Reimagining Research with Pregnant Women and Parents Who Consume Cannabis in the Era of Legalization: The Value of Integrating Intersectional Feminist and Participatory Action Approaches.

Research on women who consume cannabis has predominantly focused on the perinatal period whereby cannabis consumption is problematized, linked to negative perinatal outcomes, and related to substance use and mental health challenges. When this historical literature and research about cannabis consumption is considered through a sociolegal and intersectional lens, questions emerge about how cannabis legalization may benefit and harm women, particularly women who experience marginalization along various axes of identity such as gender, race, and class. Questions also emerge about how women who consume cannabis may be perceived, represented, and treated as part of health and social care practices, particularly while pregnant and parenting. This commentary seeks to untangle what could be at stake for pregnant women and mothers, and what could be emphasized in future research endeavors, in the new era of cannabis legalization in Canada. The authors encourage research initiatives that attend to and reimagine harm reduction philosophies, and that integrate intersectional, feminist, and participatory action research approaches.

Conceptualizing success factors for patient engagement in patient medical homes: a cross-sectional survey.

BACKGROUND: Patient engagement is a priority for health care quality improvement and health system design, but many organizations struggle to engage patients meaningfully. We describe patient engagement activities and success factors that influence organizational decision-making in Ontario's patient medical homes. METHODS: From March to May 2018, we conducted an online survey focused on practice-level patient engagement that targeted primary care organization leaders at all Ontario family health teams, community health centres, nurse practitioner-led clinics and Aboriginal Health Access Centres. We asked questions from the Measuring Organizational Readiness for Engagement (MORE) and Public and Patient Engagement Evaluation Tool (PPEET) questionnaires. We used factor and mediation analysis to identify organizational conditions and activities that are associated with the outcomes of patient engagement, affecting board decisions, program-level decisions and the formation of collaborative partnerships. RESULTS: We achieved a 53% response rate (n = 149/283); after removing missing data, our final sample size was 141 respondents. Most respondents perceived that their organization's patient engagement activities and resources were insufficient. Processes that had a direct effect on outcomes (ß = 0.7, p < 0.0001) included planning, training and supporting employees; identifying, recruiting and supporting relevant patients; and using leaders. Structures - including an organizational mission and vision for patient engagement, and policies, procedures, job positions, training programs and organizational culture that reflect that mission - indirectly affected outcomes, mediated by the aforementioned processes (ß = 0.7, p < 0.0001). INTERPRETATION: Based on the perceptions of primary care leaders, organizational structures and processes are related to successful patient engagement. Organizations that seek to improve patient engagement should assess their commitment and follow-through with associated resources and activities.

Keeping secrets, disclosing health information: an institutional ethnography of the social organisation of perinatal care for women living with HIV in Canada.

This paper describes findings from an institutional ethnography that arose out of the concerns of women living with HIV in Ontario, Canada, regarding the disclosure of their HIV status while accessing perinatal care. The enquiry traces the connections between women's experiences of perinatal care, the activities of healthcare providers delivering such care and the ruling relations that organise women's experiences and healthcare providers' activities. Focusing on HIV disclosure as a concern expressed by women, the findings make visible the day-to-day, routinised practices of healthcare providers working in perinatal care for women living with HIV, as well as the ideological discourses of 'fear of contagion' and 'AIDS hysteria' that contributed to producing the kinds of care experiences that were articulated by women. Opportunities to strengthen perinatal care policies and practices for women living with HIV are discussed.

Challenges in conducting research on collaborative mental health care: a qualitative study.

BACKGROUND: We sought to understand poor uptake of the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs), a pragmatic randomized controlled trial of a collaborative care intervention for people experiencing depression, anxiety or at-risk drinking. We explored primary care providers' experience with PARTNERs, and preferences regarding collaborative care models and trials. METHODS: In this qualitative study, we interviewed primary care providers across Ontario who had participated in PARTNERs, using stratified sampling to reach high-, low- and nonreferring providers in urban and rural settings. We audio-recorded, transcribed and thematically analyzed the interviews between May and December 2017, collecting and analyzing data concurrently until achieving saturation. RESULTS: We interviewed 23 primary care providers. They valued the unique availability of telephone-based coaching for patients but desired greater integration of the coach into their practice. They appreciated expert psychiatric recommendations but rarely changed their practices. Sites varied in organizational adoption and implementation of the study, including whether they designated a local champion, proactively identified eligible patients, integrated the study into existing workflows and reflected on (and revised) practices. These behaviours affected continuing awareness of the study and referral rates. INTERPRETATION: Study uptake was influenced by the limited relationship between PARTNERs coaches and primary care providers, and variable attention to leadership, training and quality improvement as vital elements of collaborative care. Study designs focusing on implementation could promote reach and penetration of novel interventions in the practice setting and more successfully advance collaborative care implementation.

How women living with HIV react and respond to learning about Canadian law that criminalises HIV non-disclosure: 'how do you prove that you told?'

The Women, ART and the Criminalization of HIV Study is a qualitative, arts-based research study focusing on the impact of the HIV non-disclosure law on women living with HIV in Canada. The federal law requires people living with HIV to disclose their HIV-positive status to sexual partners before engaging in sexual activities that pose what the Supreme Court of Canada called a 'realistic possibility of transmission'. Drawing on findings from seven education and discussion sessions with 48 women living with HIV regarding HIV non-disclosure laws in Canada, this paper highlights the ways in which women living with HIV respond to learning about the criminalisation of HIV non-disclosure. The most common emergent themes included: the way the law reproduces social and legal injustices; gendered experiences of intimate injustice; and the relationship between disclosure and violence against women living with HIV. These discussions illuminate the troubling consequences inherent in a law that is antithetical to the science of HIV transmission risk, and that fails to acknowledge the multiple barriers to HIV disclosure that women living with HIV experience. Women's experiences also highlight the various ways the law contributes to their experiences of sexism, racism and other forms of marginalisation in society.

Advancing Integrated Care through Psychiatric Workforce Development: A Systematic Review of Educational Interventions to Train Psychiatrists in Integrated Care.

OBJECTIVE: Integrated or collaborative care is a well-evidenced and widely practiced approach to improve access to high-quality mental health care in primary care and other settings. Psychiatrists require preparation for this emerging type of practice, and such training is now mandatory for Canadian psychiatry residents. However, it is not known how best to mount such training, and in the absence of such knowledge, the quality of training across Canada has suffered. To guide integrated care education nationally, we conducted a systematic review of published and unpublished training programs. METHOD: We searched journal databases and web-based 'grey' literature and contacted all North American psychiatry residency programs known to provide integrated care training. We included educational interventions targeting practicing psychiatrists or psychiatry residents as learners. We critically appraised literature using the Medical Education Research Study Quality Instrument (MERSQI). We described the goals, content, and format of training, as well as outcomes categorized according to Kirkpatrick level of impact. RESULTS: We included 9 published and 5 unpublished educational interventions. Studies were of low to moderate quality and reflected possible publication bias toward favourable outcomes. Programs commonly involved longitudinal clinical experiences for residents, mentoring networks for practicing physicians, or brief didactic experiences and were rarely oriented toward the most empirically supported models of integrated care. Implementation challenges were widespread. CONCLUSIONS: Similar to integrated care clinical interventions, integrated care training is important yet difficult to achieve. Educational initiatives could benefit from faculty development, quality improvement to synergistically improve care and training, and stronger evaluation. Systematic review registration number: PROSPERO 2014:CRD42014010295.

High rates of posttraumatic stress symptoms in women living with HIV in Canada.

PURPOSE: Women living with HIV experience high levels of trauma exposure before and after diagnosis. One of the most challenging outcomes following trauma exposure is posttraumatic stress disorder. Despite high exposure to traumatic events, the presence and contributors to posttraumatic stress disorder symptoms have not been examined in women living with HIV in Canada. METHODS: The current study examines the presence of, contributors to, and geographical regions associated with self-reported posttraumatic stress symptoms (PTSS) among 1405 women enrolled in the Canadian HIV Women's Sexual & Reproductive Health Cohort Study (CHIWOS). RESULTS: Separate linear regression models were run for the three provinces in the cohort: British Columbia, Ontario and Québec. Scores consistent with posttraumatic stress disorder were reported by 55.9%, 39.1% and 54.1% of the participants in each province, respectively (F(2, 1402) = 13.53, p < .001). CONCLUSIONS: The results demonstrate that women living with HIV have high rates of PTSS, and that rates and variables associated with these symptoms vary by province. These results suggest the need for trauma-informed practices and care for women living with HIV in Canada, which may need to be tailored for the community and identities of the women.

Values and preferences of women living with HIV who are pregnant, postpartum or considering pregnancy on choice of antiretroviral therapy during pregnancy.

OBJECTIVE: To investigate women's values and preferences regarding antiretroviral therapy (ART) during pregnancy to inform a BMJ Rapid Recommendation. SETTING: Primary studies reporting patient-reported outcomes relevant to decision-making regarding ART in any clinical and geographical setting. PARTICIPANTS: Women living with HIV who are pregnant, postpartum or considering pregnancy. OUTCOME MEASURES: Quantitative measurements and qualitative descriptions of values and preferences in relation to ART during pregnancy. We also included studies on women's reported barriers and facilitators to adherence. We excluded studies correlating objective measures (eg, CD4 count) with adherence, or reporting only outcomes which are not expected to differ between ART alternatives (eg, access to services, knowledge about ART). RESULTS: We included 15 qualitative studies reporting values and preferences about ART in the peripartum period; no study directly studied choice of ART therapy during pregnancy. Six themes emerged: a desire to reduce vertical transmission (nine studies), desire for child to be healthy (five studies), concern about side effects to the child (eight studies), desire for oneself to be healthy (five studies), distress about side effect to oneself (10 studies) and pill burden (two studies). None of the studies weighed the relative importance of these outcomes directly, but pill burden/medication complexity appears to be a lower priority for most women compared with other factors. Overall, the body of evidence was at low risk of bias, with minor limitations. CONCLUSIONS: Women who are or may become pregnant and who are considering ART appear to place a high value on both their own and their children's health. Evidence on the relative importance between these values when choosing between ART regimens is uncertain. There is variability in individual values and preferences among women. This highlights the importance of an individualised women-centred approach, such as shared decision-making when choosing between ART alternatives. TRIAL REGISTRATION NUMBER: International Prospective Register of Systematic Reviews:CRD42017057157.

Surviving Surveillance: How Pregnant Women and Mothers Living With HIV Respond to Medical and Social Surveillance.

Pregnant women and mothers living with HIV are under surveillance of service providers, family members, and the community at large. Surveillance occurs throughout the medical management of their HIV during pregnancy, preventing HIV transmission to their baby, infant feeding practices, and as part of assessments related to their ability to mother. Enacted and anticipatory HIV-related stigma can exacerbate the negative impact that being under surveillance has on mothers living with HIV as they move through their pregnancy, birthing, and mothering experiences. In response, women living with HIV find ways to manage their experiences of surveillance through engaging in acts of distancing, planning, and resisting at different points in time, and sometimes enacting all three practices at once. Positioning the narratives of pregnant women and mothers living with HIV in relation to their experiences of surveillance illuminates the relationship between the surveillance of mothers living with HIV and HIV-related stigma.

Understanding integrated mental health care in "real-world" primary care settings: What matters to health care providers and clients for evaluation and improvement?

PURPOSE: The integration of mental health specialists into primary care has been widely advocated to deliver evidence-based mental health care to a defined population while improving access, clinical outcomes, and cost efficiency. Integrated care has been infrequently and inconsistently translated into real-world settings; as a result, the key individual components of effective integrated care remain unclear. METHOD: This article reports findings from a qualitative study that explored provider and client experiences of integrated care. We conducted in-depth interviews with integrated care providers (n = 13) and clients (n = 9) to understand their perspectives and experiences of integrated care including recommended areas for quality measurement and improvement. The authors used qualitative content and reflexive thematic analytic approaches to synthesize the interview data. RESULTS: Clients and integrated care providers agreed regarding the overarching concepts of the what, how, and why of integrated care including co-location of care; continuity of care; team composition and functioning; client centeredness; and comprehensive care for individuals and populations. Providers and clients proposed a number of dimensions that could be the focus for quality measurement and evaluation, illuminating what is needed for successful context-sensitive spreading and scaling of integrated care interventions. CONCLUSION: With a mounting gap between the empirical support for integrated care approaches and the implementation of these models, there is a need to clarify the aims of integrated care and the key ingredients required for widespread implementation outside of research settings. This study has important implications for future integrated care research, and health care provider and client engagement in the quality movement. (PsycINFO Database Record

Evaluating the Implementation of Integrated Mental Health Care: A Systematic Review to Guide the Development of Quality Measures.

OBJECTIVE: Although the effectiveness of integrated mental health care has been demonstrated, its implementation in real-world settings is highly variable, may not conform to evidence-based practice, and has rarely been evaluated. Quality indicators can guide improvements in integrated care implementation. However, the literature on indicators for this purpose is limited. This article reports findings from a systematic review of existing measures by which to evaluate integrated care models in primary care settings. METHODS: Bibliographic databases and gray literature sources, including academic conference proceedings, were searched to July 2014. Measures used or proposed to evaluate integrated care implementation or outcomes were extracted and critically appraised. A qualitative synthesis was conducted to generate a panel of unique measures and to group these measures into broad domains and specific dimensions of integrated care program performance. RESULTS: From 172 literature sources, 1,255 measures were extracted, which were distilled into 148 unique measures. Existing literature frequently reports integrated care program effectiveness vis-à-vis evidence-based care processes and individual clinical outcomes, as well as efficiency (cost-effectiveness) and client satisfaction. No measures of safety of care and few measures of equitability, accessibility, or timeliness of care were located, despite the known benefits of integrated care in several of these areas. CONCLUSIONS: To realize the potential for quality measurement to improve integrated care implementation, future measures will need to incorporate domains of quality that are presently unaddressed; microprocesses of care that influence effectiveness, sustainability, and transferability of models of care; and client and health care provider perspectives on meaningful measures of quality.

HIV-related stigma in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada.

HIV-related stigma is associated with many psychological challenges; however, minimal research has explored how perceived HIV-related stigma intersects with psychosocial issues that mothers living with HIV may experience including depression, perceived stress and social isolation. The present study aims to describe the correlates and predictors of HIV-related stigma in a cohort of women living with HIV (WLWH) from across Ontario, Canada during pregnancy and early postpartum. From March 2011 to December 2012, WLWH ≥ 18 years (n = 77) completed a study instrument measuring independent variables including sociodemographic characteristics, perceived stress, depression symptoms, social isolation, social support and perceived racism in the third trimester and 3, 6 and 12 months postpartum. Multivariable linear regression was employed to explore the relationship between HIV-related stigma and multiple independent variables. HIV-related stigma generally increased from pregnancy to postpartum; however, there were no significant differences in HIV-related stigma across all study time points. In multivariable regression, depression symptoms and perceived racism were significant predictors of overall HIV-related stigma from pregnancy to postpartum. The present analysis contributes to our understanding of HIV-related stigma throughout the pregnancy-motherhood trajectory for WLWH including the interactional relationship between HIV-related stigma and other psychosocial variables, most notably, depression and racism.

Examining Privacy Regulatory Frameworks in Canada in the Context of HIV.

In the process of receiving perinatal care, women living with HIV (WLWH) in Canada have experienced disclosure of their HIV status without their express consent. This disclosure often occurs by well-intentioned healthcare providers; however, from the perspective of WLWH, it is a breach of confidentiality and leaves WLWH to manage the consequences. This paper is a critical review of the regulatory and legislative infrastructure that exists to protect the personal health information of WLWH in Ontario and Canada; the recourse that WLWH have in the event that their confidentiality is breached; and potential approaches that could be applied to organize the system differently to decrease the chance of a privacy breach and to facilitate appropriate collection, use and disclosure of personal health information.

"Why are you pregnant? What were you thinking?": How women navigate experiences of HIV-related stigma in medical settings during pregnancy and birth.

Having children is a growing reality for women living with HIV in Canada. It is imperative to understand and respond to women's unique experiences and psychosocial challenges during pregnancy and as mothers including HIV-related stigma. This qualitative study used a narrative methodological approach to understand women's experiences of HIV-related stigma as they navigate health services in pregnancy (n = 66) and early postpartum (n = 64). Narratives of women living with HIV expose the spaces where stigmatizing practices emerge as women seek perinatal care and support, as well as highlight the relationship between HIV-related stigma and disclosure, and the impact this has on women's pregnancy and birthing experiences.

Examining the Health Care Experiences of Women Living with Human Immunodeficiency Virus (HIV) and Perceived HIV-Related Stigma.

INTRODUCTION: The increased incidence of human immunodeficiency virus (HIV) in women, particularly marginalized women, prompted research to examine women's health service experiences at a local outpatient clinic. METHODS: A qualitative case study using semistructured interviews examined facilitators and barriers to health care services. Seventeen women living with HIV who accessed care at an outpatient HIV clinic in central west Ontario were interviewed. Thematic analysis was used to code health care experiences perceived as HIV-related stigma. RESULTS: Women perceived HIV-related stigma when health care providers lacked basic HIV knowledge and failed to uphold the ethical principles of patient-provider relationships, resulting in women's disengagement from health care. CONCLUSIONS: We propose a community-based participatory research framework to reform health care educational curriculum toward a culture of health care safety that is inclusive of people living with HIV.

"Why Aren't You Breastfeeding?": How Mothers Living With HIV Talk About Infant Feeding in a "Breast Is Best" World.

Infant feeding raises unique concerns for mothers living with HIV in Canada, where they are recommended to avoid breastfeeding yet live in a social context of "breast is best." In narrative interviews with HIV-positive mothers from Ontario, Canada, a range of feelings regarding not breastfeeding was expressed, balancing feelings of loss and self-blame with the view of responsibility and "good mothering" under the current Canadian guidelines. Acknowledging responsibility to put their child's health first, participants revealed that their choices were influenced by variations in social and cultural norms, messaging, and guidelines regarding breastfeeding across geographical contexts. This qualitative study raises key questions about the impact of breastfeeding messaging and guidelines for HIV-positive women in Canada.

A comparison of the MOS-HIV and SF-12v2 for measuring health-related quality of life of men and women living with HIV/AIDS.

BACKGROUND: The purpose of this study was to examine the relationship between the Medical Outcomes Study-HIV Health Survey (MOS-HIV) and the SF-12v2 to determine if the latter is adequate to assess the health-related quality of life (HRQoL) of men and women living with HIV/AIDS. 112 men and women living with HIV/AIDS who access care at a tertiary HIV clinic in Hamilton, Ontario were included in this cross-sectional analysis. Correlation coefficients of the MOS-HIV physical and mental health summary scores (PHS and MHS) and the SF-12v2 physical and mental component summary scales (PCS and MCS) were calculated along with common sub-domains of the measures including physical functioning (PF), bodily pain (BP), general health perceptions (GH), vitality (VT), social functioning (SF) and mental health (MH) to explore the relationship between these two HRQoL measures. The sub-domains role physical (RP) and role emotional (RE) of the SF-12v2 were compared separately to the sub-domain role functioning (RF) of the MOS-HIV. Weighted kappa scores were calculated to determine agreement beyond chance between the MOS-HIV and SF-12v2 in assigning a HRQoL state (i.e. low, moderate, good, very good). RESULTS: The MOS-HIV had mean PHS and MHS summary scores of 47.3 (SD = 11.5) and 49.2 (SD = 10.7) respectively. The mean SF-12v2 PCS and MCS scores were 47.7 (SD = 11.0) and 44.0 (SD = 10.4). The MOS-HIV and SF-12v2 physical and mental health summary scores were positively correlated (r = 0.84, p < 0.001 and r = 0.76, p < 0.001). All common sub-domains were significantly correlated at p values from < 0.001 to 0.034. Substantial agreement was observed in assigning a HRQoL state (Physical: κ = 0.788, SE = 0.095; Mental: κ = 0.707, SE = 0.095). CONCLUSIONS: This analysis validates the SF-12v2 for measuring HRQoL in adult men and women living with HIV/AIDS.

"My children and my home": the most recent and challenging stressors of HIV-positive women.

Because of negative health consequences and differences in exposure and vulnerability to stressful encounters, it is important to examine and understand the stressful experiences faced by women living with HIV. The goal of this study was to examine the most recent and challenging stressors faced and coping strategies adopted by a sample of women living with HIV. Using mixed methodology, narratives of six women's most recent and stressful experience and answers to the Ways of Coping questionnaire were collected and analysed. Two main themes arose from the stressor narratives: child-related concerns and housing issues. To address these stressors, each woman used a variety of coping strategies, the most common being seeking social support even when stressors were analysed separately according to their main themes. Implications of these findings within service provision are discussed.