Establishing a Protocol for Determining the Costs of an Integrated Set of Evidence-based Practices Aimed at Reducing Opioid Overdose Deaths.

OBJECTIVES: In the midst of the opioid overdose crisis, local jurisdictions face a choice of public health interventions. A significant barrier when considering evidence-based practices (EBPs) is the lack of information regarding their implementation cost. This protocol paper provides the methodological foundation for the economic cost evaluations of community-wide strategies on the scale of a national study. It can serve as a resource for other communities, local policymakers, and stakeholders as they consider implementing possible public health strategies in their unique settings. METHODS: We present a protocol that details (1) the process of identifying, reviewing, and analyzing individual strategies for study-funded and non-study-funded costs; (2) prospective costing tool designation, and; (3) data collection. To do this, we set up working groups with community stakeholders, reviewed financial invoices, and surveyed individuals with detailed knowledge of their community implementation. DISCUSSION: There were 3 main challenges/limitations. The first was the lack of a standard structure for documenting nonfunded costs associated with each strategy. The second was the need for timely implementation of cost data. The third was generalizability because our study designed its strategies for selected communities due to their high opioid overdose mortality rates. Future steps include more tailored questions to ask during the categorization/filter process and establishing realistic expectations for organizations regarding documenting. CONCLUSIONS: Data collected will provide a critical methodological foundation for costing large community-based EBP strategies and provide clarity for stakeholders on the cost of implementing EBP strategies to reduce opioid overdose deaths.

Community selected strategies to reduce opioid-related overdose deaths in the HEALing (Helping to End Addiction Long-term SM) communities study.

The Helping End Addictions Long Term (HEALing) Communities Study (HCS) seeks to significantly reduce overdose deaths in 67 highly impacted communities in Kentucky (KY), Massachusetts (MA), New York (NY), and Ohio (OH) by implementing evidence-based practices (EBPs) to reduce overdose deaths. The Opioid-overdose Reduction Continuum of Care Approach (ORCCA) organizes EBP strategies under three menus: Overdose Education and Naloxone Distribution (OEND), Medication Treatment for Opioid Use Disorder (MOUD), and Safer Prescribing and Dispensing Practices (SPDP). The ORCCA sets requirements for strategy selection but allows flexibility to address community needs. This paper describes and compiles strategy selection and examines two hypotheses: 1) OEND selections will differ significantly between communities with higher versus lower opioid-involved overdose deaths; 2) MOUD selections will differ significantly between urban versus rural settings. METHODS: Wave 1 communities (n = 33) provided data on EBP strategy selections. Selections were recorded as a combination of EBP menu, sector (behavioral health, criminal justice, and healthcare), and venue (e.g., jail, drug court, etc.); target medication(s) were recorded for MOUD strategies. Strategy counts and proportions were calculated overall and by site (KY, MA, NY, OH), setting (rural/urban), and opioid-involved overdose deaths (high/low). RESULTS: Strategy selection exceeded ORCCA requirements across all 33 communities, with OEND strategies accounting for more (40.8%) than MOUD (35.1%), or SPDP (24.1%) strategies. Site-adjusted differences were not significant for either hypothesis related to OEND or MOUD strategy selection. CONCLUSIONS: HCS communities selected strategies from the ORCCA menu well beyond minimum requirements using a flexible approach to address unique needs.

Protocol for community-driven selection of strategies to implement evidence-based practices to reduce opioid overdoses in the HEALing Communities Study: a trial to evaluate a community-engaged intervention in Kentucky, Massachusetts, New York and Ohio.

INTRODUCTION: Opioid-involved overdose deaths continue to surge in many communities, despite numerous evidence-based practices (EBPs) that exist to prevent them. The HEALing Communities Study (HCS) was launched to develop and test an intervention (ie, Communities That HEAL (CTH)) that supports communities in expanding uptake of EBPs to reduce opioid-involved overdose deaths. This paper describes a protocol for a process foundational to the CTH intervention through which community coalitions select strategies to implement EBPs locally. METHODS AND ANALYSIS: The CTH is being implemented in 67 communities (randomised to receive the intervention) in four states in partnership with coalitions (one per community). Coalitions must select at least five strategies, including one to implement each of the following EBPs: (a) overdose education and naloxone distribution; expanded (b) access to medications for opioid use disorder (MOUD), (c) linkage to MOUD, (d) retention in MOUD and (e) safer opioid prescribing/dispensing. Facilitated by decision aid tools, the community action planning process includes (1) data-driven goal setting, (2) discussion and prioritisation of EBP strategies, (3) selection of EBP strategies and (4) identification of next steps. Following review of epidemiologic data and information on existing local services, coalitions set goals and discuss, score and/or rank EBP strategies based on feasibility, appropriateness within the community context and potential impact on reducing opioid-involved overdose deaths with a focus on three key sectors (healthcare, behavioural health and criminal justice) and high-risk/vulnerable populations. Coalitions then select EBP strategies through consensus or majority vote and, subsequently, suggest or choose agencies with which to partner for implementation. ETHICS AND DISSEMINATION: The HCS protocol was approved by a central Institutional Review Board (Advarra). Results of the action planning process will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders. TRIAL REGISTRATION NUMBER: NCT04111939.

Exploring sexual awareness and Decision-making among adolescent girls and boys in rural Nicaragua: A socio-ecological approach.

OBJECTIVE: To explore how individual, relational, and social contexts influence adolescents' sexual awareness and decision-making in rural Nicaragua. METHODS: Eighteen semi-structured interviews were conducted with adolescent boys and girls aged 15 to 19 years. Thematic analysis identified patterns of meaning applying a socio-ecological approach. A thematic map illustrates how the themes are organized according to the socio-ecological model and suggests their interactions. RESULTS: Six main themes emerged as (1) Adolescence - a period of life changes, (2) Fears as a pathway to awareness and decision-making, (3) Awareness about protective measures, (4) Relational influences on adolescents' sexual health, (5) Service provision and institutional influences on awareness and decision-making and (6) Sociocultural determinants on adolescent sexual health. Informants of both genders expressed concern in several issues of their sexuality. They identified fear of pregnancy, STIs, and their impact on future goals, family communication, and school-based sexual education as protective factors for their sexual decision-making. Adolescents of both genders are challenging social and cultural norms by developing sexual agency. CONCLUSION: These findings imply that personal and societal factors in rural Nicaragua produce a multi-dimensional effect on adolescent sexual self-efficacy. Our study is relevant for a wider discussion about sexual awareness to promote positive development and health outcomes particularly among adolescents' girls and boys living in rural settings.

"Part of getting to where we are is because we have been open to change" integrating community health workers on care teams at ten Ryan White HIV/AIDS program recipient sites.

BACKGROUND: Community Health Workers (CHWs) have long been integrated in the delivery of HIV care in middle- and low-income countries. However, less is known about CHW integration into HIV care teams in the United States (US). To date, US-based CHW integration studies have studies explored integration in the context of primary care and patient-centered medical homes. There is a need for research related to strategies that promote the successful integration of CHWs into HIV care delivery systems. In 2016, the Health Resources and Services Administration HIV/AIDS Bureau launched a three-year initiative to provide training, technical assistance and evaluation for Ryan White HIV/AIDS Program (RWHAP) recipient sites to integrate CHWs into their multidisciplinary care teams, and in turn strengthen their capacity to reach communities of color and reduce HIV inequities. METHODS: Ten RWHAP sites were selected from across eight states. The multi-site program evaluation included a process evaluation guided by RE-AIM to understand how the organizations integrated CHWs into their care teams. Site team members participated in group interviews to walk-the-process during early implementation and following the program period. Directed content analysis was employed to examine program implementation. Codes developed using implementation strategies outlined in the Expert Recommendations for Implementing Change project were applied to group interviews (n = 20). FINDINGS: Implementation strategies most frequently described by sites were associated with organizational-level adaptations in order to integrate the CHW into the HIV care team. These included revising, defining, and differentiating professional roles and changing organizational policies. Strategies used for implementation, such as network weaving, supervision, and promoting adaptability, were second most commonly cited strategies, followed by training and Technical Assistance strategies. CONCLUSIONS: Wrapped up in the implementation experience of the sites there were some underlying issues that pose challenges for healthcare organizations. Organizational policies and the ability to adapt proved significant in facilitating CHW program implementation. The integration of the CHWs in the delivery of HIV care requires clearly distinguishing their role from the roles of other members of the healthcare delivery team.