The Effectiveness of the StaySafe Intervention Using a Paradigm for Predicting Missing Outcome Data.

Sample attrition is a confounding issue in the analysis of data collected in follow-up studies. The present study uses a regression procedure that includes a propensity score as a predictor in estimating imputed data. The utility of the procedure was addressed by comparing results from this augmented data with those from the original data. Data were from a randomized controlled study testing the utility of a tablet-based intervention designed to improve decision-making with respect to health risk behaviors. Outcomes included self-reported testing for HIV, STD, and hepatitis. Two samples were used (163 in community facilities and 348 in residential facilities). Seventy-eight in the community sample and 238 in the residential sample completed follow-up surveys. Propensity scores based on a stepwise logistic regression were used to make the calibration sample and the missing data sample as close as possible. Multilevel analysis was performed for each outcome and multiple imputation compared estimated mean differences for the augmented and original analyses. The model imputing missing data was effective for the three outcomes and increased power. Least square mean differences between augmented and original data appeared to be essentially the same for most of the outcomes. This protocol has been registered with https://www.clinicaltrials.gov/(NCT02777086).

Decision-Making Styles as a Moderator on the Efficacy of the StaySafe Tablet Intervention.

Background: People with substance use disorders often differ in their decision-making styles. The present study addressed the impact of two decision-making styles (rational and dependent) on outcomes from a StaySafe tablet computer app intervention designed to improve decision-making around health risk behaviors and previously found to be effective for justice-involved people receiving treatment for a substance use disorder and under community supervision. Objectives: Participants were justice-involved residents in residential treatment. After completing a baseline survey, participants were randomly assigned to either complete the StaySafe app or to a standard procedure condition; and then asked to complete a post-intervention survey three months after baseline (this protocol has been registered with clinicaltrials.gov NCT02777086): 348 participants completed a baseline survey and 238 completed the post-test survey. Outcomes included measures of confidence and motivation around HIV knowledge and risks and getting tested. Multilevel analyses addressed the hypothesis that outcomes were related to decision-making style. Multiple imputation (MI) was used to address the effects of missing data. Results: StaySafe was more effective for those in the lower half of the decision-making dependent scale for HIV risks (HIV-Knowledge, Hepatitis testing, HIV Services testing, and Sex Risk, as well as motivation for treatment. The decision-making rational scale was less consistently related to HIV risk. Conclusions: The present study showed individuals with substance use disorders who differed in their decision-making styles reacted differently to the StaySafe intervention. Two scales, rational decision making, and dependent decision making are relevant to consider with respect to interventions targeting improving decision making among drug users.

A psychometric reevaluation of the TCU criminal thinking scales (CTS).

In the United States, approximately 9 million people cycle in and out of jail and more than 600,000 people are released from prison each year. Unfortunately, the reentry process includes several barriers people must overcome (e.g., criminal thinking) to achieve adequate psychosocial functioning. As such, valid and reliable assessments that allow correctional staff to monitor clients' progress in treatment and test program effectiveness are paramount to reducing this major public safety concern. The TCU Criminal Thinking Scales (CTS) are a widely used assessment of criminal thinking in correctional settings. This study reevaluated the psychometric properties of the TCU CTS using Item Response Theory. Results showed the TCU CTS had good internal reliability and each scale loaded onto one factor. Item level analysis revealed most items adequately fit the model, generally measuring moderate levels of criminal thinking. Furthermore, several TCU CTS scales were negatively correlated with motivation for treatment and psychosocial functioning.

An evaluation of StaySafe, a tablet app to improve health risk decision-making among people under community supervision.

BACKGROUND: A self-administered tablet app, StaySafe, helps people under community supervision to make better decisions regarding health risk behaviors, especially those linked to HIV, viral hepatitis, and other sexually transmitted infections. The multi-session StaySafe design uses an interactive, analytical schema called WORKIT that guides users through a series of steps, questions, and exercises aimed at promoting critical thinking about health risks associated with substance use and unprotected sex. Repetition of the WORKIT schema is designed to enhance procedural memory that can be rapidly accessed when individuals are faced with making decisions about risky behaviors. METHODS: A total of 511 participants under community supervision in community and residential treatment settings from three large Texas counties completed consent forms and baseline surveys, followed by randomization to one of two conditions: 12 weekly StaySafe sessions or standard practice (SP). The study also asked participants to complete a follow-up survey three months after baseline. Outcome measures included knowledge, confidence, and motivation (KCM) scales around HIV knowledge, avoiding risky sex, HIV services, and reducing health risks; decision-making; and reports of talking about issues such as making better decisions, avoiding HIV risks, and HIV prevention or treatment with others (probation officers, counselors, trusted friend or advisor, or family members). RESULTS: Participants in both community and residential settings voluntarily completed multiple StaySafe sessions, with those in the residential settings completing more sessions. When compared with SP participants, StaySafe participants showed greater improvement in the KCM measures-HIV knowledge, avoiding sex risks, HIV services, and risk reduction skills. In addition, greater improvements in the KCM measures as well as an increased likelihood to discuss issues with others were associated with completing more StaySafe sessions. CONCLUSION: These results suggest that the StaySafe app is a feasible and potentially effective tool for improving health risk reduction decision-making for individuals under community supervision.

Critical Factors Influencing Interorganizational Relationships Between Juvenile Probation and Behavioral Health Agencies.

Although interorganizational relationships (IORs) are essential to the effective delivery of human services, very little research has examined relationships between juvenile justice agencies and behavioral health providers, and few studies have identified the most critical organizational and individual-level characteristics influencing IORs. Across 36 sites, juvenile probation officials (n = 458) and community behavioral health providers (n = 91) were surveyed about characteristics of their agencies, themselves, and IORs with each other. Generalized Linear Mixed Models were used to analyze the data. The strongest predictors included Perceived Organizational Support and individual Adaptability. Implications for research, theory and practice are discussed.

The role of physical and psychological health problems in the drug use treatment process.

The role of physical and psychological health is examined as a predictor of client engagement in prison-based drug treatment. A treatment process model was expanded to include physical and mental health issues. The sample included 6009 offenders in prison-based drug treatment, comprised of 67% male, 26% African American, 51% white, and 22% Hispanic; average age was 34.6. Half reported "some physical health concerns" and mentioned a variety of ailments. A fifth reported moderate stress on the Kessler Psychological Distress Scale (K10) and 15% reported PTSD based on the PTSD Check List (PCL). Structural equation modeling was used to model treatment engagement in terms of demographics, physical health concerns, psychological distress, HIV risky behaviors, self-esteem, decision making, and treatment motivation. Two random samples were created, with one used for estimation and the other for cross-validation. The findings suggested physical health and HIV risky behaviors have effects on client engagement through psychological functioning, and that psychological functioning has direct effects on treatment engagement.

Evaluating the Impact of a Targeted Brief HIV Intervention on Multiple Inter-Related HIV Risk Factors of Knowledge and Attitudes among Incarcerated Drug Users.

Increases in HIV prevalence indicate ongoing need for HIV interventions. A brief manualized intervention called TCU WaySafe, which addresses multiple HIV risks, was further evaluated to determine how it addressed individual's knowledge deficiencies in the assessed risks. The sample of 1256 offenders in 8 correctional substance abuse treatment programs participated either in treatment as usual (TAU) or TCU WaySafe. From multivariate multi-level analysis, WaySafe was more effective in improving the greatest need area, whether knowledge, motivation, or confidence regarding HIV risky behaviors. Findings underscored the importance of addressing HIV risk areas with greatest need for change and strengthens previous findings of the intervention's potential for individuals with varying HIV risks.

StaySafe: A self-administered android tablet application for helping individuals on probation make better decisions pertaining to health risk behaviors.

This paper describes the development and protocol for feasibility and efficacy testing of a risk reduction intervention designed to improve behavioral health outcomes among drug offenders on probation under community supervision or in residential substance abuse treatment centers. StaySafe is a self-administered tablet-based intervention for teaching better decision-making skills regarding health risk behaviors, especially those involving HIV risks. We are using pre/post, experimental/control group randomized clinical trial (RCT) in both community and residential probation settings with goals to 1) assess the feasibility and acceptance of StaySafe by examining participation rates and satisfaction measures, and 2) examine the impact of StaySafe on decision-making skills, confidence and motivation to avoid sex and drug risks, willingness to discuss health risks and concerns with helpful others, and engagement in health risk behaviors. StaySafe consists of 12 brief sessions and utilizes an evidence-based decision-making schema, called WORKIT, which guides participants through steps for identifying the problem and options, evaluating the options and making a decision about which option to carry out. Multiple sessions of StaySafe provide a practice effect so that the WORKIT steps become easily accessible to participants when making decisions. Three of the sessions provide participants a choice of activities designed to provide additional information about HIV and reinforce lessons learned during the WORKIT sessions. Preliminary data demonstrate feasibility and high levels of satisfaction with StaySafe.

A Brief Assessment for HIV Risk: The TCU HVHP Form.

Targeted HIV screens may help identify some risk-related concerns of drug-using offenders. The present study describes the Texas Christian University HIV/Hepatitis Risk Assessment (TCU HVHP) form, a 19-item self-report instrument measuring HIV and hepatitis risks based on a sample (N = 1,056) of offenders in eight prisons. Principal components analysis indicated four scales (Injection Risk, Condom Attitudes, Sex Risk, and AIDS Concern) with reliable psychometric properties with coefficient α reliabilities ranging from .72 to .88. Concurrent validities indicated the four scales were related to motivation for treatment, level of drug use, psychosocial functioning, and criminal thinking, although the patterns varied by gender. The TCU HVHP Form should be attractive to programs needing a brief assessment measuring HIV risk behaviors, attitudes toward condom use, and concerns about acquiring and transmitting HIV.

Evaluation of WaySafe: A Disease-Risk Reduction Curriculum for Substance-Abusing Offenders.

With a focus on reducing disease risk behavior in the community, a six-session curriculum, WaySafe, was developed to increase positive decision-making skills among soon-to-be-released inmates participating in a therapeutic community substance abuse treatment program. The intervention used TCU Mapping-Enhanced Counseling as an approach to focus on cognitive aspects of risky sexual and drug use behaviors in an effort to improve problem recognition, commitment to change, and strategies for avoiding behavioral risks of infections. A total of 1393 inmates from eight different institutions in two states were randomly assigned to receive WaySafe or treatment as usual (TAU). Baseline and follow-up surveys measured knowledge, confidence, and motivation regarding general HIV information, risky sex and drug use, HIV testing, and risk reduction skills. WaySafe participants had significantly better scores on all measures at follow-up than did TAU participants, supporting the efficacy of WaySafe in improving knowledge, motivation, and confidence in avoiding risky behaviors.

Effects of a strategy to improve offender assessment practices: Staff perceptions of implementation outcomes.

BACKGROUND: This implementation study examined the impact of an organizational process improvement intervention (OPII) on a continuum of evidence based practices related to assessment and community reentry of drug-involved offenders: Measurement/Instrumentation, Case Plan Integration, Conveyance/Utility, and Service Activation/Delivery. METHODS: To assess implementation outcomes (staff perceptions of evidence-based assessment practices), a survey was administered to correctional and treatment staff (n=1509) at 21 sites randomly assigned to an Early- or Delayed-Start condition. Hierarchical linear models with repeated measures were used to examine changes in evidence-based assessment practices over time, and organizational characteristics were examined as covariates to control for differences across the 21 research sites. RESULTS: Results demonstrated significant intervention and sustainability effects for three of the four assessment domains examined, although stronger effects were obtained for intra- than inter-agency outcomes. No significant effects were found for Conveyance/Utility. CONCLUSIONS: Implementation interventions such as the OPII represent an important tool to enhance the use of evidence-based assessment practices in large and diverse correctional systems. Intra-agency assessment activities that were more directly under the control of correctional agencies were implemented most effectively. Activities in domains that required cross-systems collaboration were not as successfully implemented, although longer follow-up periods might afford detection of stronger effects.

Gender as a moderator in predicting re-arrest among treated drug-involved offenders.

The primary aim of the current study is to explore gender differences on the relationships of pre-treatment risk factors and psychosocial functioning with time to re-arrest following termination from prison. The sample consisted of 384 males and 313 females who were admitted to four prison-based substance abuse treatment programs. Results showed that female inmates experienced a longer time to re-arrest than male inmates. Higher self-reported ratings of decision making confidence and peer support were associated with a lower likelihood of re-arrest for males. Males with higher self-esteem ratings were more likely to be re-arrested than males who reported lower self-esteem. Females with more self-reported criminal involvement had a higher rate of re-arrest than did those with less criminal involvement. In contrast to males, females with relatively high self-reported self-esteem had a lower rate of re-arrest than their counterparts who reported low self-esteem. Clinical implications include the importance of enhancing decision-making confidence and peer support for males and self-esteem for females.

The Influence of Client Risks and Treatment Engagement on Recidivism.

The current study modeled 12 month post-release re-arrest (recidivism) in terms of pretreatment risk factors (i.e., criminal history, criminal thinking,) and during-treatment engagement in a sample of 653 subjects admitted to four prison-based substance treatment programs. Structural Equation Modeling was used to test during-treatment engagement as a mediator variable in explaining the relationship between the pretreatment risk factors and recidivism. Results indicated that (1) a long history of criminal conduct correlated with criminal thinking, which in turn had a significantly negative relationship with engagement in treatment; (2) the level of criminal involvement had a significant relationship with re-arrest, whereas the level of criminal thinking did not influence being re-arrested directly; (3) the relationship between criminal history and re-arrest was partially mediated by criminal thinking and treatment engagement, whereas the relationship between criminal thinking and re-arrest was fully mediated by treatment engagement. The findings suggest that it is important to design interventions targeting criminal thinking and monitor treatment engagement as an indicator of treatment performance. Clinical implications also include the importance of facilitating treatment engagement and the utility of conducting prognostic assessment to inform treatment.

Organizational Readiness for Change in Correctional and Community Substance Abuse Programs.

Significant needs exist for increased and better substance abuse treatment services in our nation's prisons. The TCU Organizational Readiness for Change (ORC) survey has been widely used in community-based treatment programs and evidence is accumulating for relationships between readiness for change and implementation of new clinical practices. Results of organizational surveys of correctional counselors from 12 programs in two states are compared with samples of community-based counselors. Correctional counselors perceived strong needs for new evidence-based practices but, compared to community counselors, reported fewer resources and less favorable organizational climates. These results have important implications for successfully implementing new practices.

Resources and training in outpatient substance abuse treatment facilities.

The exposure to new clinical interventions through formalized training and the utilization of strategies learned through training are two critical components of the program change process. This study considers the combined influence of actual program fiscal resources and counselors' perceptions of workplace resources on two mechanisms of training: exposure and utilization. Data were collected from 323 counselors nested within 59 programs located in nine states. Multilevel analysis revealed that training exposure and training utilization represent two distinct constructs that are important at different stages in the Program Change Model. Training exposure is associated primarily with physical and financial resources, whereas utilization is associated with professional community and job burnout. These results suggest that financial resources are important in initial exposure to new interventions but that successful utilization of new techniques depends in part on the degree of burnout and collaboration experienced by counselors.

Integration of treatment innovation planning and implementation: strategic process models and organizational challenges.

Sustained and effective use of evidence-based practices in substance abuse treatment services faces both clinical and contextual challenges. Implementation approaches are reviewed that rely on variations of plan-do-study-act (PDSA) cycles, but most emphasize conceptual identification of core components for system change strategies. A two-phase procedural approach is therefore presented based on the integration of Texas Christian University (TCU) models and related resources for improving treatment process and program change. Phase 1 focuses on the dynamics of clinical services, including stages of client recovery (cross-linked with targeted assessments and interventions), as the foundations for identifying and planning appropriate innovations to improve efficiency and effectiveness. Phase 2 shifts to the operational and organizational dynamics involved in implementing and sustaining innovations (including the stages of training, adoption, implementation, and practice). A comprehensive system of TCU assessments and interventions for client and program-level needs and functioning are summarized as well, with descriptions and guidelines for applications in practical settings.

Individual and network interventions with injection drug users in 5 Ukraine cities.

OBJECTIVES: We evaluated the effects of an individual intervention versus a network intervention on HIV-related injection and sexual risk behaviors among street-recruited opiate injection drug users in 5 Ukraine cities. METHODS: Between 2004 and 2006, 722 opiate injection drug users were recruited to participate in interventions that were either individually based or based on a social network model in which peer educators intervened with their network members. Audio computer-assisted self-interview techniques were used to interview participants at baseline and follow-up. RESULTS: Multiple logistic analyses controlling for baseline injection and sexual risks revealed that both peer educators and network members in the network intervention reduced injection-related risk behaviors significantly more than did those in the individually based intervention and that peer educators increased condom use significantly more than did those in the individual intervention. Individual intervention participants, however, showed significantly greater improvements than did network members with respect to reductions in sexual risk behaviors. CONCLUSIONS: Social network interventions may be more effective than individually based interventions in changing injection risk behaviors among both peer educators and network members. The effectiveness of network interventions in changing sexual risk behaviors is less clear, probably owing to network composition and inhibitions regarding discussing sexual risk behaviors.

Interventions with injection drug users in Ukraine.

AIMS: To assess the effectiveness of a brief human immunodeficiency virus (HIV) testing and counseling intervention compared to a more time-consuming and expensive street-based intervention with injection drug users (IDUs). DESIGN: Cross-over experimental design in which 900 IDUs were recruited, followed by a 'wash-out' period with no recruitment, a reversal of intervention assignment areas and an additional recruitment of 900 IDUs with baseline and 6-month follow-up assessments. SETTING: Kiev, Odessa and Makeevka/Donesk Ukraine. PARTICIPANTS: A total of 1798 IDUs. MEASUREMENTS: HIV testing and audio computer-assisted self-interview (ACASI) data on socio-demographics, drug use and injection and sex-related risk behaviors. FINDINGS: Participants in both conditions reduced their injection and sex risks significantly; however, there was little difference in outcomes between conditions. IDUs who knew they were HIV-infected at baseline were significantly more likely to practice safe sex than those unaware or HIV-negative; those who first learned that they were infected at baseline changed their safe sex practices significantly more than those who already knew that they were infected at baseline and those who were HIV-negative. Younger IDUs and those injecting for a shorter period of time reported higher injection and sex risk behaviors following interventions. CONCLUSIONS: Awareness of HIV infection by street-recruited drug injectors is associated with reduced sex risks. Additional interventions are required for younger IDUs and those injecting for shorter periods of time.

Organizational factors and collaboration and integration activities in criminal justice and drug abuse treatment agencies.

Despite strong interest in improving collaborations between correctional and substance abuse treatment organizations, there is a lack of empirical data describing the existing practices. The current study used a national survey of correctional administrators to examine organizational factors related to cross-agency collaboration and integration activities between corrections and substance abuse treatment organizations. Using a measure of collaboration that scaled cross-agency activities from less structured, informal networking and coordination to more structured and formalized levels of cooperation and collaboration, we found that different correctional settings (e.g., community corrections, jails, prisons) differed significantly in terms of their collaborative activities with substance abuse treatment agencies. We also found that the organizational characteristics that were associated with different levels of collaboration and integration differed across the correctional settings. Further research is needed to better understand how and why correctional agencies decide to formalize collaborative arrangements with treatment agencies and whether these efforts lead to more favorable outcomes.

Psychosocial correlates of the perceived stigma of problem drinking in the workplace.

The purpose of this study was to evaluate a questionnaire assessment of the perceived stigma of problem drinking that was designed for use in workplace substance abuse prevention research. Municipal employees from a mid-sized city (n = 315) and a large-sized city (n = 535) completed questionnaire measures of perceived coworker stigmatization of problem drinking, drinking levels, substance-use policy attitudes, workgroup stress and interdependence, alcohol-tolerance norms, and demographic variables. Inter-item correlation coefficients showed that the measure of the stigma of problem drinking had good internal consistency reliability (.76) in both samples. Hierarchical regression analyses showed that higher education, abstinence from alcohol, stress, and perceived temperance norms were all uniquely correlated with perceived stigma. Women and men perceived the same level of stigma from coworkers. Editors' Strategic Implications: This brief, validated measure provides organizations with a way to assess the level of stigma attached to alcohol abuse in their workplace culture, thereby enabling the organization to target and promote effective strategies to decrease the stigma attached to seeking help with the goal of reducing alcohol abuse.