[Show abstract][Hide abstract] ABSTRACT: Objective:
Millions of disadvantaged youth and returning veterans are enrolled in community colleges. Our objective was to determine the prevalence of mental disorders and help-seeking behaviors among community college students.
Veterans (n=211) and non-veterans (n=554) were recruited from 11 community colleges and administered screeners for depression (PHQ-9), generalized anxiety (GAD-7), posttraumatic stress disorder (PC-PTSD), non-lethal self-injury, suicide ideation and suicide intent. The survey also asked about the perceived need for, barriers to and utilization of services. Regression analysis was used to compare prevalence between non-veterans and veterans adjusting for non-modifiable factors (age, gender and race/ethnicity).
A large proportion of student veterans and non-veterans screened positive and unadjusted bivariate comparisons indicated that student veterans had a significantly higher prevalence of positive depression screens (33.1% versus 19.5%, P<.01), positive PTSD screens (25.7% versus 12.6%, P<.01) and suicide ideation (19.2% versus 10.6%, P=.01). Adjusting for age, gender and race/ethnicity, veterans were significantly more likely than non-veterans to screen positive for depression (OR=2.10, P=.01) and suicide ideation (OR=2.31, P=.03). Student veterans had significantly higher odds of perceiving a need for treatment than non-veterans (OR=1.93, P=.02) but were more likely to perceive stigma (beta=0.28, P=.02). Despite greater need among veterans, there were no significant differences between veterans and non-veterans in use of psychotropic medications, although veterans were more likely to receive psychotherapy (OR=2.35, P=.046).
Findings highlight the substantial gap between the prevalence of probable mental health disorders and treatment seeking among community college students. Interventions are needed to link community college students to services, especially for student veterans.
Full-text · Article · Sep 2015 · General hospital psychiatry
[Show abstract][Hide abstract] ABSTRACT: Panel overview abstract Implementation research is the scientific study of methods that promote systematic uptake of research findings and other evidence-based practices into routine practice, thereby improving the quality and effectiveness of health services. As the field has progressed over the past decades , substantial advances continue in the development and application of implementation-related theories as well as innovative implementation strategies and methods. This session will provide three examples of implementation research studies that are designed to improve care through the use of evidence. The examples come from three health services areas: primary care, mental health, and HIV; from funded NIH and VA studies; and from community and hospital settings in rural and urban sites. Across the three examples, six different theories were used-providing ample examples of linking conceptual models and frameworks to study design, implementation strategies, and measurements. Each presentation will highlight the ways in which the conceptual theory was configured into the overall research design and evaluation , as well as common challenges and lessons learned while conducting implementation research. Blended facilitation to enhance PCMH program implementation: conceptual, design, and measurement considerations Integrated primary care mental health evidence-based programs improve care. The Department of Veterans Affairs mandated and provided limited national level implementation support for Primary Care-Mental Health Integration (PC-MHI) but VA facilities were slow to implement them. The Blended Facilitation study was funded by the VA to implement and evaluate an innovative implementation facilitation (IF) strategy that included a national external expert facilitator with expertise in implementation science and PC-MHI who mentored and worked with two internal regional facilita-tors to help clinics implement PC-MHI. According to the PARIHS framework, successful implementation is a function of the dynamic interaction between evidence, context and facilitation. This presentation will describe how PARIHS guided the application of the IF strategy and the study's design. For this quasi-experimental, Hybrid Type 3 study, we used mixed methods to test the effectiveness of the IF strategy and assess organizational context, perceptions of evidence, and facilitation activities. We used a consensus matching approach to select sixteen clinics that were unlikely to implement PC-MHI without assistance across four VA regions. The RE-AIM framework guided our test of IF's effectiveness using administrative data and program component interviews to measure RE-AIM dimensions. We conducted monthly debriefing interviews with and collected time data from facilitators and measured site level contextual and evidence factors through key informant interviews. We also conducted intensive case studies at four IF
Full-text · Article · Aug 2015 · Implementation Science
[Show abstract][Hide abstract] ABSTRACT: We estimated the effect of economic constraints on public health delivery systems (PHDS) density and centrality during 3 time periods, 1998, 2006, and 2012.
We obtained data from the 1998, 2006, and 2012 National Longitudinal Study of Public Health Agencies; the 1993, 1997, 2005, and 2010 National Association for County and City Health Officials Profile Study; and the 1997, 2008, and 2011 Area Resource Files. We used multivariate regression models for panel data to estimate the impact of economic constraints on PHDS density and centrality.
Findings indicate that economic constraints did not have a significant impact on PHDS density and centrality over time but population is a significant predictor of PHDS density, and the presence of a board of health (BOH) is a significant predictor of PHDS density and centrality. Specifically, a 1% increase in population results in a significant 1.71% increase in PHDS density. The presence of a BOH is associated with a 10.2% increase in PHDS centrality, after controlling for other factors.
These findings suggest that other noneconomic factors influence PHDS density centrality. (Am J Public Health. Published online ahead of print July 16, 2015: e1-e6. doi:10.2105/AJPH.2015.302769).
No preview · Article · Jul 2015 · American Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: Prior studies of mostly male U.S. service members suggest service characteristics such as deployment with combat exposure and lower rank may be a risk factor for alcohol misuse. However, these relationships have not been examined among servicewomen who may be at high risk for experiencing deployment-related stressors and associated health consequences. This cross-sectional report of US servicewomen in the Reserve or National Guard (RNG) and active component (AC) sought to examine these associations.
A Midwestern community sample of currently serving and veteran servicewomen (N=1339) completed structured telephone interviews. The Generalized Linear Model was used to examine associations between service characteristics, any binge drinking, and frequency of recent binge drinking after adjusting for demographics.
After adjusting for demographics, deployment to Iraq or Afghanistan was associated with greater odds of reporting a binge drinking episode, compared to no deployment, among servicewomen in the AC but not RNG. Deployment to Iraq or Afghanistan was also associated with more days binge drinking in both groups compared to servicewomen not deployed. Lower ranking servicewomen also reported higher odds of a binge drinking episode and higher frequency of binge drinking in both the RNG and AC.
Service characteristics including deployment to Iraq or Afghanistan (vs. those not deployed) and lower rank (vs. officers) may be a risk factor for recent binge drinking and higher frequency of binge drinking among servicewomen, after adjusting for demographic covariates. Public health and clinical implications are discussed.
Published by Elsevier Ireland Ltd.
No preview · Article · Jun 2015 · Drug and alcohol dependence
[Show abstract][Hide abstract] ABSTRACT: This study qualitatively examines the religious and spiritual dimensions of cutting down and stopping cocaine use among African Americans in rural and urban areas of Arkansas. The analyses compare and contrast the narrative data of 28 current cocaine users living in communities where the Black church plays a fundamental role in the social and cultural lives of many African Americans, highlighting the ways that participants used religious symbols, idiomatic expression, and Biblical scriptures to interpret and make sense of their substance-use experiences. Participants drew on diverse religious and spiritual beliefs and practices, including participation in organized religion, reliance on a personal relationship with God, and God's will to cut down and stop cocaine use. Our findings suggest that culturally sensitive interventions addressing the influence of religion and spirituality in substance use are needed to reduce cocaine use and promote recovery in this at-risk, minority population.
Full-text · Article · Nov 2014 · Journal of drug issues
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND
Implementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise for addressing these challenges.
Our aim was to evaluate the effectiveness of an external/internal IF strategy within the context of a Department of Veterans Affairs (VA) mandate of Primary Care–Mental Health Integration (PC-MHI).
This was a quasi-experimental, Hybrid Type III study. Generalized estimating equations assessed differences across sites.
Patients and providers at seven VA primary care clinics receiving the IF intervention and national support and seven matched comparison clinics receiving national support only participated in the study.
We used a highly partnered IF strategy incorporating evidence-based implementation interventions.
We evaluated the IF strategy using VA administrative data and RE-AIM framework measures for two 6-month periods.
Evaluation of RE-AIM measures from the first 6-month period indicated that PC patients at IF clinics had nine times the odds (OR=8.93, p
Full-text · Article · Oct 2014 · Journal of General Internal Medicine
[Show abstract][Hide abstract] ABSTRACT: To encourage access, policy makers and providers need information about variations in drug users’ treatment preferences. This study examined how rural/urban residence, stigma surrounding drug use, and perceived treatment availability and effectiveness are associated with African American cocaine users’ preferences for the site of treatment (local, or in one’s home town; nearby, or in a town nearby; and distant, or in a town farther away). Two hundred rural and 200 urban cocaine users were recruited using Respondent-Driven Sampling and completed in-person interviews. Multinomial logit regression analyses were conducted to estimate the relative odds of preferring local vs. nearby and local vs. distant treatment. Rural cocaine users preferred distant (58%) and urban users preferred local (57%) treatment. Rural residence and a lifetime history of treatment were associated with higher odds of preferring nearby vs. local treatment; older age and greater perceived local treatment effectiveness were associated with lower odds of preferring nearby vs. local treatment. Rural residence, access to an automobile, higher rejection/discrimination stigma scores, and higher Brief Symptom Inventory-Global Severity Index scores were associated with higher odds of preferring distant vs. local treatment; older age, lower educational attainment, and greater perceived discrimination after treatment were associated with lower odds of preferring distant vs. local treatment. The findings from this study suggest that a regional approach to organizing drug use treatment services could better satisfy the preferences of rural African American cocaine users, whereas local treatment services should be expanded to meet the needs of urban cocaine users.
No preview · Article · Oct 2014 · Journal of Substance Abuse Treatment
[Show abstract][Hide abstract] ABSTRACT: Objective
To examine how rural/urban residence, perceived access, and other factors impede or facilitate perceived need for drug use treatment, a concept closely linked to treatment utilization.Study DesignTwo hundred rural and 200 urban African American cocaine users who were not receiving treatment were recruited via Respondent-Driven Sampling and completed a structured in-person interview. Bivariate and multivariate analyses were conducted to test the associations between perceived need and rural/urban residence, perceived access, and other predisposing (eg, demographics), enabling (eg, insurance), and health factors (eg, psychiatric distress).Principal FindingsIn bivariate analyses, rural relative to urban cocaine users reported lower perceived treatment need (37% vs 48%), availability, affordability, overall ease of access, and effectiveness, as well as lower perceived acceptability of residential, outpatient, self-help, and hospital-based services. In multivariate analyses, there was a significant interaction between rural/urban residence and the acceptability of religious counseling. At the highest level of acceptability, rural users had lower odds of perceived need (OR = 0.21); at the lowest level, rural users had higher odds of perceived need (OR = 3.97) than urban users. Among rural users, the acceptability of religious counseling was negatively associated with perceived need (OR = 0.65). Ease of access was negatively associated (OR = 0.71) whereas local treatment effectiveness (OR = 1.47) and the acceptability of hospital-based treatment (OR = 1.29) were positively associated with perceived need among all users.Conclusions
Our findings suggest rural/urban disparities in perceived need and access to drug use treatment. Among rural and urban cocaine users, improving perceptions of treatment effectiveness and expanding hospital-based services could promote treatment seeking.
No preview · Article · Sep 2014 · The Journal of Rural Health
[Show abstract][Hide abstract] ABSTRACT: Background:
The Theory of Planned Behavior (TPB) can provide insights into perceived need for cocaine treatment among African American cocaine users.
A cross-sectional community sample of 400 (50% rural) not-in-treatment African-American cocaine users was identified through respondent-driven sampling in one urban and two rural counties in Arkansas. Measures included self-reports of attitudes and beliefs about cocaine treatment, perceived need and perceived effectiveness of treatment, and positive and negative cocaine expectancies. Normative beliefs were measured by perceived stigma and consequences of stigma regarding drug use and drug treatment. Perceived control was measured by readiness for treatment, prior drug treatment, and perceived ability to cut down on cocaine use without treatment.
Multiple regression analysis found that older age (standardized regression coefficient β=0.15, P<0.001), rural residence (β=-0.09, P=0.025), effectiveness of treatment (β=0.39, P<0.001), negative cocaine expectancies (β=0.138, P=0.003), experiences of rejection (β=0.18, P<0.001), need for secrecy (β=0.12, P=0.002), and readiness for treatment (β=0.15, P<0.001) were independently associated with perceived need for cocaine treatment.
TPB is a relevant model for understanding perceived need for treatment among African-American cocaine users. Research has shown perceived need to be a major correlate of treatment participation. Study results should be applicable for designing interventions to encourage treatment participation.
No preview · Article · May 2014 · Addictive Behaviors
[Show abstract][Hide abstract] ABSTRACT: In this article, we show that the Veterans Health Administration (VA), similar to military organizations, is a gendered organization where women Veterans’ experiences are embedded in and shaped by gender inequalities and structures of power. Based on an in-depth analysis of women Veterans’ substance use histories and VA treatment seeking experiences, we illustrate how gender power dynamics are (re)produced and maintained through everyday social interactions and organizational practices and processes that render women Veterans both visible and invisible: visible as sexual objects and invisible as suffering subjects. By retelling the illness and treatment experiences of women Veterans with trauma histories and co-occurring substance use and mental health disorders—a highly stigmatized population of Veterans—we highlight the importance of giving voice to their concerns when developing policies and programs to address the unique health care needs of women Veterans.
[Show abstract][Hide abstract] ABSTRACT: Integrating HIV testing programs into substance use treatment is a promising avenue to help increase access to HIV testing for rural drug users. Yet few outpatient substance abuse treatment facilities in the United States provide HIV testing. The purpose of this study was to identify barriers to incorporating HIV testing with substance use treatment from the perspectives of treatment and testing providers in Arkansas.
We used purposive sampling from state directories to recruit providers at state, organization, and individual levels to participate in this exploratory study. Using an interview guide, the first and second authors conducted semistructured individual interviews in each provider's office or by telephone. All interviews were recorded, transcribed verbatim, and entered into ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). We used constant comparison and content analysis techniques to identify codes, categories, and primary patterns in the data.
The sample consisted of 28 providers throughout the state, 18 from the substance use system and 10 from the public/ community health system. We identified 7 categories of barriers: environmental constraints, policy constraints, funding constraints, organizational structure, limited inter- and intra-agency communication, burden of responsibility, and client fragility.
This study presents the practice-based realities of barriers to integrating HIV testing with substance use treatment in a small, largely rural state. Some system and/or organization leaders were either unaware of or not actively pursuing external funds available to them specifically for engaging substance users in HIV testing. However, funding does not address the system-level need for coordination of resources and services at the state level.
No preview · Article · Sep 2013 · The Journal of Rural Health
[Show abstract][Hide abstract] ABSTRACT: This qualitative study is about barriers to the utilization of HIV testing as perceived by African Americans who have recently used cocaine and who live in the rural Delta region of Arkansas. Affordability, physical accessibility, and geographic availability were not perceived as barriers to HIV testing in this sample, yet acceptability was still perceived as poor. Acceptability due to social mores and norms was a major barrier. Many said testing was unacceptable because of fear of social costs. Many were confident of being HIV-negative based on risky assumptions about testing and the notification process. Small-town social and sexual networks added to concerns about reputation and risk. System approaches may fail if they focus solely on improving access to HIV services but do not take into consideration deeply internalized experiences of rural African Americans as well as involvement of the community in developing programs and services.
No preview · Article · Jul 2013 · Journal of drug issues
[Show abstract][Hide abstract] ABSTRACT: Objective:
Although stigma associated with serious mental illness, substance abuse disorders, and depression has been studied very little is known about stigma associated with Posttraumatic Stress Disorder (PTSD). This study explored stigma related to PTSD among treatment-seeking Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) combat veterans.
Sixteen treatment-seeking OEF/OIF veterans with combat-related PTSD participated in focus groups. We used qualitative methods to explore PTSD-related stigma.
Common perceived stereotypes of treatment-seeking veterans with PTSD included labels such as "dangerous/violent," or "crazy," and a belief that combat veterans are responsible for having PTSD. Most participants reported avoiding treatment early on to circumvent a label of mental illness. Participants initially reported experiencing some degree of self-stigma; however, following engagement in treatment they predominantly resisted these stereotypes. Although most participants considered combat-related PTSD as less stigmatizing than other mental illnesses, they reported difficulties with reintegration. Such challenges likely stem from both PTSD symptoms and veterans' perceptions of how the public views them. Most reported that fellow combat veterans best understood them.
Conclusions and implications for practice:
Awareness of public stereotypes impacts help seeking at least early in the course of illness. Peer-based outreach and therapy groups may help veterans engage in treatment early and resist stigma.
No preview · Article · Jun 2013 · Psychiatric Rehabilitation Journal
[Show abstract][Hide abstract] ABSTRACT: Examined the direct and interactive relationships between personality and environment as predictive of problem drug use. In the 13-yr longitudinal study, 1,201 adolescents provided self-report data concerning problem drug use, social environment, and the 4 personality constructs of disinhibition, experience seeking, depressive tendencies, and hostility. Results show that environmental and personality risk factors were predictive only when they were concurrent with problem drug abuse. Depression and hostility predicted the presence of hard drug use only within a problem drug-using network. It is concluded that social learning models based on the co-occurrence of personality and environmental influences are most predictive of concurrent use behaviors, that such models are appropriate for both cross-sectional and longitudinal prediction, and that pathways to problem use vary from substance to substance. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
No preview · Article · Oct 2012 · Journal of drug issues
[Show abstract][Hide abstract] ABSTRACT: Mental health and substance abuse are among the most commonly reported reasons for visits to Federally Qualified Health Centers (CHCs), yet only 6.5% of encounters are with on-site behavioral health specialists. Rural CHCs are significantly less likely to have on-site behavioral specialists than urban CHCs. Because of this lack of mental health specialists in rural areas, the most promising approach to improving mental health outcomes is to help rural primary care (PC) providers deliver evidence-based practices (EBPs). Despite the scope of these problems, no research has developed an effective implementation strategy for facilitating the adoption of mental health EBPs for rural CHCs. We sought to describe the conceptual components of an implementation partnership that focuses on the adaption and adoption of mental health EBPs by rural CHCs in Arkansas.
We present a conceptual model that integrates seven separate frameworks: (1) Jones and Wells' Evidence-Based Community Partnership Model, (2) Kitson's Promoting Action on Research Implementation in Health Services (PARiHS) implementation framework, (3) Sackett's definition of evidence-based medicine, (4) Glisson's organizational social context model, (5) Rubenstein's Evidence-Based Quality Improvement (EBQI) facilitation process, (6) Glasgow's RE-AIM evaluation approach, and (7) Naylor's concept of shared decision making.
By integrating these frameworks into a meaningful conceptual model, we hope to develop a successful implementation partnership between an academic health center and small rural CHCs to improve mental health outcomes. Findings from this implementation partnership should have relevance to hundreds of clinics and millions of patients, and could help promote the sustained adoption of EBPs across rural America.
No preview · Article · Sep 2012 · Progress in community health partnerships: research, education, and action
[Show abstract][Hide abstract] ABSTRACT: This study investigates the associations of recent criminal justice involvement with perceived need for alcohol treatment and alcohol treatment utilization, adjusting for demographic and clinical characteristics. We examined a national sample of adults with alcohol use disorders (N=4390) from the 2006 National Survey on Drug Use and Health. Almost 15% reported criminal justice involvement in the past year. Generalized logit models regressed perceived need for alcohol or drug treatment and past year treatment utilization (versus neither) on past year legal involvement, demographic, and clinical information. In general, results found stronger associations between frequency of criminal justice involvement for treatment utilization compared to perceived need for treatment alone. Treatment utilization was also associated with being on probation, arrests for drug possession/sale and driving under the influence but perceived need was not. Study results suggest opportunities for interventions to increase treatment rates or treatment need, a major correlate of treatment utilization.
No preview · Article · Sep 2012 · Journal of substance abuse treatment
[Show abstract][Hide abstract] ABSTRACT: We examined whether motivation to change mediated the relationships between gender and baseline alcohol severity with drinking outcome at 12-month follow-up in a longitudinal community sample.
Data were from baseline and 12-month interviews from the Rural Alcohol Study, a probability sample of rural and urban at-risk drinkers (N = 733) from six southern states. At-risk drinkers were identified through a telephone-screening interview. Measures of motivation (problem recognition and taking action) were the resultant two factors derived from the Stages of Change Readiness and Treatment Eagerness Scale. Items on social consequences of drinking measured alcohol severity. Structural equation models examined relationships between baseline alcohol severity and motivation with drinks per drinking day at 12 months.
We identified significant, direct paths between drinking at 12 months and alcohol severity and taking action with an unstandardized estimate of 0.116 (p < .05), alcohol severity and problem recognition (0.423, p < .01), and each of the two "motivation" latent constructs-problem recognition (1.846, p < .01) and taking action (-0.660, p < .01). Finally, the combined direct and negative effect of gender on alcohol consumption at 12-month follow-up was statistically significant, with an unstandardized estimate of -0.970 (p < .01).
The current study offers evidence for motivation to change as a viable mechanism through which alcohol severity is associated with subsequent drinking outcomes. More research is needed to further explore the persistence of motivation to change on drinking outcomes over time.
Full-text · Article · May 2012 · Journal of studies on alcohol and drugs