Evaluating Veterans Response Teams and Police Interventions on Veterans' Health Care Utilization.

This study examined the effects of veteran-specific cooperative police interventions, including a Veterans Response Team (VRT) and broad collaboration between local police departments and a Veterans Affairs (VA) medical center police department (local-VA police [LVP]), on veterans' health care utilization. Data were analyzed on 241 veterans (51 received VRT and 190 received LVP intervention) in Wilmington, Delaware. Nearly all veterans in the sample were enrolled in VA health care at the time of police intervention. Veterans who received VRT or LVP interventions showed similar increases in use of outpatient and inpatient mental health and substance abuse treatment services, rehabilitation services, ancillary care services, homeless programs, and emergency department/urgent care services after 6 months. These findings suggest the importance of relationship building among local police departments, VA Police, and Veterans Justice Outreach to create pathways to care to ensure that veterans are connected to needed VA health care services.

Reducing Risky Sex among Rural African American Cocaine Users: A Controlled Trial.

Rural African American cocaine users experience high rates of STIs/HIV. This NIDA-funded trial tested an adapted evidence-based risk reduction program versus an active control condition. Participants were 251 African American cocaine users in rural Arkansas recruited from 2009-2011. Outcomes included condom use skills and self-efficacy, sexual negotiation skills, peer norms, and self-reported risk behavior. The intervention group experienced greater increases in condom use skills and overall effectiveness in sexual negotiation skills. Both groups reported reductions in trading sex, improvements in condom use self-efficacy, and increased use of specific negotiation skills. Implications and limitations are discussed.

Acceptability of HIV Testing Sites Among Rural and Urban African Americans Who Use Cocaine.

African Americans (AAs) who use cocaine in the Southern region of the U.S. have a relatively high risk of HIV and need for HIV testing. Among this group, those residing in rural areas may have less favorable opinions about common HIV testing sites, which could inhibit HIV testing. We examined rural/urban variations in their acceptability of multiple HIV testing sites (private physician clinic, local health department, community health center, community HIV fair, hospital emergency department, blood plasma donation center, drug abuse treatment facility, and mobile van or community outreach worker). Results from partial proportional odds and logistic regression analyses indicate that rural AA who use cocaine have lower odds of viewing local health departments (OR = 0.09, 95 % CI = 0.03-0.21), physician offices (OR = 0.19, 95 % CI = 0.09-0.42), and drug use treatment centers (OR = 0.49; 95 % CI = 0.30-0.80) as acceptable relative to their urban counterparts. The findings have implications for further targeting HIV testing toward AAs who use of cocaine, particularly those residing in the rural South.

African Americans' Perceptions of Adherence to Medications and Lifestyle Changes Prescribed to Treat Hypertension.

More than 80 million Americans have hypertension (HTN), and African Americans (AAs) are disproportionately affected. AAs also have lower rates of adherence to HTN treatment. It is important to understand AAs' perceptions of adherence to develop effective interventions. The aim of this study is to examine AAs' perceptions of adherence to medications and lifestyle changes prescribed to treat HTN. In this qualitative study, we used purposive sampling to recruit Southern AAs with HTN aged 21 and older from a free, faith-based clinic. We recorded individual, in-person interviews about perceptions related to adherence to treatment of HTN and analyzed verbatim transcripts using content analysis and constant comparison. We also conducted medical record audits. Twenty-nine AAs participated (52% female, 38% were <50 years of age, 52% had taken anti-HTN medications for ≥5 years). Audits indicated that 65% had uncontrolled HTN during the previous year. Two main themes included causes of HTN and ways to improve blood pressure. Perceived causes of HTN included diet, stress, unhealthy actions, genes, and obesity. Ways to improve HTN included using cultural treatments "passed down," increasing exercise, reducing stress, and losing weight. Many reported using home remedies to control HTN, including drinking pickle juice. More than half of this sample had uncontrolled HTN. They identified influences of culture on perceptions of adherence including causes and treatment of HTN, and possibly detrimental home remedies. It is imperative that clinicians identify culturally appropriate interventions for this high-risk group.

Trajectory of substance use after an HIV risk reduction intervention.

BACKGROUND: Research assessments can confound the results of treatment outcome studies and can be themselves an intervention or form of aftercare. OBJECTIVE: To determine the trajectory of substance use and substance severity in a sample of African American cocaine users participating in a community-based sexual risk reduction trial. METHODS: Out-of-treatment participants were recruited using Respondent-Driven Sampling in two African American majority counties in rural Arkansas. They participated in either the sexual risk reduction condition or an active control focused on access to social services. They were interviewed at baseline, post-intervention, and 6 and 12 months post-intervention. Substance use outcome measures were use of crack cocaine, powder cocaine, marijuana, alcohol, and the Addiction Severity Index Alcohol and Drug Severity composites. A random sample of participants completed qualitative interviews post-12-month interview. RESULTS: 251 were enrolled. Substance use outcomes did not differ among the two conditions at any point in the study. Use of measured substances and the ASI composites significantly decreased between baseline and post-intervention (p < 0.01), decreases that persisted at the 12-month assessment period compared to baseline. Qualitative findings suggested that many participants identified increased awareness of their drug use and need to control it through the programs. Participants also noted strong bonding with interviewers. CONCLUSION: Clinical trials may have positive unexpected outcomes in terms of reduced substance use even though the trial is not substance use focused. Behavioral interventions for drug users that are not focused specifically on reducing drug use may nonetheless have unanticipated positive associations with reductions in drug use.

Perceptions of family history and genetic testing and feasibility of pedigree development among African Americans with hypertension.

BACKGROUND: Pedigree development, family history, and genetic testing are thought to be useful in improving outcomes of chronic illnesses such as hypertension (HTN). However, the clinical utility of pedigree development is still unknown. Further, little is known about the perceptions of African Americans (AAs) of family history and genetic testing. AIMS: This study examined the feasibility of developing pedigrees for AAs with HTN and explored perceptions of family history and genetic research among AAs with HTN. METHODS: The US Surgeon General's My Family Health Portrait was administered, and 30-60 min in-person individual interviews were conducted. Descriptive statistics were used to analyze pedigree data. Interview transcripts were analyzed with content analysis and constant comparison. RESULTS: Twenty-nine AAs with HTN were recruited from one free clinic (15 women, 14 men; mean age 49 years, standard deviation (SD) 9.6). Twenty-six (90%) reported their family history in sufficient detail to develop a pedigree. Perceptions of family history included knowledge of HTN in the family, culturally influenced family teaching about HTN, and response to family history of HTN. Most participants agreed to future genetic testing and DNA collection because they wanted to help others; some said they needed more information and others expressed a concern for privacy. CONCLUSION: The majority of AAs in this sample possessed extensive knowledge of HTN within their family and were able to develop a three-generation pedigree with assistance. The majority were willing to participate in future genetic research.

Rural/urban residence, access, and perceived need for treatment among African American cocaine users.

OBJECTIVE: To examine how rural/urban residence, perceived access, and other factors impede or facilitate perceived need for drug use treatment, a concept closely linked to treatment utilization. STUDY DESIGN: Two hundred rural and 200 urban African American cocaine users who were not receiving treatment were recruited via Respondent-Driven Sampling and completed a structured in-person interview. Bivariate and multivariate analyses were conducted to test the associations between perceived need and rural/urban residence, perceived access, and other predisposing (eg, demographics), enabling (eg, insurance), and health factors (eg, psychiatric distress). PRINCIPAL FINDINGS: In bivariate analyses, rural relative to urban cocaine users reported lower perceived treatment need (37% vs 48%), availability, affordability, overall ease of access, and effectiveness, as well as lower perceived acceptability of residential, outpatient, self-help, and hospital-based services. In multivariate analyses, there was a significant interaction between rural/urban residence and the acceptability of religious counseling. At the highest level of acceptability, rural users had lower odds of perceived need (OR = 0.21); at the lowest level, rural users had higher odds of perceived need (OR = 3.97) than urban users. Among rural users, the acceptability of religious counseling was negatively associated with perceived need (OR = 0.65). Ease of access was negatively associated (OR = 0.71) whereas local treatment effectiveness (OR = 1.47) and the acceptability of hospital-based treatment (OR = 1.29) were positively associated with perceived need among all users. CONCLUSIONS: Our findings suggest rural/urban disparities in perceived need and access to drug use treatment. Among rural and urban cocaine users, improving perceptions of treatment effectiveness and expanding hospital-based services could promote treatment seeking.

The Religious and Spiritual Dimensions of Cutting Down and Stopping Cocaine Use: A Qualitative Exploration Among African Americans in the South.

This study qualitatively examines the religious and spiritual dimensions of cutting down and stopping cocaine use among African Americans in rural and urban areas of Arkansas. The analyses compare and contrast the narrative data of 28 current cocaine users living in communities where the Black church plays a fundamental role in the social and cultural lives of many African Americans, highlighting the ways that participants used religious symbols, idiomatic expression, and Biblical scriptures to interpret and make sense of their substance-use experiences. Participants drew on diverse religious and spiritual beliefs and practices, including participation in organized religion, reliance on a personal relationship with God, and God's will to cut down and stop cocaine use. Our findings suggest that culturally sensitive interventions addressing the influence of religion and spirituality in substance use are needed to reduce cocaine use and promote recovery in this at-risk, minority population.

Correlates of HIV testing among rural African American cocaine users.

Andersen's Revised Behavioral Model of Health Services Use (RBM) was used as a framework in this correlational cross-sectional study to examine factors associated with HIV testing among a sample of 251 rural African American cocaine users. All participants reported using cocaine and being sexually active within the past 30 days. Independent variables were categorized according to the RBM as predisposing, enabling, need, or health behavior factors. Number of times tested for HIV (never, one time, two to four times, five or more times) was the outcome of interest. In ordered logistic regression analyses, HIV testing was strongly associated with being female, of younger age (predisposing factors); having been tested for sexually transmitted diseases or hepatitis, ever having been incarcerated in jail or prison (enabling factors); and having had one sex partner the past 30 days (health behavior factor). Other sexual risk behaviors, drug use, health status, and perception of risk were not associated with HIV testing. Our findings confirm the importance of routine testing in all healthcare settings rather than risk-based testing.

Beliefs and attitudes regarding drug treatment: application of the theory of planned behavior in African-American cocaine users.

BACKGROUND: The Theory of Planned Behavior (TPB) can provide insights into perceived need for cocaine treatment among African American cocaine users. METHODS: A cross-sectional community sample of 400 (50% rural) not-in-treatment African-American cocaine users was identified through respondent-driven sampling in one urban and two rural counties in Arkansas. Measures included self-reports of attitudes and beliefs about cocaine treatment, perceived need and perceived effectiveness of treatment, and positive and negative cocaine expectancies. Normative beliefs were measured by perceived stigma and consequences of stigma regarding drug use and drug treatment. Perceived control was measured by readiness for treatment, prior drug treatment, and perceived ability to cut down on cocaine use without treatment. FINDINGS: Multiple regression analysis found that older age (standardized regression coefficient ß=0.15, P<0.001), rural residence (ß=-0.09, P=0.025), effectiveness of treatment (ß=0.39, P<0.001), negative cocaine expectancies (ß=0.138, P=0.003), experiences of rejection (ß=0.18, P<0.001), need for secrecy (ß=0.12, P=0.002), and readiness for treatment (ß=0.15, P<0.001) were independently associated with perceived need for cocaine treatment. CONCLUSIONS: TPB is a relevant model for understanding perceived need for treatment among African-American cocaine users. Research has shown perceived need to be a major correlate of treatment participation. Study results should be applicable for designing interventions to encourage treatment participation.

Religiosity and sexual risk behaviors among African American cocaine users in the rural South.

PURPOSE: Racial and geographic disparities in human immunodeficency virus (HIV) are dramatic and drug use is a significant contributor to HIV risk. Within the rural South, African Americans who use drugs are at extremely high risk. Due to the importance of religion within African American and rural Southern communities, it can be a key element of culturally-targeted health promotion with these populations. Studies have examined religion's relationship with sexual risk in adolescent populations, but few have examined specific religious behaviors and sexual risk behaviors among drug-using African American adults. This study examined the relationship between well-defined dimensions of religion and specific sexual behaviors among African Americans who use cocaine living in the rural southern United States. METHODS: Baseline data from a sexual risk reduction intervention for African Americans who use cocaine living in rural Arkansas (N = 205) were used to conduct bivariate and multivariate analyses examining the association between multiple sexual risk behaviors and key dimensions of religion including religious preference, private and public religious participation, religious coping, and God-based, congregation-based, and church leader-based religious support. FINDINGS: After adjusting individualized network estimator weights based on the recruitment strategy, different dimensions of religion had inverse relationships with sexual risk behavior, including church leadership support with number of unprotected vaginal/anal sexual encounter and positive religious coping with number of sexual partners and with total number of vaginal/anal sexual encounters. CONCLUSION: Results suggest that specific dimensions of religion may have protective effects on certain types of sexual behavior, which may have important research implications.

Dimensions of religion, depression symptomatology, and substance use among rural African American cocaine users.

Research has shown a relationship between depression, substance use, and religiosity but, few have investigated this relationship in a community sample of African Americans who use drugs. This study examined the relationship between dimensions of religion (positive and negative religious coping; private and public religious participation; religious preference; and God-, clergy-, and congregation-based religious support), depression symptomatology, and substance use among 223 African American cocaine users. After controlling for gender, employment, and age, greater congregation-based support and greater clergy-based support were associated with fewer reported depressive symptoms. In addition, greater congregation-based support was associated with less alcohol use.

Development of a Patient-Centered Antipsychotic Medication Adherence Intervention.

OBJECTIVE: A substantial gap exists between patients and their mental health providers about patient's perceived barriers, facilitators, and motivators (BFMs) for taking antipsychotic medications. This article describes how we used an intervention mapping (IM) framework coupled with qualitative and quantitative item-selection methods to develop an intervention to bridge this gap with the goal of improving antipsychotic medication adherence. METHODS: IM is a stepwise method for developing and implementing health interventions. A previous study conducted in-depth qualitative interviews with patients diagnosed with schizophrenia and identified 477 BFMs associated with antipsychotic medication adherence. This article reports the results of using a variety of qualitative and quantitative item reduction and intervention development methods to transform the qualitative BFM data into a viable checklist and intervention. RESULTS: The final BFM checklist included 76 items (28 barriers, 30 facilitators, and 18 motivators). An electronic and hard copy of the adherence progress note included a summary of current adherence, top three patient-identified barriers and top three facilitators and motivators, clarifying questions, and actionable adherence tips to address barriers during a typical clinical encounter. DISCUSSION: The IM approach supplemented with qualitative and quantitative methods provided a useful framework for developing a practical and potentially sustainable antipsychotic medication adherence intervention. A similar approach to intervention development may be useful in other clinical situations where a substantial gap exists between patients and providers regarding medication adherence or other health behaviors.

Sexual sensation seeking, transactional sex, and rural African American cocaine users.

The purpose of this study was to explore correlates of sexual sensation seeking (SSS) in a sample of rural African American cocaine users. Respondent-driven sampling was used to recruit 251 participants from two impoverished rural counties in eastern Arkansas. Consistent with previous investigations, SSS scores were associated with being younger, being male, having more sexual partners, and having more unprotected sexual encounters in the previous 30 days. Multiple regression revealed that SSS was correlated with a number of oral sex acts, transactional sex (exchanging sex for food, shelter, drugs, money, or other commodities), and Addiction Severity Index drug composite. SSS continues to demonstrate a strong association with sexual risk behaviors in diverse populations, including vulnerable groups like this community. Interventions to reduce unsafe sexual behaviors among high-risk groups, including drug users and individuals who engage in transactional sex, should incorporate approaches that include high sensation seekers' needs for novelty and variety.

A qualitative analysis of provider barriers and solutions to HIV testing for substance users in a small, largely rural southern state.

PURPOSE: Integrating HIV testing programs into substance use treatment is a promising avenue to help increase access to HIV testing for rural drug users. Yet few outpatient substance abuse treatment facilities in the United States provide HIV testing. The purpose of this study was to identify barriers to incorporating HIV testing with substance use treatment from the perspectives of treatment and testing providers in Arkansas. METHODS: We used purposive sampling from state directories to recruit providers at state, organization, and individual levels to participate in this exploratory study. Using an interview guide, the first and second authors conducted semistructured individual interviews in each provider's office or by telephone. All interviews were recorded, transcribed verbatim, and entered into ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). We used constant comparison and content analysis techniques to identify codes, categories, and primary patterns in the data. FINDINGS: The sample consisted of 28 providers throughout the state, 18 from the substance use system and 10 from the public/ community health system. We identified 7 categories of barriers: environmental constraints, policy constraints, funding constraints, organizational structure, limited inter- and intra-agency communication, burden of responsibility, and client fragility. CONCLUSIONS: This study presents the practice-based realities of barriers to integrating HIV testing with substance use treatment in a small, largely rural state. Some system and/or organization leaders were either unaware of or not actively pursuing external funds available to them specifically for engaging substance users in HIV testing. However, funding does not address the system-level need for coordination of resources and services at the state level.

Risky sex in rural America: longitudinal changes in a community-based cohort of methamphetamine and cocaine users.

BACKGROUND AND OBJECTIVES: This study examined the longitudinal associations between stimulant use and sexual behaviors. METHODS: Data are from a 3-year community-based study of 710 rural stimulant users. Past 30-day crack cocaine, powder cocaine, and methamphetamine use and sexual behaviors (any sex, inconsistent condom use, and multiple sexual partners) were assessed through in-person interviews every 6 months. RESULTS: GEE analyses revealed that the odds of having sex remained steady over time, with crack cocaine and methamphetamine use positively associated with having sex. The odds of multiple sexual partners declined, but the odds of inconsistent condom use remained steady over time. Crack cocaine use was positively associated with multiple sexual partners, whereas powder cocaine use was negatively associated with inconsistent condom use. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Many rural stimulant users could potentially benefit from safe sex educational programs. Such efforts could reduce the incidence of HIV and other STIs in rural America.

A Qualitative Study of Barriers to the Utilization of HIV Testing Services Among Rural African American Cocaine Users.

This qualitative study is about barriers to the utilization of HIV testing as perceived by African Americans who have recently used cocaine and who live in the rural Delta region of Arkansas. Affordability, physical accessibility, and geographic availability were not perceived as barriers to HIV testing in this sample, yet acceptability was still perceived as poor. Acceptability due to social mores and norms was a major barrier. Many said testing was unacceptable because of fear of social costs. Many were confident of being HIV-negative based on risky assumptions about testing and the notification process. Small-town social and sexual networks added to concerns about reputation and risk. System approaches may fail if they focus solely on improving access to HIV services but do not take into consideration deeply internalized experiences of rural African Americans as well as involvement of the community in developing programs and services.

Utility of an interactive voice response system to assess antiretroviral pharmacotherapy adherence among substance users living with HIV/AIDS in the rural South.

Promoting HIV medication adherence is basic to HIV/AIDS clinical care and reducing transmission risk and requires sound assessment of adherence and risk behaviors such as substance use that may interfere with adherence. The present study evaluated the utility of a telephone-based Interactive Voice Response self-monitoring (IVR SM) system to assess prospectively daily HIV medication adherence and its correlates among rural substance users living with HIV/AIDS. Community-dwelling patients (27 men, 17 women) recruited from a non-profit HIV medical clinic in rural Alabama reported daily medication adherence, substance use, and sexual practices for up to 10 weeks. Daily IVR reports of adherence were compared with short-term IVR-based recall reports over 4- and 7-day intervals. Daily IVR reports were positively correlated with both recall measures over matched intervals. However, 7-day recall yielded higher adherence claims compared to the more contemporaneous daily IVR and 4-day recall measures suggestive of a social desirability bias over the longer reporting period. Nearly one-third of participants (32%) reported adherence rates below the optimal rate of 95% (range=0-100%). Higher IVR-reported daily medication adherence was associated with lower baseline substance use, shorter duration of HIV/AIDS medical care, and higher IVR utilization. IVR SM appears to be a useful telehealth tool for monitoring medication adherence and identifying patients with suboptimal adherence between clinic visits and can help address geographic barriers to care among disadvantaged, rural adults living with HIV/AIDS.

Cue competition effects in the planarian.

The learning abilities of planarian worms (Dugesia tigrina) were assessed by using a number of Pavlovian conditioning paradigms. Experiment 1 showed that planaria were susceptible to basic conditioning in that they readily developed a conditioned response to a change in ambient luminance when it was consistently paired with an electric shock over a number of trials. In Experiment 2, the change in luminance was presented in a compound with a vibration stimulus during conditioning. Subsequent tests revealed poor conditioning of the elements compared with control groups in which the animals were conditioned in the presence of the elements alone, an instance of overshadowing. In Experiment 3, pre-training of one of the elements before compound conditioning resulted in blocking of learning about the other element. These results add to other studies that have reported cue competition effects in animal species belonging to different phyla (chordate, mollusk, arthropod), suggesting that learning in these phyla could be ruled by similar principles. The results are discussed adopting an evolutionary-comparative approach.