Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study.

OBJECTIVE: Adults with serious mental illness have high rates of tobacco use disorder and underuse pharmacotherapy for tobacco cessation. In a previous randomized controlled trial, participants receiving community health worker (CHW) support and education for their primary care providers (PCPs) had higher tobacco abstinence rates at 2 years, partly because of increased initiation of tobacco-cessation pharmacotherapy. The authors aimed to determine the association between CHW-participant engagement and tobacco abstinence outcomes. METHODS: The authors conducted a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of the number and duration of CHW visits, number of smoking-cessation group sessions attended, and number of CHW-attended PCP visits on initiation of tobacco-cessation pharmacotherapy and tobacco abstinence were modeled via logistic regression. Interviews with 12 CHWs, 17 patient participants, and 17 PCPs were analyzed thematically. RESULTS: Year 2 tobacco abstinence was significantly associated with CHW visit number (OR=1.85, 95% CI=1.29-2.66), visit duration (OR=1.51, 95% CI=1.00-2.28), and number of group sessions attended (OR=1.85, 95% CI=1.33-2.58); effects on pharmacotherapy initiation were similar. One to three CHW visits per month across 2 years were optimal for achieving abstinence. Interviews identified CHW-patient engagement facilitators (i.e., trust, goal accountability, skills reinforcement, assistance in overcoming barriers to treatment access, and adherence). Training and supervision facilitated CHW effectiveness; barriers included PCPs' and care teams' limited understanding of the CHW role. CONCLUSIONS: Greater CHW-participant engagement, within feasible dose ranges, was associated with tobacco abstinence among adults with serious mental illness. Implementation of CHW interventions may benefit from further CHW training and integration within clinical teams.

Screening for psychotic experiences and psychotic disorders in general psychiatric settings: a systematic review and meta-analysis.

Background: The absence of systematic screening for psychosis within general psychiatric services contribute to substantial treatment delays and poor long-term outcomes. We conducted a meta-analysis to estimate rates of psychotic experiences, clinical high-risk for psychosis syndrome (CHR-P), and psychotic disorders identified by screening treatment-seeking individuals to inform implementation recommendations for routine psychosis screening in general psychiatric settings. Methods: PubMed and Web of Science databases were searched to identify empirical studies that contained information on the point prevalence of psychotic experiences, CHR-P, or psychotic disorders identified by screening inpatient and outpatient samples aged 12-64 receiving general psychiatric care. Psychotic experiences were identified by meeting threshold scores on validated self-reported questionnaires, and psychotic disorders and CHR-P by gold-standard structured interview assessments. A meta-analysis of each outcome was conducted using the Restricted Maximum Likelihood Estimator method of estimating effect sizes in a random effects model. Results: 41 independent samples (k=36 outpatient) involving n=25,751 patients (58% female, mean age: 24.1 years) were included. Among a general psychiatric population, prevalence of psychotic experiences was 44.3% (95% CI: 35.8-52.8%; 28 samples, n=21,957); CHR-P was 26.4% (95% CI: 20.0-32.7%; 28 samples, n=14,395); and psychotic disorders was 6.6% (95% CI: 3.3-9.8%; 32 samples, n=20,371). Conclusions: High rates of psychotic spectrum illness in general psychiatric settings underscore need for secondary prevention with psychosis screening. These base rates can be used to plan training and resources required to conduct assessments for early detection, as well as build capacity in interventions for CHR-P and early psychosis in non-specialty mental health settings.

Geographic range and minimum infection rate of Borrelia burgdorferi, Anaplasma phagocytophilum, Babesia microti, and Borrelia miyamotoi in Ixodes scapularis (Acari: Ixodidae) ticks in Manitoba, Canada from 1995 to 2017.

INTRODUCTION: The expanding geographical range of blacklegged ticks (BLTs), Ixodes scapularis, and its ability to transmit Borrelia burgdorferi, Anaplasma phagocytophilum, Babesia microti, and Borrelia miyamotoi poses an emerging public health risk. Our study determined the geographic distribution and the minimum infection rate (MIR) of B. burgdorferi-, A. phagocytophilum-, Ba. microti-, and B. miyamotoi-infected BLTs in Manitoba submitted to the Public Health Agency of Canada's passive tick surveillance programme from 1995 to 2017. METHODS: Regression models were used to test the association of the MIR by year for each pathogen. Ticks were tested using PCR for B. burgdorferi since 1995, A. phagocytophilum since 2006, and Ba. microti and B. miyamotoi since 2013. The global positioning system coordinates of infected and uninfected ticks submitted during the surveillance period were plotted on a map of Manitoba using ArcGIS Pro version 3.1.2 to detect changes in the geographic distribution of ticks over time. RESULTS: The overall MIR for B. burgdorferi was 139.7 (95% confidence interval [CI]: 129.0-150.5) per 1000 BLTs; however, it varied over time. After remaining stable from 1995 to 2005, the MIR increased by 12.1 per 1000 BLTs per year from 2005 to 2017 (95% CI: 7.0%-17.2%, p-value <0.01). The geographic distribution of B. burgdorferi-infected BLTs was centred around Winnipeg, Manitoba, and spread outward from this locality. The MIRs of A. phagocytophilum, Ba. microti, and B. miyamotoi were 44.8 per 1000 BLTs (95% CI: 38.1-51.6), 10.8 (95% CI: 6.6-15.0), and 5.2 (95% CI: 2.3-8.1) per 1000 BLTs, respectively, and showed no significant change over time. CONCLUSION: Passive surveillance revealed the presence of A. phagocytophilum-, Ba. microti-, and B. miyamotoi-infected BLTs in southern Manitoba and revealed an increased risk of exposure to B. burgdorferi-infected BLTs due to the increasing geographic range and MIR.

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study.

Objective: Adults with serious mental illness have high tobacco use disorder rates and underutilization of first-line tobacco cessation pharmacotherapy. In a randomized trial, participants offered community health worker (CHW) support and primary care provider (PCP) education had higher tobacco abstinence rates at two years, partly through increased tobacco cessation pharmacotherapy initiation. This study determined the association between participant-CHW engagement and tobacco abstinence outcomes. Methods: This was a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of CHW visit number and duration, CHW co-led smoking cessation group sessions attended, and CHW-attended PCP visit number on tobacco use disorder pharmacotherapy initiation and tobacco abstinence were modeled using logistic regression. Interviews with 12 CHWs, 16 participants, and 17 PCPs were analyzed thematically. Results: Year-two tobacco abstinence was associated with CHW visit number (OR=1.85, 95% CI=[1.29, 2.66]) and duration (OR=1.85, 95% CI=[1.33, 2.58]) and number of groups attended (OR=1.51, 95% CI=[1.00, 2.28]); effects on pharmacotherapy initiation were similar. 1-3 CHW visits per month over two years was optimal for achieving abstinence. Interviews identified engagement facilitators, including CHWs establishing trust, providing goal accountability, skills reinforcement, and assistance overcoming barriers to treatment access and adherence related to social determinants of health and illness factors. Robust training and supervision facilitated CHW effectiveness. Barriers included PCPs' and care teams' limited understanding of the CHW role. Conclusions: Feasible CHW engagement was associated with tobacco abstinence in adults with serious mental illness. CHW implementation may benefit from promoting CHW training and integration within clinical teams.