Effects of the Communities that Heal (CTH) intervention on perceived opioid-related community stigma in the HEALing Communities Study: results of a multi-site, community-level, cluster-randomized trial.

Background: Community stigma against people with opioid use disorder (OUD) and intervention stigma (e.g., toward naloxone) exacerbate the opioid overdose crisis. We examined the effects of the Communities that HEAL (CTH) intervention on perceived opioid-related community stigma by stakeholders in the HEALing Communities Study (HCS). Methods: We collected three surveys from community coalition members in 66 communities across four states participating in HCS. Communities were randomized into Intervention (Wave 1) or Wait-list Control (Wave 2) arms. We conducted multilevel linear mixed models to compare changes in primary outcomes of community stigma toward people treated for OUD, naloxone, and medication for opioid use disorder (MOUD) by arm from time 1 (before the start of the intervention) to time 3 (end of the intervention period in the Intervention arm). Findings: Intervention stakeholders reported a larger decrease in perceived community stigma toward people treated for OUD (adjusted mean change (AMC) -3.20 [95% C.I. -4.43, -1.98]) and toward MOUD (AMC -0.33 [95% C.I. -0.56, -0.09]) than stakeholders in Wait-list Control communities (AMC -0.18 [95% C.I. -1.38, 1.02], p = 0.0007 and AMC 0.11 [95% C.I. -0.09, 0.31], p = 0.0066). The relationship between intervention status and change in stigma toward MOUD was moderated by rural-urban status (urban AMC -0.59 [95% CI, -0.87, -0.32], rural AMC not sig.) and state. The difference in stigma toward naloxone between Intervention and Wait-list Control stakeholders was not statistically significant (p = 0.18). Interpretation: The CTH intervention decreased stakeholder perceptions of community stigma toward people treated for OUD and stigma toward MOUD. Implementing the CTH intervention in other communities could decrease OUD stigma across diverse settings nationally. Funding: US National Institute on Drug Abuse.

Identifying and Minimizing Errors in the Measurement of Early Childhood Development: Lessons Learned from the Cognitive Testing of the ECDI2030.

Challenges in measuring early childhood development (ECD) at scale have been documented, yet little is known about the specific difficulties related to questionnaire design and question interpretation. The purpose of this paper is to discuss the challenges of measuring ECD at scale in the context of household surveys and to show how to overcome them. The paper uses examples from the cognitive interviewing exercises that were conducted as part of the methodological work to develop a measure of ECD outcomes, the ECDI2030. It describes the methodological work carried out to inform the selection and improvement of question items and survey implementation tools as a fundamental step to reduce and mitigate systematic measurement error and improve data quality. The project consisted of a total of five rounds of testing, comprising 191 one-on-one, in-depth cognitive interviews across six countries (Bulgaria, India, Jamaica, Mexico, Uganda, and the USA). Qualitative data analysis methods were used to determine matches and mismatches between intention of items and false positives or false negative answers among subgroups of respondents. Key themes emerged that could potentially lead to systematic measurement error in population-based surveys on ECD: (1) willingness of child to perform task versus ability of child to perform task; (2) performing task versus performing task correctly; (3) identifying letters or numbers versus recognizing letters or numbers; (4) consistently performing task versus correctly performing task; (5) applicability of skills being asked versus observability of skills being asked; and (6) language production versus language comprehension. Through an iterative process of testing and subsequent revision, improvements were made to item wording, response options, and interviewer training instructions. Given the difficulties inherent in population-level data collection in the context of global monitoring, this study's findings confirm the importance of cognitive testing as a crucial step in careful, culturally relevant, and sensitive questionnaire design and as a means to reduce response bias in cross-cultural contexts.