Laura B. Godfrey’s research while affiliated with Hofstra University and other places

Though the implementation of science frameworks has recently been expanded to understand determinants of health equity (Woodward et al., 2021), the application of these frameworks in safety net hospital settings is new. We applied the health equity implementation framework to (a) understand the determinants of implementation and equity and (b) develop an institution-wide implementation facilitation plan for three evidence-based practices (EBPs) for posttraumatic stress disorder. We utilized researcher field notes from clinical case consultation gathered during posttraumatic stress disorder treatment implementation initiatives (cognitive processing therapy, written exposure therapy, brief skills training in affective and interpersonal regulation) at the same safety net hospital (N = 94 meetings total, from 2020 to 2023) to assess determinants of implementation and equity. We developed a qualitative codebook based on the health equity implementation framework to specify determinants and then built an implementation facilitation toolkit for multi-EBP implementation. Similar determinants were found across clinics and EBPs (e.g., provider training gaps and misperceptions about manualized treatments; inefficiencies in identification, triage, and referral pathways; patient engagement barriers related to stigma, literacy, and mistrust) with additional nuance per clinic and EBP. Institution-wide facilitation strategies were then utilized to enhance implementation and equity and focused on enhancing both access and quality of services (e.g., training and consultation, refining referral pathways) and patient engagement (e.g., culturally responsive training, consultation, and treatment delivery). Implementation science has an important role to play in enhancing health equity. Our findings illustrate how pooling determinants across clinics and treatments can help implementation scientists engage with hospital leadership and advocate for system-level implementation facilitation strategies.

Today there are about one billion migrants worldwide and about 40 million migrants in the United States. Of these migrants, 3.5 million are of Arab, Middle Eastern, and North African (Arab/MENA) descent. The Arab/MENA community in the United States has been exposed to historical, premigration, perimigration, and postmigration trauma and stress. Despite the considerable research on migrants’ trauma exposure, much remains to be known about their resilience. More recently, the resilience literature has expanded beyond the micro (individual) level to explore resilience across the ecological system. Yet the chronosystem (time, intergenerational trauma, and resilience) and the process of passing on resilience within the context of oppression remain understudied. Thus, there is a need to understand intergenerational resilience, in the context of intergenerational trauma, defined as the transmission of resilience across generations for Arab/MENA communities. This study explored the lived experiences of intergenerational resilience for first- and second-generation Arab/MENA migrants (N = 19). Data were analyzed using interpretative phenomenological analysis. Three superordinate themes emerged including maintaining culture, cultivating resilience, and outcomes of resilience. Eight subthemes emerged including collective practices, intentional teaching, observational learning, firsthand experience, opportunity, positive identity, sense of belonging, and connection from a distance. Findings add to the literature by illuminating some processes for intergenerational resilience, identifying constructs for future empirical studies (e.g., family communication, cultural maintenance), and providing direction for intervention with this population. Implications for future research and practice are provided.

This study investigates associations between minority stressors, traumatic stressors, and post-traumatic stress disorder (PTSD) symptom severity in a sample of transgender and gender diverse (TGD) adults. We utilized surveys and clinical interview assessments to assess gender minority stress exposures and responses, and PTSD. Our sample (N = 43) includes adults who identified as a minoritized gender identity (i.e., 39.5% trans woman or woman, 25.6% trans man or man, 23.3% genderqueer or nonbinary, 11.6% other identity). All participants reported at least one traumatic event (i.e., life threat, serious injury, or sexual harm). The most common trauma events reported by the sample were sexual (39.5%) and physical violence (37.2%), with 40.9% of participants anchoring their symptoms to a discrimination-based event. PTSD symptom severity was positively correlated with both distal (r = 0.36, p = .017) and proximal minority stressors (r = 0.40, p < .01). Distal minority stress was a unique predictor of current PTSD symptom severity (b = 0.94, p = .017), however, this association was no longer significant when adjusting for proximal minority stress (b = 0.18, p = 0.046). This study suggests that minority stress, especially proximal minority stress, is associated with higher PTSD symptom severity among TGD adults.

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.

Background Successful implementation of evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) in primary care may address treatment access and quality gaps by providing care in novel and less stigmatized settings. Yet, PTSD treatments are largely unavailable in safety net primary care. We aimed to collect clinician stakeholder data on organizational, attitudinal, and contextual factors relevant to EBT implementation. Methods Our developmental formative evaluation was guided by the Consolidated Framework for Implementation Research (CFIR), including (a) surveys assessing implementation climate and attitudes towards EBTs and behavioral health integration and (b) semi-structured interviews to identify barriers and facilitators to implementation and need for augmentation. Participants were hospital employees (N = 22), including primary care physicians (n = 6), integrated behavioral health clinicians (n = 8), community wellness advocates (n = 3), and clinic leadership (n = 5). We report frequency and descriptives of survey data and findings from directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach. A primary care community advisory board (CAB) helped to refine interview guides and interpret findings. Results Stakeholders described implementation determinants of the EBT related to the CFIR domains of intervention characteristics (relative advantage, adaptability), outer setting (patient needs and resources), inner setting (networks and communication, relative priority, leadership engagement, available resources), and individuals involved (knowledge and beliefs, cultural considerations). Stakeholders described strong attitudinal support (relative advantage), yet therapist time and capacity restraints are major PTSD treatment implementation barriers (available resources). Changes in hospital management were perceived as potentially allowing for greater access to behavioral health services, including EBTs. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted (patient needs and resources). Recommendations included tailoring the intervention to meet existing workflows (adaptability), system alignment efforts focused on improving detection, referral, and care coordination processes (networks and communication), protecting clinician time for training and consultation (leadership engagement), and embedding a researcher in the practice (available resources). Conclusions Our evaluation identified key CFIR determinants of implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrates that successful implementation necessitates strong stakeholder engagement.

Background: Posttraumatic stress disorder (PTSD) disproportionally affects low-income, racial and ethnic minoritized communities, where prevalence is high, yet access to evidence-based treatments (EBTs) is low. As such, there is a need to identify effective, feasible, and scalable interventions for PTSD. Stepped care approaches that include brief, low-intensity treatments are one approach to improving access yet have not been developed for adults with PTSD. Our study aims to test the effectiveness of a step one PTSD treatment in primary care while gathering information on implementation to maximize sustainability in the setting. Methods: This study will be conducted in integrated primary care in the largest safety net hospital in New England using a hybrid type 1 effectiveness-implementation design. Eligible trial participants are adult primary care patients who meet full or subthreshold criteria for PTSD. Interventions include Brief clinician-administered Skills Training in Affective and Interpersonal Regulation (Brief STAIR) versus web-administered STAIR (webSTAIR) during a 15-week active treatment period. Participants complete assessments at baseline (pre-treatment), 15 weeks (post-treatment), and 9 months (follow-up) post-randomization. We will assess feasibility and acceptability post-trial using surveys and interviews with patients, study therapists, and other key informants, and will assess the preliminary effectiveness of interventions in terms of PTSD symptom change and functioning. Conclusion: This study will provide evidence for the feasibility, acceptability, and preliminary effectiveness of brief, low-intensity interventions in safety net integrated primary care, with the aim of including these interventions in a future stepped care approach to PTSD treatment. Clinical trial number: NCT04937504.

Objective: Increasing prevalence of substance use in pregnancy presents a public health crisis that is compounded by posttraumatic stress disorder (PTSD) comorbidity. We aimed to detail the clinical complexities of PTSD treatment provision among pregnant women with substance use histories. Methods: We conducted a qualitative study using clinical case consultation field notes (N = 47 meetings) which were gathered during a hybrid effectiveness-implementation pilot study of Written Exposure Therapy (WET) for PTSD among pregnant women seen in an obstetrics-SUD clinic [2019-2021]. Patient baseline survey data (N = 25) were used to characterize the sample and contextualize engagement. Results: Participants were exposed to a high number of trauma/adversity event types. There was no association between number of trauma/adversity event types and treatment response or dropout. Qualitative findings revealed clinical features relevant to PTSD treatment, including multi-system involvement; parental trauma and substance use; relevance of substance use to trauma context and posttraumatic cognitions, emotions, and behaviors; impact of trauma on experiences of pregnancy, attachment, and child rearing; limited social networks placing women at risk of ongoing violence; and experiences of substance use discrimination. Conclusion: PTSD treatment among pregnant women with substance use histories is highly important to maternal-child health.

Objective: This pilot open trial examined the feasibility, acceptability, and preliminary effectiveness of Written Exposure Therapy (WET), a 5-session evidence-based intervention for posttraumatic stress disorder (PTSD) during pregnancy. Participants were pregnant women with comorbid PTSD and substance use disorder (SUD) receiving prenatal care in a high risk obstetrics-addictions clinic. Methods: A total of 18 participants with probable PTSD engaged in the intervention, and 10 completed the intervention and were included in outcome analyses. Wilcoxon's Signed-Rank analyses were used to evaluate PTSD and depression symptoms and craving at pre-intervention to post-intervention and pre-intervention to the 6-month postpartum follow-up. Engagement and retention in WET and therapist fidelity to the intervention manual were used to assess feasibility. Quantitative and qualitative measures of patient satisfaction were used to assess acceptability. Results: PTSD symptoms significantly decreased from pre-intervention to post-intervention (S = 26.6, p = 0.006), which sustained at the 6-month postpartum follow-up (S = 10.5, p = 0.031). Participant satisfaction at post-intervention was high. Therapists demonstrated high adherence to the intervention and excellent competence. Conclusions: WET was a feasible and acceptable treatment for PTSD in this sample. Randomized clinical trial studies with a general group of pregnant women are needed to expand upon these findings and perform a full-scale test of effectiveness of this intervention.

Objective: To understand providers' perceptions of how patient's experience of racism may impact successful implementation of a brief PTSD treatment in the safety net integrated primary care setting. To conduct a developmental formative evaluation prior to a hybrid type I effectiveness-implementation trial. Data sources and study setting: From October 2020 - January 2021, in-depth qualitative interviews were conducted with integrated primary care stakeholders (N=27) at the largest safety net hospital in New England, where 82% of patients identify as racial or ethnic minorities. Study design: Interviews with clinical stakeholders were used to (a) contextualize current patient and provider experiences and responses to racism, (b) consider how racism may impact PTSD treatment implementation, (c) gather recommendations for potential augmentation to the proposed PTSD treatment (e.g. culturally responsive delivery, cultural adaptation) and (d) gather recommendations for how to shift the integrated primary care practice to an anti-racist framework. Data collection/extraction methods: Interview data were gathered using remote data collection methods (video conferencing). Participants were hospital employees including psychologists, social workers, primary care physicians, community health workers, administrators, and operations managers. We used conventional content analysis. Principal findings: Clinical stakeholders acknowledged the impact of racism, including racial stress and trauma, on patient engagement, and noted the potential need to adapt PTSD treatments to enhance engagement. Clinical stakeholders also characterized the harms of racism on patients and providers and provided recommendations such as changes to staff training and hiring practices, examination of racist policies, and increases in support for providers of color. Conclusions: This study contextualizes providers' perceptions of racism in the integrated primary care practice and provides some suggestions for shifting to an anti-racist framework. Our findings also highlight how experiences of racism may be a PTSD treatment implementation barrier. This article is protected by copyright. All rights reserved.