Determinants of Relapse and Opportunities for Growth: Perspectives on Substance Use among American Indian Community Members.

Resulting from generations of historical oppression and systemic racism, American Indian and Alaska Native (AI/AN) communities experience serious health disparities associated with substance use disorders (SUDs). As part of a longstanding community-based participatory research intervention development project, our partnership of academic and community co-researchers conducted seven focus groups (N = 35) to understand community stakeholders' perspectives on substance use, relapse, and recovery on a rural AI reservation. Participants included cultural leaders (n = 10), SUD treatment providers (n = 5), people with SUD (n = 10), and affected family members (n = 10). Cultural leaders viewed relapse as symptomatic of historical oppression, whereas other stakeholder groups attributed relapse to individual and interpersonal risk factors such as peer influence, lack of family support, and traumatic stress. All participant groups recognized relapse as a normative aspect of recovering from SUD that presents new opportunities for learning and growth. Specifically, regaining humility, learning to ask for help, recognizing one's triggers, and strengthening commitment to change were identified as learning outcomes for people with SUD. For family members, relapse provided the opportunity to practice forgiveness and compassion, two important cultural values. All groups emphasized the importance of grounding interventions in cultural values and traditions.

Partnering with Native Communities to Develop a Culturally Grounded Intervention for Substance Use Disorder.

Studies have documented serious disparities in drug and alcohol-related morbidity and mortality among American Indians and Alaska Natives (AI/ANs) compared to other ethnic groups in the U.S. despite high rates of abstinence in these groups. Further complicating these health disparities are barriers to accessing evidence-based treatments that are culturally appropriate and acceptable. As part of a research program to promote health equity in rural communities, we developed an academic-community partnership to create a culturally grounded intervention for adults with substance use disorder (SUD) residing on a rural AI reservation. We describe the early phases of our long-term Community Based Participatory Research project and report findings from the first study we conducted. This key informant interview study consisted of in-depth qualitative interviews with 25 tribal members knowledgeable about substance use and recovery on the reservation. The goal was to understand social norms and cultural conceptualizations of substance use to inform the development of a sustainable, community-driven intervention. Participants reported that a holistic approach to recovery that emphasizes spiritual, cultural, and interpersonal harmony and connectedness was important to the community and would be necessary for the intervention to succeed. They also emphasized the need for a multi-level intervention targeting individuals, families, and the community as a whole. Through this initial study, we not only gained valuable information that will be used to guide future research and treatment efforts, but we also strengthened our partnership and built trust with the community. In this manuscript we tell the story of the development of our project and describe our shared vision for future directions.

Determinants of Transgender Individuals' Well-Being, Mental Health, and Suicidality in a Rural State.

This project utilized a Community-Based Participatory Research (CBPR) approach to conduct qualitative interviews with 30 transgender adults living in a rural state. Participants' identities spanned from trans women and men to non-binary and Two-Spirit. The aim of this study was to better understand the experiences, needs, and priorities of the participants as well as to examine possible determinants of mental health, well-being, and suicidality for transgender individuals in Montana. These factors were investigated at individual, interpersonal, community, and societal levels using an ecological framework. Qualitative results indicate that participants experienced discrimination at all levels. Participants noted that discrimination contributed to mental health challenges and limited access to adequate general and transgender-specific healthcare services, both of which impacted overall well-being. This is reflected most notably in the elevated rate of past suicidal ideation attempts among the sample. Participants reported that the ability to transition, as well as other protective factors, played a role in reducing suicidality and improving mental and physical health. Our findings highlight the need to address transgender mental health through implementing changes at multiple ecological levels.

Efforts to Increase Implementation of Evidence-Based Clinical Practices to Improve Adolescent-Friendly Reproductive Health Services.

PURPOSE: The purposes of this study were to describe changes in implementation of evidence-based clinical practices among health center partners as part of a multicomponent, community-wide teen pregnancy prevention initiative; to better understand the barriers to and facilitators of implementation of the evidence-based clinical practices; and to describe the technical assistance and training provided to the health center partners and key lessons learned. METHODS: Health center data from the second and third years (2012 and 2013) of the teen pregnancy prevention community-wide initiative were analyzed from 10 communities (the first year was a planning year; program implementation began in the second year). Data were analyzed from 48 health center partners that contributed data in both years to identify evidence-based clinical practices that were being implemented and opportunities for improvement. In addition, data were analyzed from a purposive sample of 30 health center partners who were asked to describe their experiences in implementing evidence-based clinical practices in adolescent reproductive health care and barriers and facilitators to implementation. RESULTS: Across 48 health centers in the 10 communities, 52% reported an increase in the implementation of evidence-based clinical practices from 2012 to 2013, mostly in providing contraceptive access (23%) and offering Quick Start (19%). Among health centers that reported no change (13%), the majority reported that practices were already being implemented before the initiative. Finally, among health centers that reported a decrease in implementation of evidence-based clinical practices (35%), most reported a decrease in having either hormonal contraception or intrauterine devices available at every visit (15%), having HIV rapid testing available (10%), or participating in the federal 340B Drug Discount Program (2%). In addition, health systems and community-level factors influence health center implementation of evidence-based clinical practices. In particular, support from health center leadership, communication between leadership and staff, and staff attitudes and beliefs were reported as factors that facilitated the implementation of new practices. CONCLUSIONS: To increase adolescent's use of quality, client-centered, affordable and confidential reproductive health services, improvement in the implementation of evidence-based clinical practices is needed. Efforts to identify barriers to and facilitators for implementation of evidence-based clinical practices can inform for health centers of opportunities to build their capacity to ensure that evidence-based clinical practices are being implemented.

Partnering with American Indian communities in strength-based collaborative health research: Guiding principles from the Fort Peck Ceremony of ResearchProject.

BACKGROUND: The Ceremony of Research Project was implemented to strengthen tribal communities' ability to harmonize Western research processes with Indigenous ways of knowing. METHODS: Focus groups were conducted with tribal members to understand Indigenous processes, beliefs, and practices necessary to promote positive research experiences with tribal communities. RESULTS: Findings address time; relationship building and maintenance; inclusion of diverse tribal members in the research design, as well as American Indian epistemology; respect for tribal values, beliefs, and customs throughout the research process; and the reciprocity of research. CONCLUSIONS: Our study has important implications for how researchers can take a strengthbased approach to conducting research with tribal communities.

Enhancing Adolescent Reproductive Health Services: Assessment of Health Care Practices in Holyoke and Springfield, MA Engaged in the Youth First Initiative.

Health care practices can play a key role in reducing teen pregnancies, though current health care systems do not adequately meet adolescents' reproductive health needs. To address this gap, Youth First, a Centers for Disease Control and Prevention funded, community-wide initiative in Holyoke and Springfield (Massachusetts) established partnerships with nine local health care practices to increase adolescent access to health services. However, we had limited knowledge about their reproductive health services and policies. To address this gap, assessments were conducted with staff using structured interviews and surveys to inform targeted efforts to enhance the quality and youth friendliness of adolescent reproductive health services. Findings revealed that many of the youth-friendly services best practices recommended by the CDC were not routinely implemented by all health care practices. Findings from this assessment can be used to support health care practices to facilitate widespread adoption of best practices related to meeting adolescents' reproductive health needs.

'Our only resource': Perspectives and Recommendations of Rural African American Youth on Adapting Sexual Health and Risk Reduction Interventions.

Recent studies have documented disproportionately high rates of sexually transmitted infections (STIs), HIV, and births among adolescents in rural areas of the United States. Despite this, the majority of sexual health education programs and interventions were developed for adolescents in metropolitan areas, and may not be appropriate or relevant for rural youth. The present study investigates the perspectives of 73 African American youth in rural Georgia who participated in a cognitive-behavioral intervention to reduce sexual risk behaviors, in an effort to understand how the intervention and ones similar to it may be tailored to better meet the needs of rural adolescents. Findings highlight the importance of incorporating diverse teaching and recruitment strategies into interventions when delivering them to rural youth, as well as the need to expand education and risk reduction efforts. Additional research is warranted to understand better how to meet the sexual health education needs of rural youth.

Barriers and Facilitators to Health Center Implementation of Evidence-Based Clinical Practices in Adolescent Reproductive Health Services.

PURPOSE: Despite the substantial evidence supporting the guidelines for the provision of reproductive health services for adolescents, research points to a persistent gap in their translation into health care practice. This study examines barriers and facilitators that health centers experience when implementing evidence-based clinical practices for adolescent reproductive health services and discusses strategies to address identified barriers. METHODS: Semistructured interviews were conducted with 85 leaders and staff of 30 health centers in Alabama, Georgia, Massachusetts, North Carolina, South Carolina, Pennsylvania, and Texas. Interview data were analyzed for emergent themes following a grounded theory approach. RESULTS: Data analysis revealed that certain factors at health system and community levels influenced health centers' efforts to implement evidence-based clinical practices for adolescent reproductive health care. In particular, support from health center leadership, communication between leadership and staff, and staff attitudes and beliefs were reported as factors that facilitated the implementation of new practices. CONCLUSIONS: Health center efforts to implement new practice guidelines should include efforts to build the capacity of health center leadership to mobilize staff and resources to ensure that new practices are implemented consistently and with quality.

Improving the Implementation of Evidence-Based Clinical Practices in Adolescent Reproductive Health Care Services.

PURPOSE: The purposes of the study were to describe baseline data in the implementation of evidence-based clinical practices among health center partners as part of a community-wide teen pregnancy prevention initiative and to identify opportunities for health center improvement. METHODS: Health center partner baseline data were collected in the first year (2011) and before program implementation of a 5-year community-wide teen pregnancy prevention initiative. A needs assessment on health center capacity and implementation of evidence-based clinical practices was administered with 51 health centers partners in 10 communities in the United States with high rates of teen pregnancy. RESULTS: Health centers reported inconsistent implementation of evidence-based clinical practices in providing reproductive health services to adolescents. Approximately 94.1% offered same-day appointments, 91.1% had infrastructure to reduce cost barriers, 90.2% offered after-school appointments, and 80.4% prescribed hormonal contraception without prerequisite examinations or testing. Approximately three quarters provided visual and audio privacy in examination rooms (76.5%) and counseling areas (74.5%). Fewer offered a wide range of contraceptive methods (67.8%) and took a sexual health history at every visit (54.9%). Only 45.1% reported Quick Start initiation of hormonal contraception, emergency contraception (43.1%), or intrauterine devices (12.5%) were "always" available to adolescents. CONCLUSIONS: The assessment highlighted opportunities for health center improvement. Strategies to build capacity of health center partners to implement evidence-based clinical practices may lead to accessibility and quality of reproductive health services for adolescents in the funded communities.

Improving completion rates for client intake forms through Audio Computer-Assisted Self-Interview (ACASI): results from a pilot study with the Avon Breast Health Outreach Program.

This study compares rates of completion of client intake forms (CIFs) collected via three interview modes: audio computer-assisted self-interview (ACASI), face-to-face interview (FFI), and self-administered paper-based interview (SAPI). A total of 303 clients served through the Avon Breast Health Outreach Program (BHOP) were sampled from three U.S. sites. Clients were randomly assigned to complete a standard CIF via one of the three interview modes. Logistic regression analyses demonstrated that clients were significantly more likely to complete the entire CIF via ACASI than either FFI or SAPI. The greatest observed differences were between ACASI and SAPI; clients were almost six times more likely to complete the CIF via ACASI as opposed to SAPI (AOR = 5.8, p < .001). We recommend that where feasible, ACASI be utilized as an effective means of collecting client-level data in healthcare settings. Adoption of ACASI in health centers may translate into higher completion rates of intake forms by clients, as well as reduced burden on clinic staff to enter data and review intake forms for completion.

Toward a social theory of sexual risk behavior among men in the Armed Services: understanding the military occupational habitus.

Worldwide, military personnel have been recognized as a population at elevated risk for sexually transmitted infections (STIs) and HIV; however, it is not well understood how the military occupation itself is implicated in the production of sexual risk behavior. Using qualitative and quantitative data collected from the Belize Defense Force (BDF), we employed a grounded theoretical framework and the Bourdieusian concept of the field and habitus to clarify how the military occupation is implicated in structuring aspects of sexual risk behaviors among personnel. We focus results on in-depth qualitative interviews conducted with 15 male-identified BDF personnel. We identify and describe how two field elements, namely operational tempo and ongoing exposure to occupational hazards, are occupationally specific field elements implicated in the production of sexual risk behavior through the mediating matrix of the military class habitus. Our findings demonstrate a conceptual clarity regarding the institutional field and habitus through which military personnel make sense of and act on the risk of bodily harm with regard to their own sexual behaviors. We conclude by outlining our theoretical concept so that it can be directly applied in public health efforts in order to leverage military occupational field elements for the purpose of HIV and STI prevention.

Linking peers, patients, and providers: a qualitative study of a peer integration program for hard-to-reach patients living with HIV/AIDS.

For HIV-positive individuals living in socially vulnerable circumstances, the complexities of accessing and navigating healthcare system can be overwhelming. Peer-driven interventions (PDIs) are increasingly being recognized as effective ways of addressing barriers to HIV care in the USA. The present study is a qualitative investigation of barriers, challenges, and facilitators to implementation of a peer integration program at three health centers in the USA. Findings reveal that health center staff and HIV-positive patients support the integration of HIV-positive peers on multidisciplinary healthcare teams. However, challenges related to peer-clinician communication and the risk of emotional burnout for peers may hinder program efficacy and sustainability. Practical implications and suggestions for improving the peer integration program in light of these findings are also discussed.

Condom use following a pilot test of the Popular Opinion Leader intervention in the Barbados Defence Force.

Worldwide, military personnel have been recognized as a population at elevated risk for sexually transmitted infections and HIV. However, few evidence based behavioral interventions for the prevention of HIV and STIs have been rigorously evaluated in military personnel. We adapted the Popular Opinion Leaders (POL) intervention and piloted the adapted program with the Barbados Defence Force at one military base in Barbados. Popular Opinion Leaders were selected and trained to focus conversations on condom use. Behavioral questionnaires were administered using audio computer-assisted self interview at baseline (n = 256) and 6-month follow-up (n = 303). Mid-point focus groups were conducted with a sample of 15 POLs at a 3 month mid-point assessment. Quantitative data showed moderate increases in condom use at 6-months, and significant uptake of condom use during oral-genital contact in female personnel. A subgroup analysis suggests that this change was partially mediated by post-intervention changes in injunctive norms surrounding condom use in women. Focus groups revealed that POLs were heavily focusing on condom demonstrations, condom provision within social networks, speaking with coworkers about pleasure associated with condom use, and that the most common venues for conversations included those where alcohol was consumed. During the intervention, POLs dispersed from the intervention site as a result of normal personnel movement across bases, resulting in our having to use a pre and post intervention design across the population. It is likely that larger effect sizes would be observed in efforts that account for the natural dispersion of personnel across bases.

Condom use during last sexual contact and last 30 days in two samples of Caribbean military personnel.

Condom use during last sexual contact is a survey measure that may be used to inform monitoring and evaluation indicators of recent condom use in populations at risk for HIV infection and other sexually transmitted infections, such as the uniformed services. The authors tested for differences in condom use measures that were fielded within separate Biological and Behavioral Surveillance Surveys conducted in the armed forces of two separate nations: the Dominican Republic and Belize. Both surveys included measures of condom use during last sexual contact with specified partners and both surveys included the Risk Behavior Assessment (RBA), which measures specific sexual acts and condom use frequency during a specified time period. In both samples, more than 40% of respondents who reported condom use during last sexual contact with a regular partner also reported engaging in unprotected sex when screened with the RBA. Furthermore, more than 60% of respondents who reported condom use during last sexual encounter with a commercial sex worker also reported engaging in unprotected sex when screened with the RBA. The results carry implications for monitoring and evaluation indicators of large-scale HIV prevention programs. The authors recommend that, when feasible, more in-depth instruments such as the RBA be considered to measure recent condom use in populations of uniformed services personnel.