Disseminating Community-Engaged Research Involving People Experiencing Homelessness and Diabetes Using Participatory Theater.

People experiencing homelessness balance competing priorities resulting in reduced capacity to meet the care demands of chronic conditions, including Type 2 Diabetes Mellitus (T2DM). Arts-based performances present an avenue to expose others to these challenges. This article describes the process of incorporating qualitative research findings in a community-based participatory theater production to expose audiences to the day-to-day realities of living with T2DM while simultaneously experiencing homelessness. We conducted five focus groups and two individual interviews with people living with T2DM who had experienced homelessness with guidance from a community-engaged research team. We then collaborated with a local theater company to present common themes from these focus groups in a co-created play about the experience of managing T2DM while being homeless. We performed a staged reading of the play and assessed audience members' perceived stigma through a pre- and post-survey to determine if audience engagement within our theatrical production could reduce stigma toward individuals living with diabetes and/or people experiencing homelessness. This theatrical production is titled "Life Heist: Stealing Hope While Surviving Diabetes and Homelessness." Our work illustrates the feasibility and effectiveness of using participatory theater to disseminate qualitative research findings.

The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness.

Introduction: Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH. Methods: We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions). Results: In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing. Discussion: The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.

Stories for change protocol: A randomized controlled trial of a digital storytelling intervention for Hispanic/Latino individuals with type 2 diabetes.

BACKGROUND: Hispanic/Latino adults are disproportionately impacted by type 2 diabetes mellitus (T2D). The Stories for Change (S4C) Diabetes digital storytelling intervention promotes T2D self-management among Hispanic/Latino people. We describe the S4C protocol and participant baseline characteristics. METHODS: Study eligibility criteria: Hispanic or Latino, age 18-70 years, ≥1 office visit within a year at a participating clinic, T2D diagnosis for ≥6 months, HbA1c ≥ 8%, and intention to continue care at the recruitment clinic. We used a two-group, parallel randomized controlled trial design and an intervention derived through a community-based participatory research approach. All participants received usual diabetes care and two cards describing how to engage healthcare teams and access diabetes-related resources. At baseline, the intervention group additionally viewed the 12-min, intervention video (four stories about diabetes self-management). To encourage subsequent video viewing, participants received five monthly text messages. The messages prompted them to self-rate their motivation and self-efficacy for T2D management. The control group received no additional intervention. Bilingual (English/Spanish) staff collected data at baseline, six weeks, three months, and six months including biometric measurements and a survey on diabetes self-management outcomes, theory-based measures, and the number of video views. We reviewed the number of diabetes-related appointments attended using electronic medical record data. RESULTS: Participants (n = 451; 70% women, mean age = 53 years) had an average HbA1C ≥9%. Intervention participants reported identifying with the storytellers and engaging with the stories. CONCLUSION: We present a digital storytelling intervention protocol that provides a template for future health promotion interventions prioritizing health disparity populations. CLINICALTRIAL: gov#NCT03766438.

Experiences of Hispanic Safety Net Clinic Patients With Diabetes During the COVID-19 Pandemic.

PURPOSE: The purpose of this study was to characterize the material, health (general and diabetes-specific), and social impacts of the COVID-19 pandemic on Hispanic adults with type 2 diabetes who did not experience COVID-19 infection. METHODS: This cross-sectional and longitudinal study used surveys within a clinical trial of 79 Hispanic adult clinic patients with type 2 diabetes. Cross-sectional measures included the Coronavirus Anxiety Scale, items from the Coronavirus Impact Scale, and the Pandemic Impacts Inventory. Longitudinal measures included the Summary of Diabetes Self-Care, health care utilization, and measures of diabetes self-efficacy, social support, and quality of life. RESULTS: Participants were majority low-income, Spanish-speaking females with poor diabetes control. Coronavirus anxiety was low despite majority of participants having an affected family member and frequent access barriers. More than half of participants reported moderate/severe pandemic impact on their income. Diabetes self-care behaviors did not change between prepandemic and pandemic measures. Diabetes self-efficacy and quality of life improved despite fewer diabetes-related health care visits. CONCLUSIONS: Despite high levels of access barriers, financial strain, and COVID-19 infection of family members, Hispanic adults with type 2 diabetes continued to prioritize their diabetes self-management and demonstrated substantial resilience by improving their self-efficacy and quality of life.

Feasibility and Acceptability of a Smoking Cessation Program for Individuals Released From an Urban, Pretrial Jail: A Pilot Randomized Clinical Trial.

Importance: Tobacco use prevalence among individuals involved in the criminal-legal system is 125% higher than that of the general population and leads to high levels of smoking-related morbidity and mortality. Objective: To examine the acceptability, feasibility, and preliminary clinical outcomes of a smoking cessation intervention for individuals who are incarcerated. Design, Setting, and Participants: This pilot randomized clinical trial was conducted from January 2019 to May 2020. Participants were recruited in a pretrial county jail in a large Midwestern US city and were followed up after release. Participants were incarcerated, smoked daily before incarceration, desired to stay quit or reduce cigarette smoking upon release, and expected to be released to the community within 90 days of enrollment. Data analysis was performed from June to October 2020. Interventions: Participants randomized to the counseling plus nicotine replacement therapy (NRT) group received 1 hour of smoking cessation counseling in jail, a supply of nicotine lozenges upon release, and up to 4 telephone counseling sessions after release. Those randomized to brief health education (BHE) received 30 minutes of general health education in jail. Main Outcomes and Measures: The primary clinical outcome was biologically verified 7-day point prevalence abstinence (PPA) at 3 weeks after release. Secondary clinical outcomes included 7-day PPA at 12 weeks, changes in number of cigarettes per day, and time to smoking lapse and relapse. Results: A total of 46 participants (42 men [91%]; mean [SD] age, 38.2 [9.1] years) were enrolled and remained eligible at release; 23 were randomized to the counseling plus NRT group and 23 were randomized to the BHE group. Recruitment, enrollment, and retention of participants was feasible and acceptable. There were no significant differences in smoking abstinence between groups as determined by 7-day PPA at 3 weeks (adjusted 7-day PPA, 11.9% for counseling plus NRT vs 10.6% for BHE; odds ratio, 1.13; 95% CI, 0.14-9.07) and at 12 weeks (adjusted 7-day PPA, 11.1% for counseling plus NRT vs 14.3% for BHE; odds ratio, 0.75; 95% CI, 0.09-6.11). Cigarettes per day for the counseling plus NRT group decreased more compared with the BHE group at both 3 weeks (difference [SE], -4.58 [1.58] cigarettes per day; 95% CI, -7.67 to -1.48 cigarettes per day; P = .007) and 12 weeks (difference [SE], -3.26 [1.58] cigarettes per day; 95% CI, -5.20 to -0.20 cigarettes per day; P = .04) after release. Conclusions and Relevance: Initiation of counseling plus NRT during incarceration and continuing after release is feasible and acceptable to participants and may be associated with reduced cigarette use after release. However, additional supports are needed to increase engagement in telephone counseling after release. A larger clinical trial is warranted to determine the effectiveness of counseling plus NRT. Trial Registration: ClinicalTrials.gov Identifier: NCT03799315.

Trends in Trimorbidity Among Adults Experiencing Homelessness in Minnesota, 2000-2018.

BACKGROUND: Earlier and more severe onset of chronic health conditions contributes to the increased risk of premature death among adults experiencing homelessness. Trimorbidity, a subset of multimorbidity representing overlap of physical health, mental health, and substance use conditions, disproportionately impacts adults experiencing homelessness. We know of no longitudinal data comparing trimorbidity trends among adults experiencing homelessness. OBJECTIVE: To characterize 19-year trimorbidity trends among adults experiencing homelessness. RESEARCH DESIGN: Repeated longitudinal, statewide survey administered every 3 years. SUBJECTS: Adults living throughout Minnesota experiencing homelessness. MEASURES: Reported diagnoses of chronic health conditions within 3 categories: physical health conditions (hypertension, heart disease, asthma, diabetes); mental health conditions (depression, posttraumatic stress disorder, bipolar disorder, schizophrenia/other paranoid, and delusional disorders); and substance use conditions (alcohol and illicit substances). RESULTS: A total of 25,552 surveys were completed by adults at 3-year intervals in a total of 7 waves. Participants reported increasing frequency and duration of homelessness, and more nights slept outside/in a car. 77.3% of adults experiencing homelessness in 2018 had one or more chronic health condition in any domain. From 2000 to 2018, bimorbidity and trimorbidity surpassed morbidity within a single domain. This was driven by increases in mental health conditions. In 2018, 31.7% of participants reported bimorbidity and 16.3% of adults reported trimorbidity. CONCLUSIONS: Adults experiencing homelessness bear a substantial and growing burden of bimorbidity and trimorbidity. Ensuring accessible, high quality care that includes robust services that can address all 3 categories of health is critical. Such care is best delivered in combination with affordable supportive housing.

Associations Between Polysubstance Use Patterns and Receipt of Medications for Opioid Use Disorder Among Adults in Treatment for Opioid Use Disorder.

OBJECTIVE: To examine trends in polysubstance use among adults in treatment for opioid use disorder (OUD) and estimate associations between polysubstance use patterns and receipt of medications for OUD (MOUD). METHODS: We conducted a cross-sectional longitudinal analysis of treatment admissions for opioid use from 1992 to 2017 using the Treatment Episodes Data Set-Admissions (N = 9,440,157). We used multiple logistic regression to examine co-use patterns and estimate associations between receipt of MOUD and polysubstance use categories (opioid only, any methamphetamine, any cocaine, any alcohol, any benzodiazepine). RESULTS: Between 1992 and 2017, treatment admissions involving opioid/cocaine (-17.2 percentage points [PP]) and opioid/alcohol co-use (-12.5 PP) decreased while opioid/methamphetamine (10.1 PP) and opioid/benzodiazepine co-use (5.6 PP) increased. In 2016 to 2017, receipt of medications for OUD was significantly higher for those who used opioids only (38.5%; 95% confidence interval [CI] 38.4-38.6) compared with individuals who used opioids with cocaine (35.7%; 95% CI 35.6-35.9), methamphetamine (23.9%; 95% CI 23.7-24.2), alcohol (25.0%; 95% CI 24.8-25.2), or benzodiazepines (34.6%; 95% CI 34.3-34.9). If those who co-used opioids with other substances received MOUD at the same rate as those who used opioids only, 47,400 additional people would have received MOUD between 2016 and 2017. CONCLUSIONS: Opioid/methamphetamine and opioid/benzodiazepine increased substantially between 1992 and 2017. Co-use of other substances with opioids was associated with significantly lower receipt of MOUD. Treatment facilities should increase access to MOUD for individuals who co-use opioids with other substances. This change would extend evidence-based treatment to thousands of individuals and save lives.

Electronic cigarette use patterns and chronic health conditions among people experiencing homelessness in MN: a statewide survey.

BACKGROUND: Adults experiencing homelessness have higher rates of disease and premature morbidity compared to the general population. Tobacco use is a primary contributing factor to these disparities; however, less is known regarding e-cigarette use patterns among adults experiencing homelessness and whether e-cigarettes are used in a manner that is narrowing or widening health disparities. This study aimed to describe the 1) prevalence and trends in e-cigarette use, 2) correlates of e-cigarettes use, and 3) rates of chronic health conditions by product use pattern in a community-based sample of adults experiencing homelessness. METHODS: Adults experiencing homelessness in Minnesota were surveyed by self-report in 2015 (n = 3672) and 2018 (n = 4181) regarding e-cigarette and combustible cigarette use, potential correlates of e-cigarette use, and self-reported chronic health conditions (i.e., asthma, hypertension, diabetes, and cancer). RESULTS: Frequency of use increased from 2015 to 2018 for combustible cigarettes (66.9% vs. 72.3%), e-cigarettes (11.4% vs. 14.5%), and dual combustible/e-cigarette use (10.2% vs. 12.9%). The strongest bivariate correlates of past 30-day e-cigarette use were younger age, non-binary gender identification, non-heterosexual orientation, identification as White/Caucasian, greater frequency of lifetime homelessness, substance use, lack of regular place for medical care, mental health diagnosis, criminal justice involvement, and combustible cigarette smoking. Dual users had significantly higher rates of asthma and cancer than both those using combustible cigarettes and those using neither combustible nor e-cigarettes. CONCLUSIONS: During a time when cigarette smoking, e-cigarette use, and dual use were decreasing in the general population in Minnesota, rates increased in the homeless population. We observed that the rates of dual use were more than five times greater among homeless adults compared to the general population in 2018. Correlates of e-cigarette use were identified and should be used to identify subpopulations for intervention targeting. Mechanisms of the relationship between dual use and increased risks of health conditions deserve further study.

Medications for opioid use disorder among pregnant women referred by criminal justice agencies before and after Medicaid expansion: A retrospective study of admissions to treatment centers in the United States.

BACKGROUND: Criminal justice involvement is common among pregnant women with opioid use disorder (OUD). Medications for OUD improve pregnancy-related outcomes, but trends in treatment data among justice-involved pregnant women are limited. We sought to examine trends in medications for OUD among pregnant women referred to treatment by criminal justice agencies and other sources before and after the Affordable Care Act's Medicaid expansion. METHODS AND FINDINGS: We conducted a serial, cross-sectional analysis using 1992-2017 data from pregnant women admitted to treatment facilities for OUD using a national survey of substance use treatment facilities in the United States (N = 131,838). We used multiple logistic regression and difference-in-differences methods to assess trends in medications for OUD by referral source. Women in the sample were predominantly aged 18-29 (63.3%), white non-Hispanic, high school graduates, and not employed. Over the study period, 26.3% (95% CI 25.7-27.0) of pregnant women referred by criminal justice agencies received medications for OUD, which was significantly less than those with individual referrals (adjusted rate ratio [ARR] 0.45, 95% CI 0.43-0.46; P < 0.001) or those referred from other sources (ARR 0.51, 95% CI 0.50-0.53; P < 0.001). Among pregnant women referred by criminal justice agencies, receipt of medications for OUD increased significantly more in states that expanded Medicaid (n = 32) compared with nonexpansion states (n = 18) (adjusted difference-in-differences: 12.0 percentage points, 95% CI 1.0-23.0; P = 0.03). Limitations of this study include encounters that are at treatment centers only and that do not encompass buprenorphine prescribed in ambulatory care settings, prisons, or jails. CONCLUSIONS: Pregnant women with OUD referred by criminal justice agencies received evidence-based treatment at lower rates than women referred through other sources. Improving access to medications for OUD for pregnant women referred by criminal justice agencies could provide public health benefits to mothers, infants, and communities. Medicaid expansion is a potential mechanism for expanding access to evidence-based treatment for pregnant women in the US.