Traditional Medicine and Help-Seeking Behaviors for Health Problems Among Somali Bantu Refugees Resettled in the United States.

Somali refugees have resettled in the United States in large numbers. The focus of this study was specifically on the Somali Bantu refugees, an ethnic minority group from Somalia. The goal of this study was to understand the following: (a) jinn (invisible beings or forces in Islamic theology) and related health problems resulting from jinn possession affecting Somali Bantu refugees, (b) types of traditional healing practices integrated into help-seeking behavior, and (c) pathways of care utilized to address health problems. In total, 20 participant interviews were conducted with Somali Bantu refugees resettled in the United States. Overall, participants described types of jinn and associated health problems. In addition, participants identified different pathways of care, including formal and informal health care. Participants accessed these pathways both concurrently and sequentially. Somali Bantu utilize complex and varied health care services based on their understanding of the causes of health problems and experiences with care providers.

Implementing integrated services in routine behavioral health care: primary outcomes from a cluster randomized controlled trial.

BACKGROUND: An estimated 8.2 million adults in the United States live with co-occurring mental health and substance use disorders. Although the benefits of integrated treatment services for persons with co-occurring disorders has been well-established, gaps in access to integrated care persist. Implementation research can address this gap. We evaluated if the Network for the Improvement of Addiction Treatment (NIATx) implementation strategy was effective in increasing integrated services capacity among organizations treating persons with co-occurring disorders. METHODS: This study employed a cluster randomized waitlist control group design. Forty-nine addiction treatment organizations from the State of Washington were randomized into one of two study arms: (1) NIATx strategy (active implementation strategy), or (2) waitlist (control). The primary outcome was a standardized organizational measure of integrated service capability: the Dual Diagnosis in Addiction Treatment (DDCAT) Index. Intent-to-treat analyses and per-protocol analyses were conducted to address the following questions: (1) Is NIATx effective in increasing integrated service capacity? and (2) Are there differences in organizations that actually use NIATx per-protocol versus those that do not? RESULTS: From baseline to one-year post active implementation, both the NIATx strategy and waitlist arms demonstrated improvements over time in DDCAT Index total and DDCAT dimension scores. In intent-to-treat analyses, a moderate but statistically significant difference in improvement between study arms was seen only in the Program Milieu dimension (p = 0.020, Cohen's d = 0.54). In per-protocol analyses, moderate-to-large effects in Program Milieu (p = 0.002, Cohen's d = 0.91) and Continuity of Care (p = 0.026, Cohen's d = 0.63) dimensions, and in total DDCAT Index (p = 0.046, Cohen's d = 0.51) were found. CONCLUSIONS: Overall, organizations in both study arms improved DDCAT Index scores over time. Organizations in the NIATx strategy arm with full adherence to the NIATx protocol had significantly greater improvements in the primary outcome measure of integrated service capacity for persons with co-occurring disorders. TRAIL REGISTRATION: ClinicalTrials.gov, NCT03007940 . Retrospectively registered January 2017.

Attitudes of primary care physicians toward prescribing buprenorphine: a narrative review.

BACKGROUND: The opioid epidemic is a major public health issue associated with significant overdose deaths. Effective treatments exist, such as the medication buprenorphine, but are not widely available. This narrative review examines the attitudes of primary care providers (PCPs) toward prescribing buprenorphine. METHODS: Narrative review of 20 articles published after the year 2000, using the Consolidated Framework for Implementation Research (CFIR) to organize the findings. RESULTS: Three of the five CFIR domains ("Intervention Characteristics," "Outer Setting," "Inner Setting") were strongly represented in our analysis. Providers were concerned about the clientele associated with buprenorphine, diversion, and their self-efficacy in prescribing the medication. Some believed that buprenorphine does not belong in the discipline of primary care. Other barriers included philosophical objections and stigma toward substance use disorders. Notably, two studies reported a shift in attitudes once physicians prescribed buprenorphine to actual patients. CONCLUSIONS: Negative attitudes toward buprenorphine encompassed multi-layered concerns, ranging from skepticism about the medication itself, the behaviors of patients with opioid use disorders, and beliefs regarding substance use disorders more generally. We speculate, however, that negative attitudes may be improved by tailoring support strategies that address providers' self-efficacy and level of knowledge.

Using NIATx strategies to implement integrated services in routine care: a study protocol.

BACKGROUND: Access to integrated services for individuals with co-occurring substance use and mental health disorders is a long-standing public health issue. Receiving integrated treatment services are both more effective and preferred by patients and families versus parallel or fragmented care. National policy statements and expert consensus guidelines underscore the benefits of integrated treatment. Despite decades of awareness, adequate treatment for individuals with co-occurring substance use and mental health disorders occurs infrequently. The underlying disease burden associated with alcohol, illicit and prescription drug problems, as well as mental health disorders, such as depression, posttraumatic stress disorder and schizophrenia, is substantial. METHODS: This cluster randomized controlled trial (RCT) is designed to determine if the multi-component Network for the Improvement of Addiction Treatment (NIATx) strategies are effective in implementing integrated services for persons with co-occurring substance use and mental health disorders. In this study, 50 behavioral health programs in Washington State will be recruited and then randomized into one of two intervention arms: 1) NIATx implementation strategies, including coaching and learning sessions over a 12-month intervention period to implement changes targeting integrated treatment services; or 2) wait-list control. Primary outcome measures include: 1) fidelity - a standardized organizational assessment of integrated services (Dual Diagnosis in Addiction Treatment [DDCAT] Index); and 2) penetration - proportion of patients screened and diagnosed with co-occurring disorders, proportion of eligible patients receiving substance use and mental health services, and psychotropic or substance use disorder medications. Barriers and facilitators, as determinants of implementation outcomes, will be assessed using the Consolidated Framework for Implementation Research (CFIR) Index. Fidelity to and participation in NIATx strategies will be assessed utilizing the NIATx Fidelity Scale and Stages of Implementation Completion (SIC). DISCUSSION: This study addresses an issue of substantial public health significance: the gap in access to an evidence-based practice for integrated treatment for individuals with co-occurring mental health and substance use disorders. The study utilizes rigorous and reproducible quantitative approaches to measuring implementation determinants and strategies, and may address a longstanding gap in the quality of care for persons with co-occurring disorders. TRIAL REGISTRATION: ClinicalTrials.gov NCT03007940 . Registered 02 January 2017 - Retrospectively Registered.

"We would never forget who we are": resettlement, cultural negotiation, and family relationships among Somali Bantu refugees.

Somali refugees are resettling in large numbers in the US, but little is known about the Somali Bantu, an ethnic minority within this population. Refugee youth mental health is linked to the functioning of the larger family unit. Understanding how the process of culturally adjusting to life after resettlement relates to family functioning can help identify what kind of interventions might strengthen families and lead to better mental health outcomes for youth. This paper seeks to address the following research questions: (1) How do different groups of Somali Bantu refugees describe their experiences of culturally adapting to life in the US?; and (2) How, if at all, do processes of cultural adaptation in a new country affect Somali Bantu family functioning? We conducted 14 focus groups with a total of 81 Somali Bantu refugees in New England. Authors analyzed focus groups using principles of thematic analysis to develop codes and an overarching theoretical model about the relationship between cultural adaptation, parent-child relationships, and family functioning. Views and expectations of parent-child relationships were compared between Somali Bantu youth and adults. Cultural negotiation was dependent upon broader sociocultural contexts in the United States that were most salient to the experience of the individual. Adult and youth participants had conflicting views around negotiating Somali Bantu culture, which often led to strained parent-child relationships. In contrast, youth sibling relationships were strengthened, as they turned to each other for support in navigating the process of cultural adaptation.

Military environmental exposures and risk of breast cancer in active-duty personnel and veterans: a scoping review.

Background: The effects of military environmental exposures (MEE) such as volatile organic compounds (VOCs), endocrine-disrupting chemicals (EDCs), tactile herbicides, airborne hazards and open burn pits (AHOBP), and depleted uranium on health are salient concerns for service members and Veterans. However, little work has been done to investigate the relationship between MEE and risk of breast cancer. Data sources and methods: We conducted a scoping review on MEE, military deployment/service, and risk of breast cancer among active-duty service members and Veterans. PRISMA was used. PubMed, Embase, and citations of included articles were searched, resulting in 4,364 articles to screen: 28 articles were included. Results: Most papers on military deployment and military service found a lower/equivalent risk of breast cancer when comparing rates to those without deployment or civilians. Exposure to VOCs due to military occupation or contaminated groundwater was associated with a slightly higher risk of breast cancer. Exposure to Agent Orange was not associated with an increased risk of breast cancer. Evidence regarding EDCs was limited. No paper directly measured exposure to AHOBP or depleted uranium, but deployments with known exposures to AHOBP or depleted uranium were associated with an equivalent/lower risk of breast cancer. Conclusions: Women are the fastest growing population within the military, and breast cancer poses a unique risk to women Veterans who were affected by MEE during their service. Unfortunately, the literature on MEE and breast cancer is mixed and limited, in part due to the Healthy Soldier Paradox and poor classification of exposure(s).

Sustainment of Integrated Care in Addiction Treatment Settings: Primary Outcomes From a Cluster-Randomized Controlled Trial.

OBJECTIVE: Integrated treatment services are the gold standard for addressing co-occurring mental and substance use disorders, yet they are not readily available. The Network for the Improvement of Addiction Treatment (NIATx) was hypothesized to be an effective strategy to implement and sustain integrated mental health and substance use care in addiction treatment programs. This study examined sustainment of integrated services for up to 2 years after the active implementation phase. METHODS: The effectiveness of NIATx strategies to implement and sustain integrated services was evaluated by using a cluster-randomized, waitlist control group design. Forty-nine addiction treatment organizations were randomly assigned to either NIATx1 (active implementation strategy) or NIATx2 (waitlist control). The Dual Diagnosis Capability in Addiction Treatment Index was used to evaluate organizations' capability to provide integrated care. The NIATx Stages of Implementation Completion scale was used to assess participation in and adherence to the NIATx implementation process. Linear mixed-effects modeling was used to evaluate changes from baseline to end of the sustainment period. RESULTS: Both cohorts sustained their capability to provide integrated treatment services. Both groups achieved successful implementation and sustained integrated services to a similar degree, regardless of sustainment year. Sustainment did not vary as a function of NIATx adherence. CONCLUSIONS: The delivery of integrated treatment services was sustained for 2 years after receipt of active implementation support. Future research should consider how contextual factors may predict, mediate, and moderate sustainment outcomes.