Developing a sustainability readiness strategy for health systems: Toolkit, interactive tools, and virtual support system.

While the literature strongly supports the need for sustainability of evidence-based interventions (EBIs), we present a review of the literature that indicates only three articles discuss a health-focused sustainability strategy. The aims of our sustainability readiness strategy (SRS) are to increase infrastructure capacity and EBI advocacy to impact the level of sustainability readiness. In this article, we describe the development of an evidence-informed promising practice sustainability readiness strategy (SRS) with three evidence-based components. This strategy: 1) is based on an adaptation of the Getting To Outcomes® (GTO) evidence-based implementation process, 2) includes a logic model with documented evidence of the connection between targeted readiness factors and sustainability outcomes, and 3) describes resources considered necessary to support implementation of the readiness strategy, namely a step-by-step Toolkit, Excel™ Tools, webinar coaching and evaluation guides, and a coaching and evaluation training guide. The national SRS survey results are presented. Lessons learned and future dissemination and implementation plans are described.

Long-Term Sustainability of Evidence-Based Prevention Interventions and Community Coalitions Survival: a Five and One-Half Year Follow-up Study.

This study examines (1) coalition survival, (2) prevalence of evidence-based prevention interventions (EBPIs) to reduce substance abuse implemented as part of the Tennessee Strategic Prevention Framework (SPF) State Incentive Grant (SIG), (3) EBPI sustainability, and (4) factors that predict EBPI sustainability. Secondary data were collected on 27 SPF SIG-funded coalitions and 88 EBPI and non-EBPI implementations. Primary data were collected by a telephone interview/web survey five and one-half years after the SPF SIG ended. Results from secondary data show that 25 of the 27 coalitions survived beyond the SPF SIG for one to five and one-half years; 19 coalitions (70%) were still active five and one-half years later. Further, 88 EBPIs and non-EBPIs were implemented by 27 county SPF SIG coalitions. Twenty-one (21) of 27 coalitions (78%) implemented one to three EBPIs, totaling 37 EBPI implementations. Based on primary survey data on 29 of the 37 EBPI implementations, 28 EBPIs (97%) were sustained between two and five and one-half years while 22 EBPI implementations (76%) were sustained for five and one-half years. When controlling for variability among coalitions (nesting of EBPIs in coalitions), increases in data resources (availability of five types of prevention data) was a strong predictor of length of EBPI sustainability. Positive change in extramural funding resources and level of expertise during SPF SIG implementation, as well as level of coalition formalization at the end of the SPF SIG predicted EBPI sustainability length. One intervention attribute (trialability) also predicted length of sustainability. Implications are discussed.

Gender differences in Afghan drug-abuse treatment: an assessment of treatment entry characteristics, dropout, and outcomes.

OBJECTIVE: The current study examines gender differences in drug-abuse treatment (DAT) entry, dropout, and outcomes in seven DAT centers in Afghanistan. This is the first study to examine gender differences in DAT programming in Afghanistan. DESIGN: A prospective cohort design of 504 women and men in seven DAT centers in Afghanistan was used in this study and the analyses examined whether gender differences exist for patients (1) at treatment entry, (2) at treatment dropout, and (3) for treatment outcomes. RESULTS: Gender differences were found at baseline for patient characteristics, drug use, crime, and social and occupational functioning. Results showed a trend that women remained in treatment longer than men. Looking at gender differences in treatment success, results showed greater reductions in drug use and crime, and greater social functioning among women. CONCLUSION: Results provide preliminary evidence for potential treatment success of women-tailored DAT programming in Afghanistan. Results also indicate that DAT appears to be successful among Afghan men; however, lower positive outcomes for men when compared to women suggest that more efforts should focus on tailoring DAT programming to the specific needs of Afghan men as well. Study limitations are addressed, and important policy implications are discussed.

Stakeholder perspectives on barriers for healthy living for low-income african american families.

BACKGROUND: Childhood obesity is a growing problem for children in the United States, especially for children from low-income, African American families. OBJECTIVE: The purpose of this qualitative study was to understand facilitators and barriers to engaging in healthy lifestyles faced by low-income African American children and their families. METHODS: This qualitative study used semi-structured focus group interviews with eight African American children clinically identified as overweight or obese (BMI ≥ 85) and their parents. An expert panel provided insights in developing culturally appropriate intervention strategies. RESULTS: Child and parent focus group analysis revealed 11 barriers and no definitive facilitators for healthy eating and lifestyles. Parents reported confusion regarding what constitutes nutritional eating, varying needs of family members in terms of issues with weight, and difficulty in engaging the family in appropriate and safe physical activities; to name a few themes. Community experts independently suggested that nutritional information is confusing and, often, contradictory. Additionally, they recommended simple messaging and practical interventions such as helping with shopping lists, meal planning, and identifying simple and inexpensive physical activities. CONCLUSION: Childhood obesity in the context of low-resource families is a complex problem with no simple solutions. Culturally sensitive and family informed interventions are needed to support low-income African American families in dealing with childhood obesity.

Community Influence on Youth's Use of Inhalants and Other Legal Products to Get High in Rural Alaska.

This study examines the use of inhalants and other harmful legal products (HLPs) to get high among pre-adolescents in frontier Alaska communities. Community factors that may influence use of HLPs are highlighted. This study uses secondary data from two NIH studies in 19 Alaska communities. A hierarchal generalized linear modeling technique was used to model community level effects on HLP use. The results show that lifetime use was reported by 18% of the pre-adolescents. Pre-adolescents in "dry" communities (with laws restricting alcohol use) had much higher lifetime and past 30-day HLP use. The results suggest that additional study of the relationship between use of HLPs and local laws governing availability is warranted.

Improving the oral health of residents with intellectual and developmental disabilities: an oral health strategy and pilot study.

This article presents an oral health (OH) strategy and pilot study focusing on individuals with intellectual and/or developmental disabilities (IDD) living in group homes. The strategy consists of four components: (1) planned action in the form of the behavioral contract and caregiver OH action planning; (2) capacity building through didactic and observation learning training; (3) environmental adaptations consisting of additional oral heath devices and strategies to create a calm atmosphere; and (4) reinforcement by post-training coaching. A pilot study was conducted consisting of pre- and post-assessment data collected 1 week before and 1 week after implementing a 1-month OH strategy. The study sample comprised 11 group homes with 21 caregivers and 25 residents with IDD from one service organization in a Midwestern city. A process evaluation found high-quality implementation of the OH strategy as measured by dosage, fidelity, and caregiver reactions to implementing the strategy. Using repeated cross-sectional and repeated measures analyses, we found statistically significant positive changes in OH status and oral hygiene practices of residents. Caregiver self-efficacy as a mechanism of change was not adequately evaluated; however, positive change was found in some but not all types of caregiver OH support that were assessed. Lessons learned from implementing the pilot study intervention and evaluation are discussed, as are the next steps in conducting an efficacy study of the OH strategy.

An exploratory study of 2 parenting styles and family health behaviors.

OBJECTIVE: To examine the relationships between 2 parenting styles and family nutrition and physical activity. METHODS: Parents of elementary/primary school children in the southeastern United States (N = 145) completed surveys regarding family relationships and health behaviors. RESULTS: Parents exhibiting a laissez-faire parenting style reported lower levels of family nutrition and physical activity. In addition, parent BMI moderated the relationship between laissez-faire parenting and these health behaviors. CONCLUSIONS: This study indicates that family-oriented nutrition and physical activity programs may benefit from including a focus on decreasing laissez-faire parenting, as well as helping overweight parents reduce their BMIs.

Drug use and treatment success among gang and non-gang members in El Salvador: a prospective cohort study.

BACKGROUND: This article focuses on examining drug abuse treatment (DAT) in El Salvador highlighting gang vs. non-gang membership differences in drug use and treatment outcomes. METHODS: Cross-sectional and prospective cohort designs were employed to examine the study aims. The 19 centers that met the study's inclusion criteria of one year or less in planned treatment offered varying treatment services: individual, group, family, and vocational therapy, dual diagnosis treatment, psychological testing, 12-step program, and outreach and re-entry aftercare. Most directors describe their treatment approach as "spiritual." Data were collected from 625 patients, directors, and staff from the 19 centers at baseline, of which 34 patients were former gang members. Seventy-two percent (72%) of the former patients (448) were re-interviewed six-months after leaving treatment and 48% were randomly tested for drug use. RESULTS: Eighty-nine percent (89%) of the DAT patients at baseline were classified as heavy alcohol users and 40% were using illegal drugs, i.e., crack, marijuana, cocaine, tranquilizers, opiates, and amphetamines. There were large decreases after treatment in heavy alcohol and illegal drug use, crime, and gang related risk activities. Gang members reported illegal drug use, crime, and gang related risk activity more than non-gang members, yet only 5% of the study participants were gang members; further, positive change in treatment outcomes among gang members were the same or larger as compared to non-gang members. CONCLUSIONS: Alcohol use is the drug of choice among DAT patients in El Salvador with gang member patients having used illegal drugs more than non-gang members. The study shows that DAT centers successfully reduced the use of illegal drugs and alcohol among gang and non-gang members. Although our study could not include a control group, we believe that the DAT treatment centers in El Salvador contributed to producing this treatment success among former patients. These efforts should be continued and complemented by funding support from the Salvadoran government for DAT centers that obtain certification. In addition, tailored/alternative treatment modalities are needed for gang members in treatment for heavy drinking.

Application of the PRECEDE-PROCEED Planning Model in Designing an Oral Health Strategy.

BACKGROUND: Although the poor oral health of adults with intellectual and developmental disabilities (IDD) constitutes a significant health disparity in the United States, few interventions to date have produced lasting results. Moreover, there is minimal application of planning models to inform and design a theory-based strategy that has the potential to be effective and sustainable in this population. METHODS: The PRECEDE-PROCEED planning model is being used to design and evaluate an oral health strategy for adults with IDD. The PRECEDE component involves assessing social, epidemiological, behavioral, environmental, educational, and ecological factors that informed the development of an intervention with underlying social cognitive theory assumptions. The PROCEED component consists of pilot-testing and evaluating the implementation of the strategy, its impact on mediators and outcomes of the population under study. RESULTS: A The PRECEDE assessment and strategy design results are presented including a conceptual framework and oral health strategy that are linked to social cognitive theory and Health Action Process Approach. We have developed a strategy consisting of a planned actions, capacity building, environmental adaptations, and caregiver reinforcement within group homes. The strategy is designed to increase caregiver self-efficacy, outcome expectancies, and behavioral capability, and also to create environmental influences that will lead to improved self-care behavior of the adult with IDD. It is anticipated that this strategy will improve the oral health and quality of life, including respiratory health, of individuals with IDD. The planned PROCEED component of the planning model includes a description of an in-process pilot study to refine the oral health strategy, along with a future randomized controlled clinical trial to demonstrate its effectiveness. CONCLUSIONS: The application of the PRECEDE-PROCEED planning model presented here demonstrates the feasibility of this planning model for developing and evaluating interventions for adults within the IDD population.

Examining a home environmental strategy to reduce availability of legal products that can be misused by youth.

This article presents results from a study of a home environmental strategy (HES) designed to reduce availability of harmful legal products (HLPs) in the home that can be used by youth to get high. HLPs include inhalants, prescription and nonprescription drugs, and household products that can be ingested to get high. Availability is one of the most consistent predictors of substance use among youth. Parents of 5th- to 7th-grade students in four Alaskan communities participated in telephone interviews as part of a larger study of a multicomponent community prevention model (CPM) that included a HES. The strategy was designed to encourage parents to reduce availability of HLPs by removing them from the home, and by locking up and monitoring the supplies of HLPs in the home. Data from 402 parents at Wave 1 and 371 parents at Wave 2 were analyzed using hierarchical non-Linear modeling (HNLM). Results show there was a significant decrease in HLPs in the home from Wave 1 to Wave 2, mostly inhalants and prescription and nonprescription drugs. Parents also reported a significant increase in locking up prescription and nonprescription drugs in the home. Parents' direct exposure to the HES was marginally associated with the change over time in HLP availability in the home. Indirect exposure through others and media was not associated with this change. Study lessons learned and conclusions are highlighted.

Evaluation of the therapeutic community treatment model in Thailand: policy implications for compulsory and prison-based treatment.

This study, conducted in 2005 to 2007, presents results that are based on a proscriptive cohort design. The sample consisted of 769 residents in 22 drug user treatment programs who stayed in treatment for at least 30 days to one year; 510 former residents (66%) from 21 programs (95%) were interviewed again at a 6-month post-treatment follow-up assessment. A majority of the participants were male, lived with family or relatives, had completed only primary school, and had a full-time or a part-time job prior to entering treatment. The participating therapeutic community (TC) programs were a mixture of volunteer, compulsory-probation, and prison-based programs. In-person interview data and urine testing showed that the self-reported drug use prevalence rates are reliable. The results show large positive treatment effects on 30-day and 6-month illegal drug use and small to medium effects on the severity of alcohol use and related problems. A multilevel regression analysis suggests that residents' reduced stigma, adaptation of the TC model, and frequency of alcohol and drug use-related consequences partially predict treatment success. Study limitations and policy implications are discussed.

Demographic and contextual factors associated with inhalant use among youth in rural Alaska.

BACKGROUND: Abuse of harmful legal products that can be inhaled or ingested is a serious and growing problem in many rural Alaskan communities, and particularly so among preteens. METHODS: This study analyses data collected during baseline measurements of a 5-year NIH/NIDA-funded study entitled A Community Trial to Prevent Youth's Abuse of Harmful Legal Products in Alaska. Youth in 8 communities located throughout the state participated in a survey during the fall of 2009 to measure the prevalence and availability of harmful legal products (n=697). The goal of the analysis presented here is to compare the contextual factors of inhalant users and non-users in rural Alaskan communities. RESULTS: As reported in national surveys of substance use among youth, participants in this study indicated using alcohol more than any other substance. Inhalants were the second-most common substance abused, higher than either cigarettes or marijuana. Lifetime use varied among demographic factors such as age, gender and ethnicity as well as contextual factors including academic performance, parent employment, household living situation and income. When compared to non-users, significantly larger proportions of participants reporting lifetime inhalant use indicated easy availability of inhalants in their home, school and retail outlets. Users were also significantly more likely than non-users to have consumed alcohol. CONCLUSION: Results of this study may inform the development of effective interventions in other rural communities.

Examining human rights and mental health among women in drug abuse treatment centers in Afghanistan.

Denial of human rights, gender disparities, and living in a war zone can be associated with severe depression and poor social functioning, especially for female drug abusers. This study of Afghan women in drug abuse treatment (DAT) centers assesses (a) the extent to which these women have experienced human rights violations and mental health problems prior to entering the DAT centers, and (b) whether there are specific risk factors for human rights violations among this population. A total of 176 in-person interviews were conducted with female patients admitted to three drug abuse treatment centers in Afghanistan in 2010. Nearly all women (91%) reported limitations with social functioning. Further, 41% of the women indicated they had suicide ideation and 27% of the women had attempted suicide at least once 30 days prior to entering the DAT centers due to feelings of sadness or hopelessness. Half of the women (50%) experienced at least one human rights violation in the past year prior to entering the DAT centers. Risk factors for human rights violations among this population include marital status, ethnicity, literacy, employment status, entering treatment based on one's own desire, limited social functioning, and suicide attempts. Conclusions stemming from the results are discussed.

Non-medical use of prescription drugs among youth in an Appalachian population: prevalence, predictors, and implications for prevention.

This article examines prevalence of non-medical use of prescription drugs (NMUPD) in a sample of elementary and high school students in an Appalachian Tennessee county. We found that lifetime prevalence of NMUPD (35%) was higher than prevalence of cigarette use (28%) and marijuana use (17%), but lower than lifetime prevalence of alcohol use (46%). We examined characteristics, as well as risk and protective factors in several domains, as predictors of NMUPD. For comparison, we also examined these characteristics and factors as predictors of alcohol, cigarette, and marijuana use. Using survey data from a sample of late elementary school and high school students (grades 5, 7, 9, and 11), logistic regression analyses showed that the risk factors of friends' non-medical use and perceived availability, and the protective factors of preceived risk, parents' disapproval, school commitment, and community norms against youth NMUPD were significant predictors of lifetime prevalence of NMUPD. Implications for prevention are discussed.

Influence of risk and protective factors on substance use outcomes across developmental periods: a comparison of youth and young adults.

Data were collected from samples of youth (ages 11-18; N = 38,268) and young 10 adults (ages 18-24; N = 602) across 30 Tennessee counties using surveys and telephone interviews conducted in 2006-2008. Data were analyzed using hierarchical nonlinear modeling to determine: (1) which risk and protective factors predicted alcohol and marijuana use, and (2) whether predictors differed as a function of developmental period. Findings provide preliminary evidence that prevention efforts need to take into consideration the changing environment and related influences as youth age, especially as they move from a more protected community environment to one where they live somewhat independently. Implications and limitations are discussed.

Studying implementation quality of a school-based prevention curriculum in frontier Alaska: application of video-recorded observations and expert panel judgment.

This study assesses the implementation quality of Think Smart, a school-based drug prevention curriculum that was designed to reduce use of harmful legal products (HLPs; e.g., inhalants and over-the-counter drugs), alcohol, tobacco, and other drugs among 5th- and 6th-grade students in frontier Alaska. Participating in the study were eight communities that took part in a larger randomized control trial to assess the short-term effects of the Think Smart curriculum. Video-recorded observations of the 12 core and 3 booster lessons were conducted in 20 classrooms. Ninety-five sessions were randomly selected from 228 usable videodiscs, and two pairs of researchers observed each video recording to code level of dosage, adherence to curriculum design, and teachers' delivery skills. Inter-rater reliability for all implementation quality measures was very high. An expert panel consisting of 16 scientists reviewed the results of the implementation study and concluded that the level of dosage and adherence to the curriculum design was at least as high as those yielded by similar studies. However, the panel assessed the delivery quality to be only marginal in comparison to results of other studies. The experts concluded that the implementation quality of the Think Smart curriculum was adequate even though the teachers' delivery skills were only marginal. A bootstrapping analysis, in which 1,000 samples were drawn for each implementation quality result, found the expert judgments to be reliable. The authors conclude that despite some limitations, video-recorded observations, as well as expert judgment, provide strong methodologies that should be considered for future implementation quality studies.

Increasing dental care utilization by Medicaid-eligible children: a dental care coordinator intervention.

OBJECTIVES: The aim of this study was to determine the effect of a dental care coordinator intervention on increasing dental utilization by Medicaid-eligible children compared with a control group. METHODS: One hundred and thirty-six children enrolled in Medicaid aged 4 to 15 years at baseline in 2004 who had not had Medicaid claims for 2 years, were randomly assigned to intervention or control groups for 12 months. Children and caregivers in the intervention group received education, assistance in finding a dentist if the child did not have one, and assistance and support in scheduling and keeping dental appointments. All children continued to receive routine member services from the dental plan administrator, including newsletters and benefit updates during the study. RESULTS: Dental utilization during the study period was significantly higher in the intervention group (43 percent) than in the control group (26 percent). The effect was even more significant among children living in households well below the Federal Poverty Level. The intervention was effective regardless of whether the coordinator was able to provide services in person or via telephone and mail. CONCLUSION: The dental care coordinator intervention significantly increased dental utilization compared with similar children who received routine Medicaid member services. Public health programs and communities endeavoring to reduce oral health disparities may want to consider incorporating a dental care coordinator along with other initiatives to increase dental utilization by disadvantaged children.

Reducing adolescent use of harmful legal products: intermediate effects of a community prevention intervention.

PURPOSE: Preliminary results are presented from a feasibility study of a comprehensive community prevention intervention to reduce the use of inhalants and other harmful legal products (HLPs) among adolescents in three Alaskan frontier communities conducted in 2004-2007. The legal products used to get high include over-the-counter drugs, prescription drugs, and common household products. Community mobilization, environmental and school-based strategies were implemented to reduce access, enhance knowledge of risks, and improve assertiveness and refusal skills. METHODS: Pre- and post-intervention survey data were collected from 5-7th grade students from schools in three communities using standardized instruments to assess knowledge, assertiveness, refusal skills, perceived availability, and intent to use. The intervention consisted of community mobilization and environmental strategies to reduce access to HLPs in the home, at school, and through retail establishments. In addition, the ThinkSmart curriculum was implemented in classrooms among 5th grade students to increase the knowledge of harmful effects of HLPs and improve the refusal skills. Data were analyzed using hierarchical linear models that enable corrections for correlated measurement error. RESULTS: Significant increases in knowledge of harms related to HLP use and decreases in perceived availability of HLP products were observed. The environmental strategies were particularly effective in reducing the perceived availability of HLPs among 6th and 7th graders. DISCUSSION: Although limited by the absence of randomized control groups in this preliminary study design, the results of this study provide encouragement to pursue mixed strategies for the reduction of HLP use among young people in Alaskan frontier communities.

Preventing youths' use of inhalants and other harmful legal products in frontier Alaskan communities: a randomized trial.

This study tests for the efficacy of a school-based drug prevention curriculum (Think Smart) that was designed to reduce use of Harmful Legal Products (HLPs, such as inhalants and over-the-counter drugs), alcohol, tobacco, and other drugs among fifth- and sixth-grade students in frontier Alaska. The curriculum consisted of 12 core sessions and 3 booster sessions administered 2 to 3 months later, and was an adaptation of the Schinke life skills training curriculum for Native Americans. Fourteen communities, which represented a mixture of Caucasian and Alaska Native populations in various regions of the state, were randomly assigned to intervention or control conditions. Single items measuring 30-day substance use and multi-item scales measuring the mediators under study were taken from prior studies. Scales for the mediators demonstrated satisfactory construct validity and internal reliability. A pre-intervention survey was administered in classrooms in each school in the fall semester of the fifth and sixth grades prior to implementing the Think Smart curriculum, and again in the spring semester immediately following the booster session. A follow-up survey was administered 6 months later in the fall semester of the sixth and seventh grades. A multi-level analysis found that the Think Smart curriculum produced a decrease (medium size effect) in the proportion of students who used HLPs over a 30-day period at the 6 month follow-up assessment. There were no effects on other drug use. Further, the direct effect of HLPs use was not mediated by the measured risk and protective factors that have been promoted in the prevention field. Alternative explanations and implications of these results are discussed.