{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:07:39Z","timestamp":1760144859465,"version":"build-2065373602"},"reference-count":59,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2024,5,28]],"date-time":"2024-05-28T00:00:00Z","timestamp":1716854400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100016815","name":"Third Coast Center for AIDS Research (CFAR)","doi-asserted-by":"publisher","award":["P30 AI117943"],"award-info":[{"award-number":["P30 AI117943"]}],"id":[{"id":"10.13039\/100016815","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Electronic patient portals represent a promising means of integrating mental health assessments into HIV care where anxiety and depression are highly prevalent. Patient attitudes toward portal-based mental health screening within HIV clinics have not been well described. The aim of this formative qualitative study is to characterize the patient-perceived facilitators and barriers to portal-based anxiety and depression screening within HIV care in order to inform implementation strategies for mental health screening. Twelve adult HIV clinic patients participated in semi-structured interviews that were audio recorded and transcribed. The transcripts were coded using constructs from the Consolidated Framework for Implementation Research and analyzed thematically to identify the barriers to and facilitators of portal-based anxiety and depression screening. Facilitators included an absence of alternative screening methods, an approachable design, perceived adaptability, high compatibility with HIV care, the potential for linkage to treatment, an increased self-awareness of mental health conditions, the ability to bundle screening with clinic visits, and communicating an action plan for results. The barriers included difficulty navigating the patient portal system, a lack of technical support, stigmatization from the healthcare system, care team response times, and the novelty of using patient portals for communication. The patients in the HIV clinic viewed the use of a portal-based anxiety and depression screening tool as highly compatible with routine HIV care. Technical difficulties, follow-up concerns, and a fear of stigmatization were commonly perceived as barriers to portal use. The results of this study can be used to inform implementation strategies when designing or incorporating portal-based mental health screening into other HIV care settings.<\/jats:p>","DOI":"10.3390\/ijerph21060692","type":"journal-article","created":{"date-parts":[[2024,5,28]],"date-time":"2024-05-28T07:38:39Z","timestamp":1716881919000},"page":"692","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Patient Perspectives on Portal-Based Anxiety and Depression Screening in HIV Care: A Qualitative Study Using the Consolidated Framework for Implementation Research"],"prefix":"10.3390","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2266-5690","authenticated-orcid":false,"given":"Jacob A.","family":"Walker","sequence":"first","affiliation":[{"name":"Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Erin M.","family":"Staab","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Chicago, Chicago, IL 60637, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jessica P.","family":"Ridgway","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Chicago, Chicago, IL 60637, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jessica","family":"Schmitt","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Chicago, Chicago, IL 60637, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Melissa I.","family":"Franco","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Chicago, Chicago, IL 60637, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Scott","family":"Hunter","sequence":"additional","affiliation":[{"name":"Chicago Center for HIV Elimination, Department of Medicine, University of Chicago, Chicago, IL 60637, USA"},{"name":"WCG Clinical Endpoint Solutions, Hamilton, NJ 08540, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Darnell","family":"Motley","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Chicago, Chicago, IL 60637, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Neda","family":"Laiteerapong","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Chicago, Chicago, IL 60637, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,5,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1411","DOI":"10.1097\/QAD.0000000000002227","article-title":"Mental health and HIV\/AIDS: The need for an integrated response","volume":"33","author":"Remien","year":"2019","journal-title":"AIDS"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1136\/bmjspcare-2019-001952","article-title":"Global prevalence of depression in HIV\/AIDS: A systematic review and meta-analysis","volume":"9","author":"Rezaei","year":"2019","journal-title":"BMJ Support. Palliat. Care"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1016\/j.cpr.2016.11.005","article-title":"Anxiety symptoms and disorders among adults living with HIV and AIDS: A critical review and integrative synthesis of the empirical literature","volume":"51","author":"Brandt","year":"2017","journal-title":"Clin. Psychol. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1411","DOI":"10.1093\/cid\/ciy309","article-title":"Depression and Anxiety as Risk Factors for Delayed Care-Seeking Behavior in Human Immunodeficiency Virus-Infected Individuals in South Africa","volume":"67","author":"Rane","year":"2018","journal-title":"Clin. Infect. Dis."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1080\/13548500124807","article-title":"Rates and correlates of HIV treatment adherence among late middle-aged and older adults living with HIV disease","volume":"6","author":"Catz","year":"2001","journal-title":"Psychol. Health Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1089\/10872910260066705","article-title":"Individual and system level factors associated with treatment nonadherence in human immunodeficiency virus-infected men and women","volume":"16","author":"Chang","year":"2002","journal-title":"AIDS Patient Care STDS"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1080\/1354850021000015267","article-title":"Mental health, substance use and disclosure are significantly associated with the medical treatment adherence of HIV-infected mothers","volume":"7","author":"Mellins","year":"2002","journal-title":"Psychol. Health Med."},{"key":"ref_8","first-page":"407","article-title":"Baseline predictors of three types of antiretroviral therapy (ART) adherence: A 2-year follow-up","volume":"18","author":"Diamond","year":"2006","journal-title":"AIDS Care"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1328","DOI":"10.4088\/JCP.08l04885","article-title":"Effect of anxiety symptoms on adherence to highly active antiretroviral therapy in HIV-infected women","volume":"70","author":"Roux","year":"2009","journal-title":"J. Clin. Psychiatry"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"458","DOI":"10.1007\/s10608-014-9608-x","article-title":"Medication Adherence and HIV Symptom Distress in Relation to Panic Disorder Among HIV-Positive Adults Managing Opioid Dependence","volume":"38","author":"Kosiba","year":"2014","journal-title":"Cogn. Ther. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1975","DOI":"10.1097\/QAD.0000000000000797","article-title":"The effect of antidepressant treatment on HIV and depression outcomes: Results from a randomized trial","volume":"29","author":"Pence","year":"2015","journal-title":"AIDS"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1007\/s11606-019-05192-3","article-title":"The Role of Screening in Depression Diagnosis and Treatment in a Representative Sample of US Primary Care Visits","volume":"35","author":"Samples","year":"2020","journal-title":"J. Gen. Intern. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"igz011","DOI":"10.1093\/geroni\/igz011","article-title":"Screening Older Adults for Depression: Barriers Across Clinical Discipline Training","volume":"3","author":"Smith","year":"2019","journal-title":"Innov. Aging"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1177\/1062860619884639","article-title":"Improving Depression Screening in Underserved Populations in a Large Urban Academic Primary Care Center: A Provider-Centered Analysis and Approach","volume":"35","author":"Henry","year":"2020","journal-title":"Am. J. Med. Qual."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"ofz146","DOI":"10.1093\/ofid\/ofz146","article-title":"Expanded HIV Clinic-Based Mental Health Care Services: Association With Viral Suppression","volume":"6","author":"Aggarwal","year":"2019","journal-title":"Open Forum Infect. Dis."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1016\/j.jana.2013.05.004","article-title":"Implementation of PHQ-9 depression screening for HIV-infected patients in a real-world setting","volume":"25","author":"Edwards","year":"2014","journal-title":"J. Assoc. Nurses AIDS Care"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"105833","DOI":"10.1016\/j.cct.2019.105833","article-title":"Implementing electronic substance use disorder and depression and anxiety screening and behavioral interventions in primary care clinics serving people with HIV: Protocol for the Promoting Access to Care Engagement (PACE) trial","volume":"84","author":"Satre","year":"2019","journal-title":"Contemp. Clin. Trials"},{"unstructured":"(2022, April 06). Ryan White HIV\/AIDS Program Funding, Available online: https:\/\/ryanwhite.hrsa.gov\/about\/budget.","key":"ref_18"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1197\/jamia.M2835","article-title":"Initial experience with patient-clinician secure messaging at a VA medical center","volume":"16","author":"Byrne","year":"2009","journal-title":"J. Am. Med. Inf. Assoc."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"S85","DOI":"10.1016\/j.pmrj.2017.02.005","article-title":"It Takes Two to Tango: Engaging Patients and Providers with Portals","volume":"9","author":"Shah","year":"2017","journal-title":"PM R"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1111\/1475-6773.12134","article-title":"The Medicare Electronic Health Record Incentive Program: Provider performance on core and menu measures","volume":"49","author":"Wright","year":"2014","journal-title":"Health Serv. Res."},{"unstructured":"Heisey-Grove, D., and Pately, V. (2014). ONC Data Brief: Ant, Certified, and Basic: Quantifying Physician EHR Adoption through 2014.","key":"ref_22"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jad.2016.08.034","article-title":"Use of an on-line patient portal in a depression collaborative care management program","volume":"208","author":"Pecina","year":"2017","journal-title":"J. Affect. Disord."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1089\/apc.2017.0303","article-title":"PositiveLinks: A Mobile Health Intervention for Retention in HIV Care and Clinical Outcomes with 12-Month Follow-Up","volume":"32","author":"Dillingham","year":"2018","journal-title":"AIDS Patient Care STDS"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1026","DOI":"10.1080\/10810730.2015.1018617","article-title":"Correlation of Internet Use for Health Care Engagement Purposes and HIV Clinical Outcomes Among HIV-Positive Individuals Using Online Social Media","volume":"20","author":"Saberi","year":"2015","journal-title":"J. Health Commun."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e71","DOI":"10.2196\/jmir.1603","article-title":"Factors influencing the use of a Web-based application for supporting the self-care of patients with type 2 diabetes: A longitudinal study","volume":"13","author":"Nijland","year":"2011","journal-title":"J. Med. Internet Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"S52","DOI":"10.1097\/MLR.0b013e31827808db","article-title":"Evaluating patient access to Electronic Health Records: Results from a survey of veterans","volume":"51","author":"Nazi","year":"2013","journal-title":"Med. Care"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1016\/j.acap.2013.02.002","article-title":"Correlates of patient portal enrollment and activation in primary care pediatrics","volume":"13","author":"Ketterer","year":"2013","journal-title":"Acad. Pediatr."},{"doi-asserted-by":"crossref","unstructured":"Zhong, X., Liang, M., Sanchez, R., Yu, M., Budd, P.R., Sprague, J.L., and Dewar, M.A. (2018). On the effect of electronic patient portal on primary care utilization and appointment adherence. BMC Med. Inf. Decis. Mak., 18.","key":"ref_29","DOI":"10.1186\/s12911-018-0669-8"},{"doi-asserted-by":"crossref","unstructured":"Reed, M.E., Huang, J., Brand, R.J., Neugebauer, R., Graetz, I., Hsu, J., Ballard, D.W., and Grant, R. (2019). Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal. PLoS ONE, 14.","key":"ref_30","DOI":"10.1371\/journal.pone.0217636"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1117","DOI":"10.1007\/s11606-011-1749-y","article-title":"Use of an electronic patient portal among disadvantaged populations","volume":"26","author":"Ancker","year":"2011","journal-title":"J. Gen. Intern. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e188","DOI":"10.2196\/jmir.7417","article-title":"Access to Electronic Personal Health Records Among Patients With Multiple Chronic Conditions: A Secondary Data Analysis","volume":"19","author":"Greenberg","year":"2017","journal-title":"J. Med. Internet Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e8","DOI":"10.2196\/resprot.2302","article-title":"Barriers and Facilitators of Online Patient Portals to Personal Health Records Among Persons Living with HIV: Formative Research","volume":"2","author":"Luque","year":"2013","journal-title":"JMIR Res. Protoc."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2995","DOI":"10.1002\/ppul.24949","article-title":"Integration of mental health screening and treatment into cystic fibrosis clinics: Evaluation of initial implementation in 84 programs across the United States","volume":"55","author":"Quittner","year":"2020","journal-title":"Pediatr. Pulmonol."},{"doi-asserted-by":"crossref","unstructured":"Premji, S.S., Dobson, K.S., Prashad, A., Yamamoto, S., Tao, F., Zhu, B., Wu, X., Lu, M., and Shao, S. (2021). What stakeholders think: Perceptions of perinatal depression and screening in China\u2019s primary care system. BMC Pregnancy Childbirth, 21.","key":"ref_35","DOI":"10.1186\/s12884-020-03473-y"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"S15","DOI":"10.1016\/j.japh.2020.03.010","article-title":"Patient and prescriber perceptions of depression screening within a community pharmacy setting","volume":"60","author":"Mospan","year":"2020","journal-title":"J. Am. Pharm. Assoc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"112461","DOI":"10.1016\/j.psychres.2019.06.036","article-title":"Clarity out of chaos: Use of theory in implementation research","volume":"283","author":"Damschroder","year":"2020","journal-title":"Psychiatry Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1186\/1748-5908-4-50","article-title":"Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science","volume":"4","author":"Damschroder","year":"2009","journal-title":"Implement. Sci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e48935","DOI":"10.2196\/48935","article-title":"Population-Level Portal-Based Anxiety and Depression Screening Perspectives in HIV Care Clinicians: Qualitative Study Using the Consolidated Framework for Implementation Research","volume":"8","author":"Zimmer","year":"2024","journal-title":"JMIR Form. Res."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"857","DOI":"10.1007\/s11606-022-07779-9","article-title":"Pragmatic Clinical Trial of Population Health, Portal-Based Depression Screening: The PORTAL-Depression Study","volume":"38","author":"Franco","year":"2023","journal-title":"J. Gen. Intern. Med."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1097\/JMQ.0000000000000126","article-title":"Population Health Management Approach to Depression Symptom Monitoring in Primary Care via Patient Portal: A Randomized Controlled Trial","volume":"38","author":"Staab","year":"2023","journal-title":"Am. J. Med. Qual."},{"unstructured":"(2022, April 06). CFIR Guide. Available online: https:\/\/cfirguide.org\/guide\/app\/#\/.","key":"ref_42"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1111\/j.1365-2648.2007.04569.x","article-title":"The qualitative content analysis process","volume":"62","author":"Elo","year":"2008","journal-title":"J. Adv. Nurs."},{"unstructured":"(2022, April 06). CFIR Constructs. Available online: https:\/\/cfirguide.org\/constructs\/.","key":"ref_44"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"114523","DOI":"10.1016\/j.socscimed.2021.114523","article-title":"Sample sizes for saturation in qualitative research: A systematic review of empirical tests","volume":"292","author":"Hennink","year":"2022","journal-title":"Soc. Sci. Med."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1167\/tvst.11.1.16","article-title":"Perspectives on Implementing the Patient Health Questionnaire-4 in Low-Vision Service Organizations to Screen for Depression and Anxiety","volume":"11","author":"Elsman","year":"2022","journal-title":"Transl. Vis. Sci. Technol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/s13033-022-00520-3","article-title":"Barriers and facilitators to implementing the HEADSS psychosocial screening tool for adolescents living with HIV\/AIDS in teen club program in Malawi: Health care providers perspectives","volume":"16","author":"Kip","year":"2022","journal-title":"Int. J. Ment. Health Syst."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1007\/s10461-016-1659-4","article-title":"Feasibility and Acceptability of a Task-Shifted Intervention to Enhance Adherence to HIV Medication and Improve Depression in People Living with HIV in Zimbabwe, a Low Income Country in Sub-Saharan Africa","volume":"22","author":"Abas","year":"2018","journal-title":"AIDS Behav."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1737","DOI":"10.1007\/s10461-020-03103-w","article-title":"Feasibility and Acceptability of a Program to Promote Positive Affect, Well-Being and Gender Empowerment in Black Women Living with HIV","volume":"25","author":"Bassett","year":"2021","journal-title":"AIDS Behav."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1007\/s10461-019-02412-z","article-title":"Feasibility and Acceptability of an Online Positive Affect Intervention for Those Living with Comorbid HIV Depression","volume":"23","author":"Bassett","year":"2019","journal-title":"AIDS Behav."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"2730","DOI":"10.1177\/1359105320926526","article-title":"Feasibility, acceptability, and preliminary impact of telemedicine-administered cognitive behavioral therapy for adherence and depression among African American women living with HIV in the rural South","volume":"26","author":"Junkins","year":"2021","journal-title":"J. Health Psychol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1143","DOI":"10.1089\/tmj.2021.0318","article-title":"Portal Message Language Use Prior to Suicide, Suicide Attempts, and Hospitalization for Depression","volume":"28","author":"Duvall","year":"2022","journal-title":"Telemed. e-Health"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1046\/j.1525-1497.2003.20823.x","article-title":"Patient perspectives of medical confidentiality: A review of the literature","volume":"18","author":"Sankar","year":"2003","journal-title":"J. Gen. Intern. Med."},{"doi-asserted-by":"crossref","unstructured":"Jimenez, J., Del Rio, A., Berman, A.N., and Grande, M. (2023). Personalizing Digital Health: Adapting Health Technology Systems to Meet the Needs of Different Older Populations. Healthcare, 11.","key":"ref_54","DOI":"10.20944\/preprints202304.0078.v1"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1109","DOI":"10.1176\/appi.ps.201800056","article-title":"Message Framing and Engagement in Specialty Mental Health Care: A Follow-up Analysis","volume":"69","author":"Mavandadi","year":"2018","journal-title":"Psychiatr. Serv."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"371","DOI":"10.3389\/fpubh.2019.00371","article-title":"Effects of Goal-Framed Messages on Mental Health Education among Medical University Students: Moderating Role of Personal Involvement","volume":"7","author":"Bai","year":"2019","journal-title":"Front. Public Health"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"e28369","DOI":"10.2196\/28369","article-title":"Mental Health Screening in General Practices as a Means for Enhancing Uptake of Digital Mental Health Interventions: Observational Cohort Study","volume":"23","author":"Whitton","year":"2021","journal-title":"J. Med. Internet Res."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"e45974","DOI":"10.2196\/45974","article-title":"Patients\u2019 Experiences of a National Patient Portal and Its Usability: Cross-Sectional Survey Study","volume":"25","author":"Simola","year":"2023","journal-title":"J. Med. Internet Res."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"e148","DOI":"10.2196\/jmir.4255","article-title":"Patient Portals and Patient Engagement: A State of the Science Review","volume":"17","author":"Irizarry","year":"2015","journal-title":"J. Med. 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