Adolescent Substance Use at the Intersection of Sexual Orientation and Gender Identity.

BACKGROUND: Substance use in adolescence is associated with multiple negative outcomes. Lesbian, gay, or bisexual or transgender or nonbinary (TNB) youth, and those who question their sexual orientation or gender, are more likely to engage in substance use than straight or cisgender youth. However, the extant literature largely considers sexual orientation and gender identity independently. Accordingly, this study examines the associations between the intersectional identities of sexual orientation and gender and substance use to identify those with the greatest need for prevention interventions. METHODS: Data were from 36 504 high school students aged 14 to 18 years (mean = 15.7, SD = 1.18) enrolled in the 2019 Healthy Kids Colorado Survey using a statewide stratified random sampling design. Logistic regression models examined the associations between intersectional sexual orientation and gender on marijuana use, prescription drug misuse, and polysubstance use, as well as depression and violence victimization (eg, forced sex, partner violence). RESULTS: Adjusted odds of substance use for sexual and gender minority youth varied by intersectional identity and substance. The largest effect sizes were seen for prescription drug misuse, especially among those questioning their gender and sexual orientation and heterosexuals either questioning their gender or who identified as TNB. Effect sizes for marijuana use and polysubstance use were highest for TNB and heterosexual participants. Depression and violence victimization were significantly associated with each substance use outcome. CONCLUSIONS: Interventions to reduce substance use in these populations may benefit from targeted interventions for youth with different intersectional identities, and a focus on violence prevention and depression screening and treatment.

Child Maltreatment, Mental Health, and Self-Reported Health Among Adolescent Girls in Child Welfare: Mediating Pathways.

Child maltreatment is common in the US and has been shown to be associated with physical and psychological health problems in adolescence and adulthood. Based on the allostatic load theory, this study examined the association between different types of child maltreatment (emotional, physical, and sexual abuse, and physical neglect) and self-rated health, and the mediating roles of post-traumatic stress and depression in these relationships. Participants were 249 girls involved in the child welfare system, ages 12-19 years, the majority of whom were African American. A one item self-reported general health measure, the Child Trauma Questionnaire-Short Form (CTQ-SF), Child PTSD Symptom Scale (CPSS) and the Child Depression Inventory (CDI) measured self-reported health, child maltreatment, and posttraumatic and depression symptoms, respectively. Higher levels of emotional, physical, and sexual abuse, and physical neglect were significantly associated with poorer ratings of health. PTSD and depression were significant mediators between histories of childhood emotional, physical, and sexual abuse and physical health. In conclusion, results indicate that the pathways from child abuse to physical health problems in adolescents are through psychological distress. Trauma focused interventions to reduce symptoms of PTSD and depression among this vulnerable group of adolescents are essential to improve health.

Ten years of implementation outcomes research: a scoping review.

BACKGROUND: Proctor and colleagues' 2011 paper proposed a taxonomy of eight implementation outcomes and challenged the field to address a research agenda focused on conceptualization, measurement, and theory building. Ten years later, this paper maps the field's progress in implementation outcomes research. This scoping review describes how each implementation outcome has been studied, research designs and methods used, and the contexts and settings represented in the current literature. We also describe the role of implementation outcomes in relation to implementation strategies and other outcomes. METHODS: Arksey and O'Malley's framework for conducting scoping reviews guided our methods. Using forward citation tracing, we identified all literature citing the 2011 paper. We conducted our search in the Web of Science (WOS) database and added citation alerts sent to the first author from the publisher for a 6-month period coinciding with the WOS citation search. This produced 1346 titles and abstracts. Initial abstract screening yielded 480 manuscripts, and full-text review yielded 400 manuscripts that met inclusion criteria (empirical assessment of at least one implementation outcome). RESULTS: Slightly more than half (52.1%) of included manuscripts examined acceptability. Fidelity (39.3%), feasibility (38.6%), adoption (26.5%), and appropriateness (21.8%) were also commonly examined. Penetration (16.0%), sustainability (15.8%), and cost (7.8%) were less frequently examined. Thirty-two manuscripts examined implementation outcomes not included in the original taxonomy. Most studies took place in healthcare (45.8%) or behavioral health (22.5%) organizations. Two-thirds used observational designs. We found little evidence of progress in testing the relationships between implementation strategies and implementation outcomes, leaving us ill-prepared to know how to achieve implementation success. Moreover, few studies tested the impact of implementation outcomes on other important outcome types, such as service systems and improved individual or population health. CONCLUSIONS: Our review presents a comprehensive snapshot of the research questions being addressed by existing implementation outcomes literature and reveals the need for rigorous, analytic research and tests of strategies for attaining implementation outcomes in the next 10 years of outcomes research.

More than just Reminders: Using text Messaging to Improve HIV care Outcomes Among Youth and Young Adults Living with HIV.

This study evaluated engagement, satisfaction, and efficacy of an automated and live two-way text messaging intervention that linked youth and young adults at high risk for poor HIV outcomes to their medical case managers, with the aims of increasing viral load suppression rates and improving medical visit attendance. Participants (N = 100) were an average age of 22-23 years old. Most were Black (93%) and men who have sex with men (82%). A total of 89,681 automated text messages were sent to participants; and 62% of participants engaged in monthly text-message exchanges with medical case managers. McNemar's test results indicated that a significantly greater proportion of intervention participants were virally suppressed at 6 and 12 month follow-up than at enrollment. Adjusted odds ratio results showed a significant association between likelihood of achieving viral suppression at 6 and 12 months, and a greater number of participant responses to automated text messages. Future research should prospectively compare outcomes between usual care case management and usual care plus text-messaging to test for significant differences between groups.

RESUMEN: La presente investigación evaluó el compromiso, la satisfacción y la eficacia de una intervención de mensajes de texto bidireccional automatizada y en vivo que vinculó a jóvenes y adultos jóvenes con altos riesgos de resultados deficientes del VIH con sus administradores de casos médicos, con el objetivo de aumentar las tasas de supresión de la carga viral y mejorar la asistencia a las visitas médicas. Los participantes (n = 100) tenían una edad promedio de 22 a 23 años. La mayoría eran negros (93,0%) y hombres que tienen sexo con hombres (82,0%). Un total de 89.681 mensajes de texto automatizados fueron enviados a los participantes; y 62,0% de los participantes participaron en intercambios de mensajes de texto mensuales con los administradores de casos médicos. Los resultados de la prueba de McNemar indicaron que una proporción significativamente mayor de participantes de la intervención fueron suprimidos viralmente a los 6 y 12 meses de seguimiento que al momento de la inscripción. Los resultados del índice de probabilidad ajustado mostraron una asociación significativa entre la probabilidad de lograr la supresión viral a los 6 y 12 meses, así como un mayor número de respuestas de los participantes a los mensajes de texto automatizados. Las investigaciones futuras deben comparar prospectivamente los resultados entre la gestión de casos de atención habitual y la atención habitual más mensajes de texto para evaluar las diferencias significativas entre los grupos.

Help Is Available: Supporting Mental Wellness Through Peer Health Navigation with Young Black Men Who Have Sex with Men with HIV.

Young black men who have sex with men (YBMSM) with HIV experience disproportionate rates of trauma, incarceration, poverty, racial discrimination, and homophobia. The synergistic effects of these adverse experiences, along with increased rates of mental health disorders, increase their risk for poor health. To address this need, the study authors adapted a current HIV service model to include a peer-health navigation intervention (WITH U) to attend to behavioral health, health literacy, linkage to services, and psychosocial support for YBMSM with HIV. This longitudinal, mixed-methods, nonexperimental study reports on the mental health burden among participants and the association between participation in WITH U and mental wellness outcomes. Participants (N = 65) were an average age of 25-26 years (mean = 25.48, standard deviation = 2.51). Over 25% of participants reported clinically significant depression and/or anxiety symptoms and nearly half the participants reported experiencing post-traumatic stress symptoms that were at least moderately difficult to handle. Quantitative analyses indicated no significant positive association between intervention engagement and mental health symptoms; however, reporting a greater number of depression symptoms was associated with attending fewer intervention sessions. Qualitative data analysis revealed that participants' mental wellness was positively impacted by participating in the intervention and that participants preferred to receive mental wellness support from peer health navigators (HNs) rather than licensed mental health professionals. Yet, peer HNs did not feel adequately prepared to address participants' mental wellness concerns. Increased training for peer HNs and development of a linkage process to more formalized mental health services with community input may strengthen mental wellness support.

Six practical recommendations for improved implementation outcomes reporting.

BACKGROUND: Implementation outcomes research spans an exciting mix of fields, disciplines, and geographical space. Although the number of studies that cite the 2011 taxonomy has expanded considerably, the problem of harmony in describing outcomes persists. This paper revisits that problem by focusing on the clarity of reporting outcomes in studies that examine them. Published recommendations for improved reporting and specification have proven to be an important step in enhancing the rigor of implementation research. We articulate reporting problems in the current implementation outcomes literature and describe six practical recommendations that address them. RECOMMENDATIONS: Our first recommendation is to clearly state each implementation outcome and provide a definition that the study will consistently use. This includes providing an explanation if using the taxonomy in a new way or merging terms. Our second recommendation is to specify how each implementation outcome will be analyzed relative to other constructs. Our third recommendation is to specify "the thing" that each implementation outcome will be measured in relation to. This is especially important if you are concurrently studying interventions and strategies, or if you are studying interventions and strategies that have multiple components. Our fourth recommendation is to report who will provide data and the level at which data will be collected for each implementation outcome, and to report what kind of data will be collected and used to assess each implementation outcome. Our fifth recommendation is to state the number of time points and frequency at which each outcome will be measured. Our sixth recommendation is to state the unit of observation and the level of analysis for each implementation outcome. CONCLUSION: This paper advances implementation outcomes research in two ways. First, we illustrate elements of the 2011 research agenda with concrete examples drawn from a wide swath of current literature. Second, we provide six pragmatic recommendations for improved reporting. These recommendations are accompanied by an audit worksheet and a list of exemplar articles that researchers can use when designing, conducting, and assessing implementation outcomes studies.

"We Are Doing the Absolute Most That We Can, and No One Is Listening": Barriers and Facilitators to Health Literacy within Transgender and Nonbinary Communities.

Transgender and nonbinary (TNB) individuals face disparities in nearly every aspect of health. One factor associated with poor health outcomes in other marginalized populations is health literacy, yet no identified studies examine health literacy in TNB samples. Moreover, most health literacy frameworks focus primarily on the capacities of individual patients to understand and use healthcare information, with little attention given to provider literacy and environmental factors. In partnership with a statewide LGBTQ advocacy organization, we recruited 46 transgender and nonbinary individuals to participate in seven focus groups conducted in urban, suburban, and rural locations throughout Colorado. TNB participants consistently engaged in efforts to increase their own health literacy and that of their medical providers yet faced multiple barriers to improve care. Difficulty identifying and physically reaching care, insurance and out-of-pocket expenses, negative experiences with healthcare providers and staff, provider incompetence, discriminatory and oppressive practices, and exclusionary forms and processes emerged as barriers to enacted health literacy among participants. Conversely, facilitators of enacted healthcare literacy included positive experiences with healthcare providers and staff, and inclusive forms and processes.

Alcohol use at the intersection of sexual orientation and gender identity in a representative sample of youth in Colorado.

BACKGROUND AND OBJECTIVES: Lesbian, gay, bisexual, and questioning (LGBQ) youth are at greater risk of problematic alcohol use than their heterosexual peers, yet there is a dearth of research examining variability in alcohol use among youth that simultaneously accounts for sexual orientation and gender identity. This paper examines the relationship between alcohol use and intersecting identities of sexual orientation and gender while accounting for this population's disproportionate experiences of depression and dating and sexual violence. METHODS: The study used a representative sample (n = 27,621) of high school students. Logistic regressions were used to determine if earlier age at first drink, 30-day alcohol use, and binge drinking were significantly related to intersectional sexual orientation and gender identity. Secondary models added depression, dating violence, and sexual violence to analyses to determine if they explained any of the variance in alcohol use variables in LGBQ and transgender youth. RESULTS: Transgender youth who identified as heterosexual or questioning their sexual orientation were at greatest risk for early initiation of alcohol use and binge drinking. These relationships between intersectional identity and alcohol use became nonsignificant when depression, dating violence, and sexual violence were added to the models. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This is the first study to examine relationships between intersecting identities of sexual orientation and gender identity and alcohol use among youth. Risky alcohol use among transgender youth may be attributed to experiences of depression, dating violence, and sexual violence impacting these populations. Interventions should focus on reducing transgender youth exposure to violence.

Ten years of implementation outcome research: a scoping review protocol.

INTRODUCTION: A 2011 paper proposed a working taxonomy of implementation outcomes, their conceptual distinctions and a two-pronged research agenda on their role in implementation success. Since then, over 1100 papers citing the manuscript have been published. Our goal is to compare the field's progress to the originally proposed research agenda, and outline recommendations for the next 10 years. To accomplish this, we are conducting the proposed scoping review. METHODS AND ANALYSIS: Our approach is informed by Arksey and O'Malley's methodological framework for conducting scoping reviews. We will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We first aim to assess the degree to which each implementation outcome has been investigated in the literature, including healthcare settings, clinical populations and innovations represented. We next aim to describe the relationship between implementation strategies and outcomes. Our last aim is to identify studies that empirically assess relationships among implementation and/or service and client outcomes. We will use a forward citation tracing approach to identify all literature that cited the 2011 paper in the Web of Science (WOS) and will supplement this with citation alerts sent to the second author for a 6-month period coinciding with the WOS citation search. Our review will focus on empirical studies that are designed to assess at least one of the identified implementation outcomes in the 2011 taxonomy and are published in peer-reviewed journals. We will generate descriptive statistics from extracted data and organise results by these research aims. ETHICS AND DISSEMINATION: No human research participants will be involved in this review. We plan to share findings through a variety of means including peer-reviewed journal publications, national conference presentations, invited workshops and webinars, email listservs affiliated with our institutions and professional associations, and academic social media.

Associations Between Social Support and Social Media Use Among Young Adult Cisgender MSM and Transgender Women Living With HIV.

Social media platforms offer the opportunity to develop online social networks. Use of these platforms has been particularly attractive to younger sexual and gender minority individuals as well as those living with HIV. This cross-sectional study examined the perceived level of social support and associations with social media use among youth and young adult cisgender men who have sex with men (MSM) and transgender (trans) women living with HIV and examined these associations by gender identity. The study drew from baseline data collected from 612 cisgender MSM and 162 trans women enrolling in one of 10 demonstration sites that were part of a Health Resources and Services Administration Special Projects of National Significance initiative. The individual projects were designed to evaluate the potential for social media/mobile technology-based interventions to improve retention in care and HIV health outcomes. The data used in this study came from baseline surveys completed when participants enrolled in a site between October 2016 and May 2018. Results demonstrated that a significantly greater proportion of MSM than trans women participants reported the use of social media platforms (e.g., Facebook: MSM = 86%, trans women = 62%; Instagram: MSM = 65%, trans women = 35%). Furthermore, increased social media use improved perceptions of social support only among MSM participants (direct adjusted OR = 1.49) and not trans women participants (gender identity interaction term adjusted OR = 0.64). These results revealed that MSM participants perceived greater social benefit from the use of social media platforms than trans women, which could be a result of generalized online transphobia experienced by trans women. More nuanced data on various social media platforms, that is, anonymous versus profile-based, and group differences, are needed to better understand how social media platforms can be best utilized to optimize health care outcomes among sexual and gender minority youth and young adults living with HIV.

E-VOLUTION: A Text Messaging-Powered Intervention-Connection, Support, and HIV Eradication.

This longitudinal, nonexperimental, quantitative study examined the acceptability, feasibility, and efficacy of a texting intervention that was added to medical case management for youth and young adults at high risk for poor HIV outcomes. The intervention, E-VOLUTION, sent automated text messages to youth participants living with HIV that reminded them to take prescribed medication and attend medical visits. Automated texts also asked clients about mood, housing, and ability to pay bills. Client responses to automated texts that indicated challenges triggered alerts for their medical case manager, who then followed up to address the issue. Participants (N = 100) were an average age between 22 and 23 years and most were Black (95%) and men who have sex with men (82%). Over a period of 26 months 89,681 automated texts were sent, resulting in 450 alerts. Additionally, clients and medical case managers exchanged more than 17,000 texts. Results of Spearman correlations indicated significant associations between greater frequency of alerts triggered and greater likelihood of kept medical appointments (p < .05). Findings also showed significant associations between greater frequency of texting with a medical case manager and greater likelihood of viral load suppression and kept medical visits at 12-month follow-up (p < .01). More frequent substance use was associated with more alerts triggered (p < .01). Use of text messaging was acceptable to the participants and is a culturally responsive way to engage youth participants living with HIV in care. Future research may examine the use of structured behavioral health assessments in the automated texting framework, as well as compare outcomes between automated and two-way texting groups.

Exploring Bullying Perpetration and Victimization Among Adolescent Girls in the Child Welfare System: Bully-Only, Victim-Only, Bully-Victim, and Noninvolved Roles.

Childhood abuse is a common experience for youth in the child welfare system, increasing their risk of bullying perpetration and victimization. Little research exists that has examined the rates of bullying perpetration and victimization for child welfare-involved adolescent girls. The study addressed the following aims: (a) to generate frequency estimates of physical, nonphysical, and relational forms of bullying perpetration and victimization; (b) to identify the frequency of bully-only, victim-only, bully-victim, and noninvolved roles; and (c) to identify risk and protective factors that correlate with these bullying role types. Participants were 236 girls (12-19 years) in the child welfare system from a Midwestern urban area. Participants were referred to the study to join a trauma-focused group program. Seventy-five percent of the total sample were youth of color, with the remaining 25% identifying as White, non-Hispanic. Data were collected through baseline surveys that assessed childhood abuse, bullying perpetration and victimization, posttraumatic stress, substance misuse, aggression-related beliefs and self-efficacy, placement type, placement instability, and mental health service use. Child welfare-involved adolescent girls were found to assume all four major role types: bully-only (6.4%, n = 15), victim-only (20.3%, n = 48), bully-victim (44.1%, n = 104), and nonvictims (29.2%, n = 69). The bully-victim rate was approximately 7 times higher than the rate found in a nationally representative sample of non-child welfare-involved youth. The current study identified posttraumatic stress disorder (PTSD) symptoms, anger self-efficacy, and alcohol use as significant correlates of bullying roles. The identification of a substantially higher rate of bully-victims has important practice implications, suggesting child welfare and school systems adopt trauma-informed systems of care. Bully-victims are very likely traumatized children who are in need of effective trauma treatment rather than punitive sanctions.

Technology-Based Alcohol Interventions in Primary Care: Systematic Review.

BACKGROUND: Primary care settings are uniquely positioned to reach individuals at risk of alcohol use disorder through technology-delivered behavioral health interventions. Despite emerging effectiveness data, few efforts have been made to summarize the collective findings from these delivery approaches. OBJECTIVE: The aim of this study was to review recent literature on the use of technology to deliver, enhance, or support the implementation of alcohol-related interventions in primary care. We focused on addressing questions related to (1) categorization or target of the intervention, (2) descriptive characteristics and context of delivery, (3) reported efficacy, and (4) factors influencing efficacy. METHODS: We conducted a comprehensive search and systematic review of completed studies at the intersection of primary care, technology, and alcohol-related problems published from January 2000 to December 2018 within EBSCO databases, ProQuest Dissertations, and Cochrane Reviews. Of 2307 initial records, 42 were included and coded independently by 2 investigators. RESULTS: Compared with the years of 2000 to 2009, published studies on technology-based alcohol interventions in primary care nearly tripled during the years of 2010 to 2018. Of the 42 included studies, 28 (64%) were randomized controlled trials. Furthermore, studies were rated on risk of bias and found to be predominantly low risk (n=18), followed by moderate risk (n=16), and high risk (n=8). Of the 24 studies with primary or secondary efficacy outcomes related to drinking and drinking-related harms, 17 (71%) reported reduced drinking or harm in all primary and secondary efficacy outcomes. Furthermore, of the 31 studies with direct comparisons with treatment as usual (TAU), 13 (42%) reported that at least half of the primary and secondary efficacy outcomes of the technology-based interventions were superior to TAU. High efficacy was associated with provider involvement and the reported use of an implementation strategy to deliver the technology-based intervention. CONCLUSIONS: Our systematic review has highlighted a pattern of growth in the number of studies evaluating technology-based alcohol interventions in primary care. Although these interventions appear to be largely beneficial in primary care, outcomes may be enhanced by provider involvement and implementation strategy use. This review enables better understanding of the typologies and efficacy of these interventions and informs recommendations for those developing and implementing technology-based alcohol interventions in primary care settings.

The Moderating Effect of Marijuana Use on the Relationship between Delinquent Behavior and HIV Risk among Adolescents in Foster Care.

Adolescents in foster care experience mental health and substance use problems that place them at risk for HIV, yet the exact nature of the relationship remains unclear. This study examined the co-occurring influences of mental health problems and substance use on HIV risk and determined whether substance use moderated the effect of mental health problems on HIV risk behaviors among adolescents in foster care. Regression analyses of cross-sectional data collected through structured interviews with 334 adolescents, aged 15-18 years, determined which mental health problems and substances increased HIV risk behaviors. Adolescents with delinquency and anxiety/depression engaged in significantly more HIV risk behaviors than their counterparts, controlling for race, gender, and type of childhood abuse. Further, any marijuana use significantly moderated the effects of delinquent behaviors on HIV risk, differentially increasing HIV risk among those who engaged in delinquent behaviors.