Increasing access to behavioral health care: Examples of task shifting in two U.S. government health care systems.

INTRODUCTION: Addressing U.S. health disparities in behavioral health care requires innovative solutions to expand access beyond the traditional specialty behavioral health (BH) service model. One evidence-based strategy to increase access is task shifting, whereby tasks usually reserved for licensed clinicians are delegated to less specialized but uniquely capable health workers. Health care systems in the United States have been slow to adopt this approach, despite the widespread success of task shifting in other countries. However, two large government health care systems have employed unique task-shifting models for decades, integrating nonclinician health workers into BH settings: the Defense Health Agency (behavioral health technicians) and the Veterans Health Administration (peer specialists). METHOD: This conceptual article provides overviews of these successful approaches. Challenges and opportunities, and the potential for other U.S. health care systems to adopt task shifting for behavioral health care with paraprofessionals such as community health workers (CHWs), are discussed. RESULTS: CHWs and other paraprofessionals are ideally situated to increase access to behavioral health care, but barriers must be overcome. Recommendations are provided based on lessons from these federal system approaches to task shifting. DISCUSSION: Expanding task-shifting paradigms as the Defense Health Agency and Veterans Health Administration have done may be vital to reaching more people who could benefit from BH intervention and prevention strategies. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Developing a Text Messaging Intervention to Prevent Binge and Heavy Drinking in a Military Population: Mixed Methods Development Study.

BACKGROUND: Alcohol misuse is the fourth leading cause of death in the United States and a significant problem in the US military. Brief alcohol interventions can reduce negative alcohol outcomes in civilian and military populations, but additional scalable interventions are needed to reduce binge and heavy drinking. SMS text messaging interventions could address this need, but to date, no programs exist for military populations. OBJECTIVE: We aimed to develop an SMS text messaging intervention to address binge and heavy drinking among Airmen in Technical Training in the US Air Force. METHODS: We implemented a 2-phase, mixed methods study to develop the SMS text messaging intervention. In phase 1, a total of 149 respondents provided feedback about the persuasiveness of 49 expert-developed messages, preferences regarding message frequency, timing and days to receive messages, and suggested messages, which were qualitatively coded. In phase 2, a total of 283 respondents provided feedback about the persuasiveness of 77 new messages, including those developed through the refinement of messages from phase 1, which were coded and assessed based on the Behavior Change Technique Taxonomy (BCTT). For both phases, mean persuasiveness scores (range 1-5) were calculated and compared according to age (aged <21 or ≥21 years) and gender. Top-ranking messages from phase 2 were considered for inclusion in the final message library. RESULTS: In phase 1, top-rated message themes were about warnings about adverse outcomes (eg, impaired judgment and financial costs), recommendations to reduce drinking, and invoking values and goals. Through qualitative coding of suggested messages, we identified themes related to warnings about adverse outcomes, recommendations, prioritizing long-term goals, team and belonging, and invoking values and goals. Respondents preferred to receive 1 to 3 messages per week (124/137, 90.5%) and to be sent messages on Friday, Saturday, and Sunday (65/142, 45.8%). In phase 2, mean scores for messages in the final message library ranged from 3.31 (SD 1.29) to 4.21 (SD 0.90). Of the top 5 highest-rated messages, 4 were categorized into 2 behavior change techniques (BCTs): valued self-identity and information about health consequences. The final message library includes 28 BCTT-informed messages across 13 BCTs, with messages having similar scores across genders. More than one-fourth (8/28, 29%) of the final messages were informed by the suggested messages from phase 1. As Airmen aged <21 years face harsher disciplinary action for alcohol consumption, the program is tailored based on the US legal drinking age. CONCLUSIONS: This study involved members from the target population throughout 2 formative stages of intervention development to design a BCTT-informed SMS text messaging intervention to reduce binge and heavy drinking, which is now being tested in an efficacy trial. The results will determine the impact of the intervention on binge drinking and alcohol consumption in the US Air Force.

Motives for using electronic nicotine delivery systems (ENDS) as a cessation tool are associated with tobacco abstinence at 1-year follow-up: A prospective investigation among young adults in the United States Air Force.

Introduction: Smokers use electronic nicotine delivery systems (ENDS), including e-cigarettes, as a harm reduction strategy even though the Food and Drug Administration (FDA) has not approved them for tobacco cessation. The limited literature about ENDS use for cigarette cessation is concerning for the U.S. military, which is largely comprised of young adults at increased risk for tobacco use. Thus, the current study aims to evaluate use of ENDS products as a cessation tool in relation to point-prevalence tobacco abstinence at one-year follow-up in a cohort of 8,901 U.S. Air Force personnel attending entry-level job training from March 2016 to April 2019. Methods: A propensity-score adjusted multinomial logistic regression model was used to assess the association between the baseline motives for ENDS use (i.e., for cigarette cessation versus alternative reasons) and tobacco use at the one-year follow-up (cigarette use, non-cigarette tobacco product use, and tobacco abstinence) among those reporting history of cigarette use at baseline. Results: Smokers reporting ENDS use for cigarette cessation were more likely to be abstinent at one-year follow-up (Odds Ratio[OR] = 1.62, 95% CI: 1.06-2.49, P =.03) as well as quit using non-cigarette tobacco products (OR = 2.11, 95% CI: 1.65-2.70, P <.001) than those reporting ENDS use for alternative reasons. Conclusions: Current tobacco users are recommended to use FDA-approved products for smoking cessation, such as nicotine replacement therapy. However, given the high prevalence of cigarette use among military populations, ENDS may provide a useful alternative harm reduction strategy for this high-risk population.

Decreasing alcohol use among young adults presenting for service in the U.S. Air Force: An epidemiological surveillance study.

U.S. surveys demonstrate recent decreases in the prevalence of alcohol use and binge drinking among young adults. The current study aims to determine whether similar trends are evident in a similarly aged cohort of service members in the US Air Force to inform ongoing prevention efforts. Participants were 103,240 Air Force personnel in entry-level training between 2016 and 2019. Participants anonymously completed the AUDIT (Alcohol Use Disorder Identification Test) regarding their pre-service drinking. Logistic regression analyses and the Cochran-Armitage test were conducted to measure population trends over the study duration with stratification by age (<21 vs. ≥21) and evaluation of specific alcohol behaviors. Between 2016 and 2019, the proportion of young service members endorsing any alcohol use significantly decreased for both the <21 group (i.e. from 38.9% to 32.6%) and the ≥21 group (i.e. from 80.6% to 77.5%). Among those who endorsed drinking, a decrease over time in binge use was also observed from 46.6% to 37.8% for the <21 group and from 34.2% to 27.5% for the ≥21 group. Responses to other specific alcohol risk items and total AUDIT scores also demonstrated decreases. Binge use and risky drinking remained disproportionately common among those under the legal drinking age. It is encouraging to observe a shift toward abstinence and decreased binge use among this population of young military recruits. However, given the risk for many adverse health and legal consequences in this population, more work is needed to prevent problematic drinking, especially among those under the legal drinking age.

Reengagement for Long-Term Smoking-Cessation In Military Personnel, Retirees, Family Members (TRICARE): A Randomized Trial.

INTRODUCTION: We sought to determine what type of treatment reengagement after smoking relapse would increase long-term cessation. AIMS AND METHODS: Participants were military personnel, retirees, and family members (TRICARE beneficiaries) recruited across the United States from August 2015 through June 2020. At baseline, consented participants (n = 614) received a validated, four-session, telephonic tobacco-cessation intervention with free nicotine replacement therapy. At the 3-month follow-up, 264 participants who failed to quit or relapsed were offered the opportunity to reengage in cessation. Of these, 134 were randomized into three reengagement conditions: (1) repeat initial intervention ("recycle"), (2) Smoking reduction with eventual cessation goal ("rate reduction"), or (3) Choose #1 or #2 ("choice"). Prolonged abstinence and 7-day point prevalence abstinence were measured at 12 months. RESULTS: Despite being in a clinical trial advertised as having the opportunity for reengagement, only 51% (134 of the 264) of participants who still smoked at 3-month follow-up were willing to reengage. Overall, participants randomized to recycle had higher prolonged cessation rates at 12 months than rate reduction conditions (OR = 16.43, 95% CI: 2.52 to 107.09, Bonferroni adjusted p = .011). When participants who randomly received recycle or rate reduction were pooled, respectively, with participants who chose recycle or rate reduction in the Choice group, recycle had higher prolonged cessation rates at 12 months than rate reduction (OR = 6.50, 95% CI: 1.49 to 28.42, p = .013). CONCLUSIONS: Our findings suggest service members and their family members who fail to quit smoking but are willing to reengage in a cessation program are more likely to benefit from repeating the same treatment. IMPLICATIONS: Finding methods that are both successful and acceptable to reengage people who smoke who want to quit can have a significant impact on improving the health of the public by reducing the portion of the population who smoke. This study suggests that repeating established cessation programs will result in more people ready to quit successfully achieving their goal.

Tobacco quitline performance: Comparing the impacts of early cessation and proactive re-engagement on callers' smoking status at follow-up at 12 months.

INTRODUCTION: While tobacco Quitlines are effective in the promotion of smoking cessation, the majority of callers who wish to quit still fail to do so. The aim of this study was to determine if 12-month tobacco Quitline smoking cessation rates could be improved with re-engagement of callers whose first Quitline treatment failed to establish abstinence. METHODS: In an adaptive trial, 614 adult smokers, who were active duty, retired, and family of military personnel with TRICARE insurance who called a tobacco Quitline, received a previously evaluated and efficacious four-session tobacco cessation intervention with nicotine replacement therapy (NRT). At the scheduled follow-up at 3 months, callers who had not yet achieved abstinence were offered the opportunity to re-engage. This resulted in three caller groups: 1) those who were abstinent, 2) those who were still smoking but willing to re-engage with an additional Quitline treatment; and 3) individuals who were still smoking but declined re-engagement. A propensity score-adjusted logistic regression model was generated to compare past-7-day point prevalence abstinence at 12 months post Quitline consultation. RESULTS: Using a propensity score adjusted logistic regression model, comparison of the three groups resulted in higher odds of past-7-day point prevalence abstinence at follow-up at 12 months for those who were abstinent at 3 months compared to those who re-engaged (OR=9.6; 95% CI: 5.2-17.8; Bonferroni adjusted p<0.0001), and relative to those who declined re-engagement (OR=13.4; 95% CI: 6.8-26.3; Bonferroni adjusted p<0.0001). There was no statistically significant difference in smoking abstinence between smokers at 3 months who re-engaged and those who declined re-engagement (OR=1.39; 95% CI: 0.68-2.85). CONCLUSIONS: Tobacco Quitlines seeking to select a single initiative by which to maximize abstinence at follow-up at 12 months may benefit from diverting additional resources from the re-engagement of callers whose initial quit attempt failed, toward changes which increase callers' probability of success within the first 3 months of treatment. TRIAL REGISTRATION: This study is registered at clinicaltrials.gov (NCT02201810).

Predictors of Re-Engagement after Relapse in a Tobacco Quit Line Intervention: Secondary Analysis from a Randomized Clinical Trial.

People who smoke often make several quit attempts before successfully maintaining abstinence. Therefore, incorporating re-engagement for people who fail to initially quit could increase quit attempts and ultimately increase cessation rates. Within the context of quit line-based interventions, it remains unknown what characteristics are associated with re-engagement. The purpose of this study was to assess associations between demographic and motivational characteristics, tobacco use, and initial intervention engagement with re-engagement in a tobacco quit line intervention. Among 372 adults who reported smoking three months after initiating a quit line-facilitated quit attempt as part of a larger randomized clinical trial, associations between personal characteristics (e.g., age, gender, nicotine dependence, and confidence in their ability to quit smoking) and initial intervention engagement (number of completed counseling sessions and use of nicotine replacement therapy (NRT)) with re-engagement (accepting an offer to re-initiate the quit line intervention) were determined using multivariable logistic regression modeling. Compared to non-White participants, White participants had lower odds of re-engaging (OR: 0.42, 95% CI: 0.23, 0.75). Number of initial counseling sessions completed was associated with re-engaging. NRT use during the initial intervention was not associated with re-engaging. Initial intervention engagement is important in the process of re-engagement, specifically attending counseling sessions. Exploration of associations between initial intervention engagement and potentially modifiable motivational factors is needed to be potentially leveraged in future interventions to maintain continued engagement in cessation among adults who smoke.