Listening Sessions to Shape the Innovative NIH ComPASS Common Fund Program to Advance Health Equity.

The National Institutes of Health (NIH) recognized the need for a research program to address the underlying structural factors that impact health. To inform the development of the NIH Common Fund Community Partnerships to Advance Science for Society (ComPASS) Program, NIH obtained input through community listening sessions. Through its design, ComPASS recognizes the essential role of community organizations as the lead in addressing persistent structural and social challenges to accelerate progress toward advancing health equity. (Am J Public Health. Published online ahead of print April 18, 2024:e1-e5. https://doi.org/10.2105/AJPH.2024.307656).

The intersection of health and housing: Analysis of the research portfolios of the National Institutes of Health, Centers for Disease Control and Prevention, and U.S. Department of Housing and Urban Development.

BACKGROUND: Housing is a major social determinant of health that affects health status and outcomes across the lifespan. OBJECTIVES: An interagency portfolio analysis assessed the level of funding invested in "health and housing research" from fiscal years (FY) 2016-2020 across the National Institutes of Health (NIH), the United States Department of Housing and Urban Development (HUD), and the Centers for Disease Control and Prevention (CDC) to characterize the existing health and housing portfolio and identify potential areas for additional research and collaboration. METHODS/RESULTS: We identified NIH, HUD, and CDC research projects that were relevant to both health and housing and characterized them by housing theme, health topic, population, and study design. We organized the assessment of the individual housing themes by four overarching housing-to-health pathways. From FY 2016-2020, NIH, HUD, and CDC funded 565 health and housing projects combined. The Neighborhood pathway was most common, followed by studies of the Safety and Quality pathway. Studies of the Affordability and Stability pathways were least common. Health topics such as substance use, mental health, and cardiovascular disease were most often studied. Most studies were observational (66%); only a little over one fourth (27%) were intervention studies. DISCUSSION: This review of the research grant portfolios of three major federal funders of health and housing research in the United States describes the diversity and substantial investment in research at the intersection between housing and health. Analysis of the combined portfolio points to gaps in studies on causal pathways linking housing to health outcomes. The findings highlight the need for research to better understand the causal pathways from housing to health and prevention intervention research, including rigorous evaluation of housing interventions and policies to improve health and well-being.

Strategic Directions in Preventive Intervention Research to Advance Health Equity.

As commissioned by the Society for Prevention Research, this paper describes and illustrates strategic approaches for reducing health inequities and advancing health equity when adopting an equity-focused approach for applying prevention science evidence-based theory, methodologies, and practices. We introduce an ecosystemic framework as a guide for analyzing, designing, and planning innovative equity-focused evidence-based preventive interventions designed to attain intended health equity outcomes. To advance this process, we introduce a health equity statement for conducting integrative analyses of ecosystemic framework pathways, by describing the role of social determinants, mechanisms, and interventions as factors directly linked to specific health equity outcomes. As background, we present health equity constructs, theories, and research evidence which can inform the design and development of equity-focused intervention approaches. We also describe multi-level interventions that when coordinated can produce synergistic intervention effects across macro, meso, and micro ecological levels. Under this approach, we encourage prevention and implementation scientists to apply and extend these strategic directions in future research to increase our evidence-based knowledge and theory building. A general goal is to apply prevention science knowledge to design, widely disseminate, and implement culturally grounded interventions that incrementally attain specific HE outcomes and an intended HE goal. We conclude with recommendations for conducting equity-focused prevention science research, interventions, and training.

America's opioid crisis: the need for an integrated public health approach.

Continued increases in overdose deaths and recent declines in life expectancy call for need to adopt comprehensive public health approaches to the United States opioid crisis and to establish an infrastructure to avert future crises. Successfully addressing the challenges posed by the crisis requires a translational, integrated approach that combines the contribution of neuroscience, pharmacology, epidemiology, treatment services and prevention. It also is critical to integrate interventions across settings, including healthcare, justice, education and social service systems. This review highlights four interconnected themes: (1) social determinants of health and disease; (2) person-centered approaches for prevention and treatment; (3) bridging the gap between implementation science and practice; and (4) using data to build learning systems of care, relevant to public health approaches to address the opioid crisis. We discuss how across these four themes taking into account the influence of developmental factors on brain function and sensitivity to environmental stimuli including drugs, addressing the complex interactions between biological and social factors, and promoting an ongoing dialogue across disciplines and settings will help accelerate public health advances that are evidenced based and sustainable to address the current opioid crisis and avert future ones.

Building the Evidence Base to Inform Planned Intervention Adaptations by Practitioners Serving Health Disparity Populations.

Many evidence-based interventions (EBIs) have been developed to prevent or treat major health conditions. However, many EBIs have exhibited limited adoption, reach, and sustainability when implemented in diverse community settings. This limitation is especially pronounced in low-resource settings that serve health disparity populations. Often, practitioners identify problems with existing EBIs originally developed and tested with populations different from their target population and introduce needed adaptations to make the intervention more suitable. Although some EBIs have been extensively adapted for diverse populations and evaluated, most local adaptations to improve fit for health disparity populations are not well documented or evaluated. As a result, empirical evidence is often lacking regarding the potential effectiveness of specific adaptations practitioners may be considering. We advocate an expansion in the emphasis of adaptation research from researcher-led interventions to research that informs practitioner-led adaptations. By presenting a research vision and strategies needed to build this area of science, we aim to inform research that facilitates successful adaptation and equitable implementation and delivery of EBIs that reduce health disparities.

Screening and counseling for Intimate Partner Violence: a vision for the future.

We describe a vision of screening and intervention for Intimate Partner Violence informed by deliberations during the December 2013 Intimate Partner Violence Screening and Counseling Research Symposium and the resultant manuscripts featured in this special issue of the Journal of Women's Health. Our vision includes universal screening and intervention, when indicated, which occurs routinely as part of comprehensive physical and behavioral health services that are both patient centered and trauma informed. Areas for future research needed to realize this vision are discussed.

HIV risk behaviors: risky sexual activities and needle use among adolescents in substance abuse treatment.

This study estimated prevalence of HIV risk behaviors and its association with substance use and mental health problems among adolescents in treatment. A pooled dataset of 9,519 adolescents admitted to substance abuse treatment programs between 2002 and 2006 was analyzed. HIV risk behaviors, substance use, and mental health problems were assessed at treatment intake. Sixty percent of adolescents were engaged in at least one sexual or needle use risk behavior in the year prior to entering treatment. Sex with multiple partners, sex under the influence of alcohol or drugs, and unprotected sex were the most prevalent HIV risk behaviors. Several gender differences were found for specific types of sexual and needle use behaviors. Adolescents with substance dependence or other comorbid mental health problems were at increased odds for HIV risk. Findings suggest treatment programs may benefit adolescents better by screening them consistently for HIV risk behaviors and incorporating tailored interventions.

Predictors of drug treatment completion among parole violators.

This study examined the predictors of treatment completion among 380 state parole violators consecutively admitted to a comprehensive 12-month drug treatment program in lieu of reincarceration. Offenders were placed on intensive parole supervision throughout the 12-month treatment protocol and received three months of residential substance abuse treatment followed by nine months of outpatient counseling. Overall 123 (32.4%) of the offenders completed the 12-month treatment protocol. The primary reason for noncompletion was a positive drug screen. Bivariate analyses were performed to determine independent predictors of program completion. Four variables (age, past 30-day heroin use, total months incarcerated, and significant problems with mother) from the baseline Addiction Severity Index were found to be correlated with treatment completion (p <.10). These factors and other demographics (race, marital status, education) and variables found predictive of program completion in previous studies were entered into a multiple logistic regression model. Overall the final model found that only two factors--older age (p < .03) and no heroin use in the past 30 days (p < .02) significantly predicted treatment completion. These findings suggest that among parolees with moderate to extensive criminal justice histories younger individuals and those with recent heroin use respond less favorably to comprehensive substance abuse treatment services and intensive parole supervision.

Predictors of opiate agonist treatment retention among injection drug users referred from a needle exchange program.

AIMS: The aim of this study was to examine the effect of a case management intervention on retention in opiate agonist therapy among injection drug users (IDUs) referred from a needle exchange program (NEP). DESIGN, INTERVENTION, PARTICIPANTS, AND SETTING: A randomized trial of a strengths-based case management intervention versus passive referral (control) was conducted among NEP attendees requesting and receiving referrals to subsidized, publicly funded opiate agonist treatment programs in Baltimore, MD. MEASUREMENTS: Multivariable Cox regression models were used to identify predictors of treatment retention using an ecological model approach, taking into account factors at the individual, social, and environmental level. FINDINGS: Of 245 IDUs, 127 (51.8%) entered opiate agonist treatment, for whom median retention was 7.9 months. The intervention was not associated with longer retention (p = .91). Individual-level factors predictive of shorter retention included being employed and greater levels of psychiatric distress. Participants who had prior treatment experience and multiple treatment requests were retained significantly longer. Social factors adversely affecting treatment retention included unstable housing and buying drugs for others. Living further away from the treatment site was an environmental barrier that negatively affected treatment retention. CONCLUSIONS: Multilevel interventions that address individual, social, and environmental factors are necessary to improve substance abuse treatment retention and treatment outcomes among IDUs referred from NEP.

The impact of opiate agonist maintenance therapy on drug use within social networks of injecting drug users.

This study examined whether participation in opiate drug treatment is associated with changes in drug use and injecting drug use within the social networks of injecting drug users. Participants were 245 injecting drug users who attended the Baltimore Needle Exchange Program during 2002-2004 and requested treatment and received a referral for opiate agonist treatment as part of an intervention to improve treatment outcomes. Data included interviews at baseline, 3, 6, 12, and 18 months and drug treatment program agency records. The mean age of participants was 42.2 years; 77% were African American, 69% were male, and 48% entered treatment. Final generalized estimating equations (GEE) models indicated that participants that entered opiate drug treatment exhibited approximately a 20% decrease in the proportional odds of having friends that used drugs (p = 0.04). Additionally, participants that entered opiate drug treatment exhibited a 26% decrease in the proportional odds of having friends that injected drugs (p = 0.01). These findings contribute evidence to further understand the dynamics between opiate drug treatment, changes in social network risk, and treatment outcomes, as well as suggest an important role for peer-based interventions to support entry and retention in opiate drug treatment.

The relationship between lifetime abuse and suicidal ideation in a sample of injection drug users.

This study examined the relationship between lifetime abuse and suicidal ideation in a sample of 245 injection drug users (IDUs) who attended the Baltimore Needle Exchange Program and received a referral for opiate agonist therapy. Data were obtained from baseline interviews and HIV antibody tests. The sample mean age was 42.2 (SD = 8.1 ); 77% were African American; 69% were male. Overall, 27% reported thoughts of suicide in the last six months, and lifetime emotional, physical and sexual abuse was reported by 17%, 12% and 10%, respectively. In bivariate analyses, recent suicidal ideation was associated with emotional (odds ratio [OR] = 3.2; p = 0.001), physical (OR = 2.5; p = 0.026), and sexual abuse (OR = 5.0; p < 0.001). In multiple logistic regression models controlling for HIV status and Center for Epidemiological Studies Depression (CES-D) score, individuals who experienced emotional abuse were more than twice as likely to report recent suicidal ideation (adjusted odds ratio [AOR] = 2.6; p = 0.011); those who experienced sexual abuse were four times more likely to report suicidal ideation (AOR = 4.0; p = 0.004). These findings suggest that emotional and sexual abuse might be risk factors for suicidality among IDUs and also might suggest that suicide prevention should be an integral part of drug treatment for treatment-seeking IDUs.

The effect of a case management intervention on drug treatment entry among treatment-seeking injection drug users with and without comorbid antisocial personality disorder.

We examined the effect of a case management intervention on drug treatment entry among injection drug users (IDUs) with and without comorbid antisocial personality disorder (ASPD). Injection drug users attending the Baltimore Needle Exchange Program who sought and were granted referrals to opioid agonist treatment were randomized to receive a strengths-based case management intervention or passive referral. Of 162 IDUs, 22.8% met the DSM-IV criteria for ASPD. Compared to those without ASPD, IDUs with comorbid ASPD who spent 25 or more minutes with their case manager prior to their treatment entry date were 3.51 times more likely to enter treatment than those receiving less than 5 min, adjusting for intervention status, race, and treatment site (95% confidence interval 1.04-11.89). Providing case management services to IDUs with comorbid ASPD may facilitate treatment entry and reduce the negative consequences of drug abuse.

Facilitating entry into drug treatment among injection drug users referred from a needle exchange program: Results from a community-based behavioral intervention trial.

We evaluated a case management intervention to increase treatment entry among injecting drug users referred from a needle exchange program (NEP). A randomized trial of a strengths based case management (intervention) versus passive referral (control) was conducted among NEP attenders requesting and receiving referrals to subsidized, publicly funded opiate agonist treatment programs in Baltimore, MD. Logistic regression identified predictors of treatment entry within 7 days, confirmed through treatment program records. Of 247 potential subjects, 245 (99%) participated. HIV prevalence was 19%. Overall, 34% entered treatment within 7 days (intervention: 40% versus control: 26%, p=0.03). In a multivariate "intention to treat" model (i.e., ignoring the amount of case management actually received), those randomized to case management were more likely to enter treatment within 7 days. Additional "as treated" analyses revealed that participants who received 30 min or more of case management within 7 days were 33% more likely to enter treatment and the active ingredient of case management activities was provision of transportation. These findings demonstrate the combined value of offering dedicated treatment referrals from NEP, case management and transportation in facilitating entry into drug abuse treatment. Such initiatives could be implemented at more than 140 needle exchange programs currently operating in the United States. These data also support the need for more accessible programs such as mobile or office-based drug abuse treatment.

Social contextual factors associated with entry into opiate agonist treatment among injection drug users.

We tested hypotheses that social living arrangement and drug use in one's network are independently associated with entry into opiate agonist treatment modalities. Injection drug users (IDUs) attending the Baltimore Needle Exchange Program who received a referral for drug abuse treatment were studied. Baseline interviews, HIV testing, and the Addiction Severity Index (ASI) were administered. Agency records were used to confirm entry into a treatment program offering opiate agonist maintenance therapy within 30 days of the baseline interview. Logistic regression was used to identify predictors of treatment entry. To date, of 245 IDUs, 39% entered such a program. Multivariate logistic regression models controlling for age and intervention status revealed that compared to individuals who lived alone, in a controlled, or nonstable environment (e.g., streets, abandoned house, transitional housing program, or boarding house), individuals who lived with a sexual partner were 3 times more likely to enter treatment (adjusted Odds Ratio [aOR]=3.04; p=0.013) and those who lived with family or friends were almost 3 times more likely to enter treatment (aOR=2.72; p=0.016). In the bivariate analyses, a marginal association was observed between being responsible for children or others and entry into treatment (p=0.066); however, this association was not significant in the multivariate model. Findings from this study suggest that supportive living environments may facilitate entry into treatment and may be helpful in devising appropriate and targeted interventions to encourage drug treatment entry.

Clinical features associated with receipt of alcohol treatment.

OBJECTIVE: In this study, we sought to identify specific clinical features of alcohol dependence and other characteristics of recent drinkers that might help differentiate drinkers who receive treatment. METHOD: In 1998, field staff for the National Household Survey on Drug Abuse assessed 18,722 sampled adults, including 12,437 who reported drinking in the year prior to survey, most of whom self-marked answers to standard items on drug experiences, including clinical features of alcohol dependence and receipt of treatment. Statistical analyses took into account the complex sampling procedures and the interdependencies between individual responses. RESULTS: Multivariate modeling with generalized linear model and generalized estimating equations with statistical adjustment for age, gender and race revealed that individuals who received treatment reported all seven clinical features more often than drinkers who did not receive treatment, with the greatest differences observed for alcohol-related emotional problems (adjusted odds ratio [adj. OR] = 15.0), health problems (adj. OR = 13.5), reduced important activities (adj. OR = 10.4) and inability to cut down (adj. OR = 10.1) (all p values < .05). The observed treatment-related differences were less pronounced for other clinical features (e.g., reported tolerance [adj. OR = 4.8], using more than was intended [adj. OR = 6.2] and salience of alcohol-related behavior [adj. OR = 6.2]; all p values < .05). Further statistical adjustment for frequency of alcohol use and age of first alcohol use did not alter these estimates appreciably. CONCLUSIONS: Reasons for observed excess occurrence of alcohol-related problems among community samples of drinkers who receive treatment deserve more attention in future research. A key research question is whether self-awareness of alcohol-related problems motivates drinkers to seek treatment or if treatment promotes awareness and decreases denial about alcohol problems.

Hanging out with the wrong crowd: how much difference can parents make in an urban environment?

This longitudinal study of youths growing up in an urban area tests whether and by how much increased levels of supervision and monitoring by parents might influence levels of affiliation with delinquent and deviant peers--possibly our most sturdily replicated proximal determinant of early-onset illegal drug use and associated conduct problems in adolescence, aside from aggression and rule-breaking in childhood. Standardized interviews were used to assess parenting, affiliation with deviant peers, and other characteristics of the urban-dwelling youths in this epidemiologically defined sample (>70% African American heritage). Longitudinal analyses and generalized estimating equation (GEE) methods were used to estimate prospective relationships across the transition from late childhood into early adolescence. Results from the longitudinal analyses showed that higher levels of monitoring signaled later lower levels of affiliation with deviant peers, even with statistical adjustment for multiple covariates (beta=-0.04; 95% confidence interval [CI]=-0.07 to -0.02; P=.001). Closer parental supervision at ages 8-9 years was linked to subsequently lower levels of deviant peer affiliation (beta=-0.05; 95% CI=-0.08 to -0.01), and subsequent age-associated increases in levels of parental supervision from year to year were followed by decreases in levels of affiliation with deviant peers (beta=-0.12; 95% CI=-0.15 to -0.09). The main evidence from this study indicates that maintenance of parental supervision and monitoring through the transition from childhood to adolescence may yield important reductions in levels of affiliation with deviant peers, even in the context of our urban and sometimes socially disadvantaged community environments.

Using the chronic care model to improve treatment of alcohol use disorders in primary care settings.

OBJECTIVE: Alcohol use disorders (AUDs) are serious and often chronic medical conditions that present a significant public health concern. The Chronic Care Model (CCM), originally designed to improve care for patients with chronic conditions, is also applicable to a broad range of individuals with AUDs. In this article, we describe the CCM and discuss ways it can be adapted in primary care settings to improve care for AUDs. METHOD: We review the evidence for considering the spectrum of AUDs as a chronic disease and discuss how the CCM might guide the reorganization of care to improve the delivery of effective interventions in primary care settings. We also solicited specific advice and feedback from an expert panel by means of a listserv. RESULTS: The CCM is a heuristic model that offers an approach to increase the ability of PCPs to identify, treat and effectively manage AUDs. Research suggests the model works well for a variety of chronic illnesses and across a number of different organizational settings. Implementation of the model in the case of AUDs has the potential to improve their care. CONCLUSIONS: Given the potentially chronic and relapsing nature of AUDs, it is important for the alcohol treatment community to be aware of the current research on improving care for chronic illnesses and to consider how the CCM might be adapted to improve care for AUDs. Further work is needed on developing tools, self-management support resources and training strategies before the CCM can be evaluated in real world settings.