community pharmacy mental healthcare capacity building. We evaluated the Bloom Program as a demonstration project using mixed methods. A retrospective chart audit was conducted to examine outcomes and these are reported in this paper.ResultsWe collected 201 patient charts from 23 pharmacies in Nova Scotia with 182 patients having at least one or more follow-up visits. Anxiety (n = 126, 69%), depression (n = 112, 62%), and sleep disorders (n = 64, 35%) were the most frequent mental health problems. Comorbid physical health problems were documented in 57% (n = 104). The average number of prescribed medications was 5.5 (range 0 to 24). Sixty seven percent (n = 122) were taking multiple psychotropics and 71% (n = 130) reported taking more than one medication for physical health problems. Treatment optimization was the leading reason for enrollment with more than 80% seeking improvements in symptom management and daily functioning. There were a total of 1233 patient-care meetings documented, of which the duration was recorded in 1098. The median time for enrolling, assessing, and providing follow-up care by pharmacists was 142 min (mean 176, SD 128) per patient. The median follow-up encounter duration was 15 min. A total of 146 patient care encounters were 60 min or longer, representing 13.3% of all timed encounters.ConclusionsPharmacists work with patients with lived experience of mental illness and addictions to improve medication related outcomes including those related to treatment optimization, reducing polytherapy, and facilitating withdrawal from medications. Pharmacists can offer their services frequently and routinely without the need for an appointment while affording patient confidentiality and privacy. Important roles for pharmacists around the deprescribing of various medications (e.g., benzodiazepines) have previously been supported and should be optimized and more broadly implemented. Further research on the best mechanisms to incentivize pharmacists in mental illness and addiction’s care should be explored.

Background: the bloom Program was designed to enhance pharmacists' care of people with lived experience of mental illness and addictions in Nova scotia. the Program's demonstration period was from september 2014 to December 2016 and included a qualitative evaluation of the patient experience. Methods: Patients were recruited for individual interviews through bloom Program pharmacies. Interviews were transcribed verbatim and analyzed following braun and clarke's 6-step approach for thematic analysis. Results: ten patients were interviewed between May and June 2016. ten themes were determined through data analysis and included medication management, accessing pharmacists in a new way, providing social support, bridging service gaps, providing interim care, reducing financial barriers, navigation and advocacy, holistic approaches, empowerment through knowledge and awareness and collaboration. Discussion: Pharmacists expectedly provided medication management activities to patients for both physical and mental health concerns in the bloom Program. Many activities conducted with bloom Program patients fell outside of dispensing roles and medication management. these activities, such as social support, triage, navigation and increasing access, which were highly valued by patients, are poorly measured and assessed in pharmacy practice research. Conclusion: Participants in the bloom Program reported the significant contributions of pharmacists and pharmacy teams in their overall health and wellness. Future evaluations of interventions like the bloom Program should include measurement of constructs valued by patients and also consider impacts on inequalities and inequities. Pharmacy practice researchers can benefit from other research and evaluation being conducted for primary care interventions.

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Research on community responses to environmental toxicity has richly described the struggles of citizens to identify unrecognized toxins, collect their own environmental health facts, and use them to lobby authorities for recognition and remediation. Much of this literature is based on an empiricist premise: it is concerned with exploring differences in how laypeople and experts perceive what is presumed to be a singular toxic reality that preexists these varying perspectives. Here, we seek to reexamine this topic by shifting the focus from facts to facticity—that is, by exploring the many types of knowledge that communities develop about toxicity and how these knowledges articulate with the ideas of scientific and governmental authorities about what kinds of information are valid bases for policymaking. In making this shift, we are influenced by work in semiotic anthropology and science and technology studies (STS), which emphasizes that lived experience generates distinct realities rather than different perceptions of the same underlying state. Using this framework, we present an analysis of oral history interviews conducted in 2013–14 in the small American town of Ambler, Pennsylvania. Part of Ambler’s legacy as a nineteenth- and twentieth-century center of asbestos manufacture is that it is home to two massive asbestos-containing waste sites, one of which was being remediated by the Environmental Protection Agency (EPA) at the time of this study. Our interviews demonstrate that even asbestos, a toxin with a well-established public narrative, is a fundamentally different object for different members of the Ambler community. For many of these individuals, the epistemology and practices of the EPA are incongruent with or tangential to their toxicity-related experiences and their consequent concerns for the future. As such, our findings suggest caution in framing the community engagement efforts of environmental health agencies primarily as facilitations of citizen science; this approach does not acknowledge the multiplicity of toxic realities.

Objective Real-time audiovisual consultation (telemedicine) has been proven feasible and is a promising alternative to interfacility transfer. We sought to describe caregiver perceptions of the decision to transfer his or her child to a pediatric emergency department and the potential use of telemedicine as an alternative to transfer. Methods Semistructured interviews of caregivers of patients transferred to a pediatric emergency department. Purposive sampling was used to recruit caregivers of patients who were transferred from varying distances and different times of the day. Interviews were conducted in person or on the phone by a trained interviewer. Interviews were recorded, transcribed, and analyzed using modified grounded theory. Results Twenty-three caregivers were interviewed. Sixteen (70%) were mothers; 57% of patients were transported from hospitals outside of the city limits. Most caregivers reported transfer for a specific resource need, such as a pediatric subspecialist. Generally, caregivers felt that the decision to transfer was made unilaterally by the treating physician, although most reported feeling comfortable with the decision. Almost no one had heard about telemedicine; after hearing a brief description, most were receptive to the idea. Caregivers surmised that telemedicine could reduce the risks and cost associated with transfer. However, many felt telemedicine would not be applicable to their particular situation. Conclusions In this sample, caregivers were comfortable with the decision to transfer their child and identified potential benefits of telemedicine as either an adjunct to or replacement of transfer. As hospitals use advanced technology, providers should consider families' opinions about risks and out-of-pocket costs and tailoring explanations to address individual situations.