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. Author manuscript; available in PMC: 2025 Apr 1.
Published in final edited form as: Res Nurs Health. 2023 Nov 19;47(2):242–250. doi: 10.1002/nur.22355

Understanding Healthcare Engagement for People Who Inject Drugs

Omeid Heidari 1, Abigail Winiker 2, Derek T Dangerfield II 3, Jennifer Wenzel 4,5, Tamar Rodney 6, Shruti Mehta 7, Becky Genberg 8
PMCID: PMC10961200  NIHMSID: NIHMS1943573  PMID: 37982368

Abstract

People who inject drugs (PWID) are at an increased risk of multimorbid mental health and chronic diseases, which are frequently underdiagnosed and under-treated due to systemic barriers and ongoing substance use. Healthcare engagement is essential to address these conditions and prevent excess morbidity and mortality. The goal of this study was to understand how PWID engage in care for their chronic health conditions and substance use treatment given the known historic and pervasive barriers. We conducted 24 semi-structured qualitative interviews informed by the Behavioral Model for Vulnerable Populations between July and September 2019. Participants were sampled across a range of co-morbidities, including co-occurring mental health disorders. Thematic analysis was conducted to explore experiences of healthcare engagement for multimorbid chronic diseases, mental health, and treatment for substance use disorder. Mean age for participants was 58 years; 63% reported male sex and 83% reported Black race. Interviews yielded themes regarding healthcare access and wrap-around services, positive patient-provider relationships, service integration for substance use treatment and mental health, healthcare needs alignment, medications for opioid use disorder stigma, and acceptance of healthcare. Taken together, participants described how these themes enabled healthcare engagement. Engagement in care is crucial to support health and recovery. Clinical implications include the importance of strengthening patient-provider relationships, encouraging integration of medical and mental health services, and counseling on substance use treatment options in a non-stigmatizing manner. Additionally, policy to reimburse wrap-around support for substance use recovery can improve care engagement and outcomes related to chronic diseases, mental health, and substance use among PWID.

Keywords: Mental health, Patient-provider relationship, Integrated care, Substance use treatment

Introduction

People who inject drugs (PWID) have an increased risk of morbidity and mortality from overdose, complications from infectious diseases such as Hepatitis C and HIV, as well as from multimorbid chronic diseases (Puzhko et al., 2017; Zibbell et al., 2018). Healthcare engagement encompasses healthcare access as well as the actions taken by patients to receive the greatest benefit from health services. Engagement in healthcare is essential for PWID to receive harm reduction services, treatment for substance use, including with medications for opioid use disorder (MOUD), mental health care, and prevent excess morbidity and mortality from comorbid chronic health conditions (Gruman et al., 2010; National Prevention Council, 2011; Office of National Drug Policy, 2010). However, while outpatient care engagement remains a goal, PWID continue to utilize acute care at high rates. Authors from one systematic review showed that PWID utilize emergency department services 4.8 times more than the general population, with multiple studies showing injection drug use as a strong predictive factor of increased ED visits (Kendall et al., 2017; Lewer et al., 2020; Nambiar et al., 2017). In another systematic review younger age, incarceration, homelessness, lack of health insurance, and poor provider continuity are associated with decreased engagement in primary care for PWID (Heidari et al., 2023), while visits with a primary care provider and receipt of MOUD are strong protective factors against ED utilization (Kendall et al., 2017).

Understanding the complex nature of healthcare engagement for PWID is essential to improve health outcomes and decrease the cost burden on health systems, particularly accounting for co-occurring mental health diagnoses (Tormohlen et al., 2021). PWID have high burden of multimorbid chronic and mental health diagnoses, particularly at older ages (Heidari et al., 2022; Salter et al., 2011) and have poor prognosis for both substance use and their multimorbid chronic diseases. This highlights the need to holistically examine engagement in outpatient care where both substance use and other multimorbid chronic disease can be managed (Joseph et al., 2016; Lazarus et al., 2016). This is particularly true for those with a co-occurring mental health diagnosis, which has been associated with greater substance use treatment non-adherence (Krawczyk et al., 2017). Given the known barriers faced by this population, understanding experiences of engagement in care can inform future efforts to address the growing burden of multimorbidity, including mental health diagnoses, in this population.

The Behavioral Model for Vulnerable Populations (BMVP) provides a framework to examine healthcare engagement. From the model, predisposing, enabling, need, and health behavior factors influence healthcare utilization and engagement (Gelberg et al., 2000). Predisposing factors are individual characteristics such as age, gender, and relationship status, sexual orientation, and substance use. Enabling characteristics are organizational and financing factors such as health insurance status, health service resources, and region of residence. Need characteristics refer to those that are both perceived by an individual and those evaluated by healthcare providers. Health behaviors are actions taken by individuals for management of their multimorbid diseases and substance use. This framework is useful to study healthcare engagement as it provides a framework to understand characteristics associated with engagement in care salient to PWID (Figure 1).

Figure 1:

Figure 1:

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Adapted Behavioral Model for Vulnerable Populations

The purpose of this study is to explore healthcare engagement for chronic physical and mental health disorders and substance use disorder treatment among current and former people who inject drugs with qualitative interviews. Using the BMVP to identify salient factors associated with healthcare engagement for PWID, we explore the role of healthcare environments in addressing chronic and mental health care relevant to ongoing substance use and long-term recovery from substance use disorder among PWID. Findings from this study can inform holistic outpatient care engagement for this population to address chronic and mental health diseases sooner and engage in harm reduction and/or substance use treatment services.

Methods

Study Population

Data were collected from the AIDS Linked to the Intravenous Experience (ALIVE) study, a community-based cohort with current and former PWID in Baltimore, MD, described in detail elsewhere (Vlahov et al., 1991). Eligibility criteria for the parent study included being 18 years or older and having a history of injection drug use (i.e. opioids, cocaine, methamphetamine, etc). ALIVE recruited its first participants in 1988 and conducted subsequent recruitment waves of new participants occurred during 1994–1995, 1998, 2005–2008, and 2015–2018. Because the youngest participants in the ALIVE cohort were recruited during the 2015–2018 wave, only individuals recruited before 2008 were eligible for this study to recruit a sample with longer healthcare engagement history with diagnosed multimorbid chronic diseases. All participants provided written informed consent prior to participation in the ALIVE study, and oral consent prior to the in-depth interview. The Johns Hopkins Bloomberg School of Public Health Institutional Review Board approved all study procedures.

Recruitment

Eligible participants were approached during their ALIVE study visit for screening and consent. Individuals were eligible if they were a member of one of the recruitment waves described above and reported two or more chronic physical or mental health disorders collected as part of their ALIVE study visit (Table 1).

Table 1.

Sample characteristics of 24 ALIVE participants

Predisposing
Age (mean, std. dev) 58 (6.9)
Female sex 9 (37%)
Black race 20 (83%)
Enabling
Insurance 22 (92%)
Income<$5,000 per year 13 (54%)
Disability (SSI/SSDI) 16 (67%)
Same provider last 2 years 13 (54%)
Health Behaviors (last 6 months)
Any drug use 11 (46%)
Injection drug use only 9 (37%)
Alcohol 10 (42%)
Cigarettes 18 (75%)
Healthcare Utilization (last 6 months)
Emergency room visit 5 (21%)
Outpatient clinic visit 16 (67%)
MOUD 13 (54%)
Chronic disease prevalence
Arthritis 13 (54%)
Anxiety/Depression 16 (67%)
Bipolar/Schizophrenia disorder 8 (33%)
Diabetes 2 (8%)
Hepatitis C 17 (71%)
HIV 6 (25%)
Hypertension 25 (100%)
Hyperlipidemia 4 (17%)
Obstructive airway 10 (42%)
Renal dysfunction 6 (25%)
Number of co-occurring diseases
2–3 4 (33%)
4–5 13 (38%)
6–8 7 (29%)
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Data Collection

We conducted 24 semi-structured qualitative interviews with a sample of participants from an ongoing cohort of current and former people who inject drugs. Using the BMVP as a guiding framework, a qualitative description methodology was applied, focusing on participants’ perspectives of factors related to healthcare engagement (Bradshaw et al., 2017; Gelberg et al., 2000). Interviews were conducted between July and September 2019 and lasted 20–60 minutes. Participants received $20.00 for interview completion. Interviews were conducted until saturation was reached regarding the role of healthcare environments and providers in healthcare engagement for PWID. The consolidated criteria for reporting qualitative research (COREQ) were utilized to maximize quality and trustworthiness (Tong et al., 2007).

Data Analysis

Interviews were audio recorded and transcribed by an IRB-approved transcription service. An initial a priori codebook based on the BMVP was used to inform initial coding. The study team then jointly listened to multiple interviews and revised the codebook, identifying themes and conducting in vivo coding (Saldana, 2009). Coding was conducted in Atlas.ti version 8.4 (Atlast.ti, 2017). The research team independently coded multiple transcripts. Inconsistencies were resolved and codebook revisions were made until sufficient inter-coder agreement was reached (Krippendorf’s alpha=0.78). Thematic analysis was conducted to explore within and expand upon major domains from the BVMP’s enabling, need, and health behavior domains which facilitated healthcare engagement. Themes included similar responses, novel responses associated with interview questions, and patterns in participant responses which added a novel understanding of healthcare engagement (Denzin & Lincoln, 2011). The data presented focuses on themes related to outpatient primary and mental healthcare utilization and engagement for people who inject drugs.

Results

The median age for participants was 57 years (range: 34–73), with 83% reporting male sex and 83% reporting Black race (Table 1). Almost all participants (n=22, 92%) reported having health insurance. Nearly half of participants reported any drug use in the last 6 months (n=22, 46%), and 37% (n=9) reported injection drug use. Chronic disease profiles of the study population showed over 67% (n=16) had at least 4 multimorbid diseases. There was also a high burden of mental health diagnoses, with 67% (n=16) of participants reporting anxiety and/or depression and 33% (n=8) reporting bipolar disorder and/or schizophrenia.

Themes identified that facilitated engagement in outpatient care included healthcare access and wrap-around services, patient-provider relationships, service integration, healthcare needs alignment, social network influence, MOUD stigma, and acceptance of healthcare.

Healthcare access and wrap-around services

Participants described clinic navigation as assistance that facilitated access to health insurance and other social services and addressed their non-medical needs that impacted their ability to engage in care. Because of this assistance, almost all participants reported having health insurance or another means of paying for their care, including prescription coverage. Additionally, participants with a co-occurring mental health diagnosis reported they had accessed a clinic service that reduced out of pocket healthcare costs. One participant commented: “I’ve got an insurance card. I’ve got a counselor so…if something’s wrong or anything, I just let her know and she’ll take care of it” (Participant 24, age 55, comorbidities: arthritis, bipolar/schizophrenia disorder, anxiety/depression, hypertension). These wrap-around services, which included health insurance navigation and services that reduced financial burden to care, also included linkage to housing and filing disability and supplemental nutrition assistance applications.

Patient-provider relationships

Participants emphasized satisfaction and heightened engagement in healthcare when they viewed their relationship with their medical provider positively. Participants described returning for appointments and trusting the providers with whom they described having a ‘friendship-like’ relationship. Individuals whose providers worked to establish rapport and open communication viewed their healthcare experiences positively:

“But to me it’s more like a friend because she probes until she can find out what’s going on with you and try to help you because people have crisis and just by looking you can’t tell what’s going on with a person, sometimes you have to dig a little deeper” (Participant 14, age 54, comorbidities: arthritis, anxiety/depression, hepatitis C, hypertension, obstructive airway).

Such reports demonstrate the importance of patient-centered relationship building, a key element in participants’ desire to remain engaged in their treatment.

Service integration

Integrated care services emerged as an important facilitator of participants’ healthcare engagement. Participants reported appreciating that their primary care provider (PCP) was their MOUD prescriber. Participants with a co-occurring mental health diagnosis further emphasized an appreciation for when mental health and primary care were integrated in the same facility or managed by one provider. Additionally, access within a PCP’s office to MOUD or other treatments enabled individuals to more readily engage in their care. One participant emphasized the value of accessing MOUD and primary care at the same facility: “It’s a Suboxone program that I’m on, but my primary care provider is there also.” This client was also able to receive hepatitis C treatment at the same location, sharing: “[My doctor’s] the one that got me on the hep C medicine…and we had been talking about it for a minute. Every time I went to see her, she was like, ‘you ready, you ready?’” (Participant 23, Age 59, comorbidities: anxiety/depression, hepatitis C, HIV, hypertension). This participant’s experiences in particular demonstrate across themes how a positive patient-provider relationship enabled by financial security in healthcare coverage and integrated coverage for healthcare needs enabled healthcare engagement.

Healthcare needs alignment

Engagement in and satisfaction with care was higher for participants whose self-perceived needs aligned with the actual needs diagnosed by their provider. This theme was most pronounced with participants who had a co-occurring mental health diagnosis. Participants described satisfaction when providers worked to address patients’ perceived needs with treatment, resources, and education.

One participant’s experience (Participant 21, age 34, comorbidities: anxiety/depression, bipolar/schizophrenia disorder, diabetes, hypertension, obstructive airway) of working to address her mental health conditions through consistent engagement with a community-based clinic highlighted this finding. “I started going there back in 2011. I needed a place to go because I was feeling like…I would never be anything.” She attended health education classes and daily programs through which she worked to stabilize her mental health. During this time, she recalled many emergency room visits, mental health crises, and limited insight into her bipolar diagnosis. “I was very angry…they were trying to put me on the right medication that would stabilize me because I was just everywhere at that time. And it took them about five years to get me on the right medication.” This participant’s story highlights how through gradual treatment and clinic-based services, she gained insight into her diagnosis, which aligned her perceived needs with the bipolar disorder and other comorbidities diagnosed by her provider. This alignment allowed her to better manage her mental health and other comorbidities: “I just had a quick temper. And now I take my medication....for my mood swings, and for my blood pressure.” By understanding patients’ unique experiences with their health conditions, providers can most effectively support their needs, thereby maximizing engagement in care.

Social networks influence engagement

Participants reported how some members of their social networks helped facilitate their care engagement for chronic disease management. Participants described their social networks as a source of knowledge and experience for managing chronic diseases, providing them strength through their care journey. One client stated: “That’s why I talk to certain people, what they going through, and I tell them what I’m going through… we’ll be sharing information for us or what to do, or what type of help to get to help each other and whatnot” (Participant 2, age 55, comorbidities: anxiety/depression, arthritis, hypertension, hyperlipidemia, kidney dysfunction, obstructive airway). Having social network support was a powerful means through which some participants felt encouraged to remain engaged in recovery and chronic disease treatment.

MOUD stigma

Most participants listed the use of MOUD (methadone or buprenorphine) as a means of supporting their healthcare engagement by allowing them to reduce their drug use or abstain entirely. However, there were some participants who expressed negative impressions of MOUD. These participants often expressed these negative comments regarding MOUD and a preference for utilizing detox in combination with group counseling to support their recovery. When asked the resources utilized to reduce or abstain from drug use, one participant with negative perceptions of MOUD remarked, “Get into a program. Go to NA [Narcotic Anonymous] …Get into a halfway house, stay there, and listen to people that’s already been through what I’m going through.” (Participant 24, age 55, comorbidities: arthritis, bipolar/schizophrenia disorder, anxiety/depression, hypertension). A common sentiment among those with negative impressions of MOUD that it is “trading one drug for another.” Responding to the same question, another participant expanded on their negative perception of MOUD with:

I know people that’s been on the methadone program for 30 years. 30 years! They need to have some kind of cutoff. I didn’t take no methadone…I just got tired of being tired. I just told myself, “Okay. You’ll be sick for a few days. It’s better for you to be sick for two, or three, or four days than you having to go for months and years and years and wondering, do whatever to try to get the drug.” (Participant 5, age 57, comorbidities: anxiety/depression, arthritis, hepatitis C, hypertension, hyperlipidemia, obstructive airway)

Acceptance of healthcare

When healthcare providers offered supportive advice and sufficient resources, patients felt better equipped to both control their substance use and manage their chronic diseases, facilitating engagement in care. Most participants stated that providers could not help patients with substance use cessation “until [the patient] was ready,” demonstrating the importance of providers meeting patients where they are psychologically in the recovery process. Participants further emphasized the value of having their providers remain an open, judgement free source of care, even for those actively using substances or experiencing a relapse. Participants desired care teams who worked to meet every individual’s unique recovery needs, emphasizing that providers should consistently provide a positive and accepting presence:

“Listen to them. Just listen. And just encourage them. They can get better. Because a lot of people don’t do that. They just, “Well, you’re using, and you want to go kill yourself, just go kill yourself.” But if they got somebody that’s positive in their corner, it’s a big difference” (Participant 5, age 57, comorbidities: anxiety/depression, arthritis, hepatitis C, hypertension, hyperlipidemia, obstructive airway)

Discussion

This study explored experiences with healthcare engagement among PWID in Baltimore, Maryland. Participants identified their healthcare providers as a source of both advice and resources, which they felt helped them to better engage in care for substance use and chronic disease management. Participants emphasized the importance of substance use treatment, highlighting the benefits of integration of SUD and mental health treatment into primary care. These findings have important implications for future research and clinical practice designed to maximize engagement of current/former PWID, particularly those diagnosed with multiple mental and other chronic comorbidities.

Managing chronic diseases was salient and likely a function of multimorbidity. These participants also listed the need to stabilize their mental health as a provision for cessation from substance use and injection. This theme falls within the need domain of the BMVP. Healthcare providers can engage PWID to understand their care goals (perceived needs), present the evaluated needs, which are the diseases diagnosed by the provider, and utilize shared decision-making principles to set priorities for care (Hawk et al., 2017). Multiple studies have shown that substance use and mental health disorders are highly correlated (Kelly & Daley, 2013; Tormohlen et al., 2021). While no study could be located to confirm our findings of participant descriptions of stabilizing mental health as a means for substance use cessation, some studies identified that the treatment needs of individuals with a triple diagnosis of substance use disorder, mental health disorder, and chronic disease remains unaddressed, with some evidence demonstrating an improvement of chronic disease management following treatment for mental health disorders (Genberg et al., 2019; Tegger et al., 2008).

Access to and coverage by health insurance was listed as a facilitator as suggested by the enabling domain of BMVP model. Many studies have confirmed this finding, demonstrating a positive association between health insurance and health engagement (Barocas et al., 2014; Hoots et al., 2017). One study in particular demonstrated that PWID in states that expanded Medicaid were significantly more likely to have health insurance, a usual source of healthcare, and access to MOUD compared to those in non-expansion states (Lewis et al., 2020). Healthcare access, particularly expanded Medicaid though the Affordable Care and Patient Protection Act, remains an important provision for healthcare engagement for PWID.

Participants listed their patient-provider relationship, particularly having a friendship-like quality to their relationship, as an important factor in their healthcare engagement, consistent with existing literature (Barocas et al., 2014; Biello et al., 2018). While we asked participants in our study generally how their relationship with their provider impacted engagement behaviors, participants focused on instances when the patient-provider relationship enabled aspects of healthcare engagement such as adherence to existing regimens and initiating new treatments. The BMVP lists patient-provider relationship as a component related to patient’s satisfaction with health services. When looking across themes, participants reported the same increased satisfaction with their care and a positive patient-provider relationship when their care was integrated with one provider. Participants particularly desired accessing their primary care and mental health services in the same location. Conversely, a stigmatizing provider relationship has been shown to impact engagement negatively for PWID (Muncan et al., 2020). Providers serving this population should prioritize training to provide destigmatized and accessible care in order to build the positive patient-provider relationship described in this theme and improve care engagement (Biello et al., 2018; Muncan et al., 2020).

While stigma was not directly asked in the interview, a small subset of participants who preferred non-medication strategies for their recovery expressed stigma against utilizing MOUD. While not directly reported by participants, their language mirrored some language from 12-step programs, where there has been a persistent cultural stigma against those who utilize MOUD (Krawczyk et al., 2018). Despite this, there is robust evidence of the benefits of MOUD as a gold standard treatment for opioid use disorder (National Academies of Sciences and Medicine, 2019), which was supported by most participants in this study who listed it as a means for their substance use reduction or abstinence. Providers should support a “medication first” approach to prescribe MOUD to patients who desire it with as few barriers as possible (Winograd et al., 2019). Additionally, there is evidence that peer-based support groups, similar to 12 step programs, can play a role in long term recovery when they provide a holistic and non-stigmatized environment for participants (Krawczyk et al., 2018).

Co-location of services for this population has received increased national attention from policy makers, with a report from the Surgeon General listing the growing impetus from integrated care services for this population as a key area for health centers to increase capacity (US Department of Health and Human Services, 2016). The wrap-around model provides linkage to services including disability, housing, and social worker support (Kay & Westfall, 2020). These services, however, are not often available at all clinic facilities and are frequently limited when they are offered. The Comprehensive Addiction Resources Emergency (CARE) Act provides funding to health centers and systems for hiring clinicians and ancillary healthcare workers to provide these wraparound services and improve engagement in care, particularly for the vulnerable subset of individuals with co-occurring mental health disorders (Comprehensive Addiction Resources Emergency (CARE) Act, 2019). Legislation of this nature expands much needed services that are often underfunded but highlighted by study participants as necessary resources for engagement.

Social networks were described facilitators to healthcare engagement, which has been seen in other studies (Biello et al., 2018) and within the enabling domain of the BMVP. Social networks could be a source of information to control their chronic disease. Clinicians should view individuals’ social networks as a key area for assessment and intervention, leveraging positive interactions as a means for ongoing engagement while counseling their patients to be mindful and providing support to avoid social networks that are deleterious to their health and care outcomes. Leveraging social networks during clinical visits can be an important means for delivery of health messages, referrals to care, and distribution of naloxone and other harm reduction services (Dayton et al., 2021; Falade-Nwulia et al., 2022).

Overall, these themes identify provider and systemic practices which can support current/former PWID patients. In the Acceptance of healthcare theme, patients felt most supported when providers identified their priorities for care across chronic disease, mental health, and substance use treatment/harm reduction needs. In practicing with a harm reduction lens, providers can engage in shared decision making with patients, attempt to integrate mental health and substance use treatment services within their practice or clinic setting, and ensure that they present treatment options in a non-stigmatizing manner (Hawk et al., 2017). Additionally, this includes understanding that abstinence from or reduction of drug use is not the priority of some patients, and these priorities change over time (Kapadia et al., 2021). Overall, these themes when taken together identify areas for healthcare providers to enable healthcare engagement for PWID to support their holistic health needs.

There are limitations to consider. This study was conducted in Baltimore, Maryland, where the population has unique access to health care services and expanded Medicaid insurance not available to PWID in some US states. However, there were 24 interviews conducted in total with a variety of multimorbid chronic and mental health diagnoses to provide an understanding of outpatient healthcare engagement for this population. Additionally, interviews were conducted prior to the COVID-19 pandemic. While healthcare systems have changed and new methods of engagement, such as telehealth (Mahmoud et al., 2022), emerged during the pandemic, our participants were able to convey their experiences to obtain an understanding of how this population engages in their healthcare for their complex needs.

Future studies with this population should continue to explore participants’ perceptions for optimal healthcare engagement, which can provide avenues for interventions and leverage strengths for sustained healthcare. Additionally, while the BMVP provided a framework for this study, future studies will benefit from an additional intersectional lens to interview guides and thematic analysis to understand how stigma, racism, sexism and ageism experienced by PWID impact healthcare engagement for holistic healthcare needs Participants highlighted a positive patient-provider relationship, sustained health insurance, alignment of their healthcare needs with those designated by healthcare providers, and receipt of integrated care that can address pressing health needs. Policy considerations include the continued provision of publicly available insurance and passage of legislation that provides funding for clinics to provide wraparound services to individuals with substance use disorders. Finally, this study affirms the importance of healthcare integration in addition to meeting the needs of this population at the level at which they are able to accept care.

No Patient or Public Contribution:

While we acknowledge and thank ALIVE participants for their time for data collection and sharing their perspectives, no ALIVE participants, other people who use drugs, and service users were involved in data collection, analysis or interpretation of data, or in preparation of the manuscript.

Funding

This work was funded by the National Institutes of Health grant numbers R01DA036297 (MPI Mehta and Kirk), KL2TR002317 (PI Amory to OH) and the Robert Wood Johnson Foundation Future of Nursing Scholars Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Conflict of Interest:

The authors declare no conflicts of interest.

Contributor Information

Omeid Heidari, University of Washington, School of Nursing, Department of Child, Family, and Population Health Nursing, Seattle, WA.

Abigail Winiker, Johns Hopkins University, Bloomberg School of Public Health, Department of Health, Behavior, and Society, Baltimore, MD.

Derek T. Dangerfield, II, George Washington University, Milken Institute School of Public Health, Department of Prevention and Community Health, Washington, DC.

Jennifer Wenzel, Johns Hopkins University, School of Nursing, Baltimore, MD; Johns Hopkins University, School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.

Tamar Rodney, Johns Hopkins University, School of Nursing, Baltimore, MD.

Shruti Mehta, Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD.

Becky Genberg, Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD.

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