Low-dose computed tomography-based lung cancer screening represents a complex clinical undertaking that could require multiple referrals, appointments, and time-intensive procedures. These steps may pose difficulties and raise concerns among patients, particularly minority, under-, and uninsured populations. The authors implemented patient navigation to identify and address these challenges. They conducted a pragmatic randomized controlled trial of telephone-based navigation for lung cancer screening in an integrated, urban safety-net health care system. Following standardized protocols, bilingual (Spanish and English) navigators educated, motivated, and empowered patients to traverse the health system. Navigators made systematic contact with patients, recording standardized call characteristics in a study-specific database. Call type, duration, and content were recorded. Univariable and multivariable multinomial logistic regression was performed to investigate associations between call characteristics and reported barriers. Among 225 patients (mean age 63 years, 46% female, 70% racial/ethnic minority) assigned navigation, a total of 559 barriers to screening were identified during 806 telephone calls. The most common barrier categories were personal (46%), provider (30%), and practical (17%). System (6%) and psychosocial (1%) barriers were described by English-speaking patients, but not by Spanish-speaking patients. Over the course of the lung cancer screening process, provider-related barriers decreased 80% ( P = 0.008). The authors conclude that patients undergoing lung cancer screening frequently report personal and health care provider-related barriers to successful participation. Barrier types may differ among patient populations and over the course of the screening process. Further understanding of these concerns may increase screening uptake and adherence. Clinical Trial Registration number: (NCT02758054).

Background: Heterogeneity in healthcare systems’ organizational structures, policies and decisions influences practice implementation and care delivery. While quantitative data harmonization has been used to compare outcomes, few have conducted cross-site qualitative inquiry of healthcare delivery; thus, little is known about how to harmonize qualitative data across multiple settings. Objective: We illustrate a methodological approach for a theory-driven qualitative data harmonization process for the PROSPR II Cervical Research Center, a large multi-site, mixedmethods study evaluating cervical cancer screening across three diverse healthcare settings. Methods: We compared three geographically, socio-demographically, and structurally diverse healthcare systems using a multi-modal qualitative data collection strategy. We grounded our sampling strategy in a cervical cancer screening process model, then tailored it for system-specific differences (e.g., clinic staffing structure and individual roles). Data collection tools included domains corresponding to shared research objectives (e.g., abnormal follow-up) while accommodating local context. Analysis drew on operational domains from the screening process model and constructs from the Consolidated Framework for Implementation Research and Normalization Process Theory. Results: Exemplars demonstrate how data harmonization revealed insights suggesting opportunities to improve clinical processes across healthcare systems. Discussion: This analysis advances the application of qualitative methods in implementation science, where assessing context is key to responding to organizational challenges and shaping implementation strategies across multiple health systems. We demonstrate how systematically collecting, analyzing and harmonizing qualitative data elucidates the impact of process factors and accelerates efforts to identify opportunities for quality improvement interventions.

In 2002, the United States embraced the Housing First approach, which led to the widespread adoption of this approach in cities across the nation. This resulted in programmatic variations of Housing First and calls for clarity about the Housing First model. This study uses a comparative case study approach to explore the differences across Housing First programs in five selected cities: Dallas, Austin, Houston, Los Angeles, and Salt Lake City. It focuses on one aspect of programmatic variation: housing type. Data collection consisted of in-depth interviews with 53 participants, documentation review, and site visits. Findings show differences in the type of housing used and explore the reasons why Housing First programs select such housing configurations. The results highlight how programmatic variation does not necessarily mean the Housing First model lacks clarity. Rather, homeless service providers adapt the model to address local challenges and needs, resulting in the variation seen across programs and cities. The findings elucidate the debate about variation in the Housing First model and the call for fidelity.

Poor treatment outcomes, disease recurrence, and medical co-morbidities contribute to the significant burden caused by depressive disorders. Increasing physical activity in persons with depression has the potential to improve both depression treatment outcomes and physical health. However, evidence for physical activity interventions that can be delivered as part of depression treatment remains limited. This study will examine a Behavioral Activation teletherapy intervention adapted to include a specific focus on increasing physical activity. The two-phase study will include a preliminary pilot study (n = 15) to evaluate and refine the manualized intervention using a mixed-methods approach followed by a single-arm study to evaluate feasibility and preliminary efficacy of the adapted BA teletherapy. Participants will be adults, age 18–64, with moderate to severe depressive symptoms (defined as a PHQ-9 score ≥10) and who currently engage in 90 min or less of moderate-to-vigorous physical activity. Individuals will be excluded if they have a current or past manic or hypomanic episode, psychosis, schizophrenia or schizophreniform disorder, or active suicidal ideation, or if not medically-cleared to exercise. The BA intervention will consist of 8 weekly sessions, followed by 2 bi-weekly booster sessions. Feasibility outcomes will include metrics of screening, enrollment, intervention adherence and fidelity, and participant retention. Intervention preliminary efficacy will be evaluated through assessment of changes in depressive symptoms and moderate-to-vigorous physical activity. Data from this trial will be used to support the conduct of a randomized controlled trial to evaluate the efficacy of the adapted BA intervention.

The Affordable Care Act (ACA) expanded access and assistance to many Americans, but health care remains prohibitively expensive for some, including people with insurance. The COVID-19 pandemic brought to the forefront the precarious conditions of those facing financial and health crises, including American Indians and Alaska Natives (AI/ANs). Theoretically, AI/ANs should have some insulation because of their health care access through Indian Health Service (IHS) and ACA Tribal health insurance options. We use 2018 National Financial Capability Study's survey data to examine household medical debt and cost avoidance behaviors. Findings show AI/ANs are more likely to have medical debt and skip filling prescriptions due to costs than non-Hispanic Whites. Implications are AI/ANs may face financial and health burdens due to insufficient health coverage, possibly exacerbated by the shortcomings of IHS or other underlying factors. Future research should use a qualitative approach to elucidate factors influencing health care finances and behaviors of AI/AN communities.

Background: Guidelines for management of abnormal cervical cancer screening results have increased in complexity over the past two decades. Little is known about how patient-, clinician-, and organization-level factors influence implementation when guidelines change. Process mapping may offer insights into organizational processes and facilitate visualization for potential intervention opportunities. Methods: We conducted an iterative multimodal qualitative assessment to compare abnormal cervical cancer screening management between two health systems: a safety-net institution and an integrated health system. We interviewed clinicians and staff to generate (phase I, May 2019–March 2021) and validate (phase II, July–Oct 2022) process maps at both systems. We conducted a rapid and thematic content analysis and engaged clinical and nonclinical stakeholders during interpretation. Results: At both health systems, process maps informed by phase I participants (n = 31) identified a gap in care during patients’ transition back to primary care following resolution of abnormal tests by gynecologists. In phase II, participants (n = 21) validated and revised maps, noting guideline updates and quality improvement initiatives. Although each system deployed unique strategies to address gaps in care, strategies in common included creating electronic health record–based clinical decision support tools, enabling gynecologists to provide real-time e-consults to primary care clinicians, and engaging patients via the portal. Conclusions: The complexity of cervical cancer screening management guidelines elevates the importance of identifying system-level tools to support clinician decision-making and coordinate between primary and specialty care teams. Impact: Process maps are valuable in generating cross-system comparisons by documenting clinical workflows, identifying care gaps, and engaging participants in formulating potential interventions.