What motivates people with substance use disorders to pursue treatment? A patient-centered approach to understanding patient experiences and patient-provider interactions.

OBJECTIVES: To identify and define potential positive and negative factors in patient experiences and patient-provider interactions that are associated with the pursuit and maintenance of treatment by those suffering from substance use disorders (SUD). METHODS: Two focus groups with patients in treatment for SUD were performed. The focus groups focused on questions aimed at mapping factors associated with initiating and maintaining treatment along the transtheoretical model of change. Four in-depth interviews with healthcare providers involved in the treatment of patients with SUD were also conducted to understand providers' perspective on similar factors. RESULTS: Fourteen patients were included in the focus groups. Patients identified their life prior to treatment as chaotic and further identified internal and external factors that influenced seeking treatment. The four healthcare providers identified primarily social issues such as lack of housing as an external barrier. Both patients and providers cited the importance of a trusting and empathetic relationship between the patient and providers, as well as the patient's willingness to change as primary motivating factors for the initiation and maintenance of treatment. CONCLUSIONS: From a patient and provider perspective, facilitators and barriers for initiating and maintaining may vary by person and are multifactorial.

Variation in Veteran Identity as a Factor in Veteran-Targeted Interventions.

The sociocultural identities that people self-assign or accept influence their interpersonal interactions and decision making. Identity-based interventions attempt to influence individuals by associating healthy behaviors with in-group membership. Outreach and educational efforts aimed at veterans may rely on "typical" veteran identity stereotypes. However, as discussed in this Open Forum, there is evidence that veteran identity is not monolithic but rather fluctuates on the basis of personal characteristics and individual military service experiences. Overall, the impact of veteran identity on veterans' health behaviors and use of health care is not known and has been understudied. A major limiting factor is the lack of a standardized measure of veteran identity that can assess variations in salience, prominence, and emotional valence.

Contextually appropriate measurement as the basis for culturally appropriate interventions: a case study in Managua, Nicaragua.

Despite recent advances in U.S. health care, racial and ethnic minorities experience significantly worse health and mental health outcomes. Policy responses to this problem are based on available research, which is often premised on a misinterpretation of the cultural concepts that underlie people's health and mental health. Health researchers often rely upon measurements with questionable cultural validity. This contributes to a lack of understanding of health disparities that nondominant populations experience and creates obstacles to the development of effective policies to alleviate them. Even statistically valid or literally translated measurements often fail to account for different social and cultural contexts and/or neglect to consider vital information about the population studied or its history. This article reports on the content validity of measures used in a study that investigated predictors of mental health in Managua, Nicaragua. Results reveal a polarized response structure and lack of cultural relevance in underlying concepts measured.

Brief version of the Internalized Stigma of Mental Illness (ISMI) scale: psychometric properties and relationship to depression, self esteem, recovery orientation, empowerment, and perceived devaluation and discrimination.

OBJECTIVE: The internalized stigma of mental illness impedes recovery and is associated with increased depression, reduced self-esteem, reduced recovery orientation, reduced empowerment, and increased perceived devaluation and discrimination. The Internalized Stigma of Mental Illness (ISMI) scale is a 29-item self-report questionnaire developed with consumer input that includes the following subscales: Alienation, Discrimination Experience, Social Withdrawal, Stereotype Endorsement, and Stigma Resistance. Here we present a 10-item version of the ISMI containing the two strongest items from each subscale. METHOD: Participants were all outpatient veterans with serious mental illness. Following the rigorous scale-reduction methods set forth by Stanton and colleagues (2002), we selected the 10 items, tested the psychometrics of the shortened scale in the original validation sample (N = 127), and cross-checked the results in a second dataset (N = 760). RESULTS: As expected, the ISMI-10 retained the essential properties of the ISMI-29, including adequate internal consistency reliability and external validity in relation to depression, self-esteem, recovery orientation, perceived devaluation and discrimination, and empowerment. The ISMI-10 scores are normally distributed and have similar descriptive statistics to the ISMI-29. The reliability and depression findings were replicated in a cross-validation sample. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: We conclude that the ISMI-10 has strong psychometric properties and is a practical, reliable, and valid alternative to the original ISMI-29. Future work should test the ISMI-10 in more diverse samples. This shorter version should reduce respondent burden in program evaluation projects that seek to determine whether participation in psychosocial rehabilitation programming reduces internalized stigma.

A model of internalized stigma and its effects on people with mental illness.

OBJECTIVES: The investigators aimed to examine the prevalence of internalized stigma among individuals with serious mental illness and to construct and test a hypothesized model of the interrelationships among internalized stigma, self-concept, and psychiatric symptoms. METHODS: One hundred individuals, most of whom were African American and had a diagnosis of serious mental illness, were receiving mental health services from one of three community outpatient mental health programs or one Veterans Affairsmedical center. They completed an interview that included measures of internalized stigma, psychiatric symptoms, self-esteem, selfefficacy, and recovery orientation. Structural equation modeling (SEM) was used to examine the interrelationships among these variables. RESULTS: Thirty-five percent of participants reported moderate to severe levels of internalized stigma, which was not significantly associated with any demographic variable or diagnosis. However, greater internalized stigma was associated with lower levels of self-esteem, self-efficacy, and recovery orientation, as well as with more severe psychiatric symptoms. The SEM produced a nonsignificant chi square statistic and other fit indices indicative of a good model fit (goodness-of-fit index=.96, root mean square error of approximation=.011). CONCLUSIONS: Results suggest that internalized stigma was prevalent and problematic among individuals with serious mental illness. There may be multiple pathways through which stigma and discrimination lead to negative outcomes, suggesting that interventions to reduce internalized stigma need to target multiple points along these pathways in order to be effective.

Individual and community predictors of maternal smoking in the city of Baltimore: what can be learned from a predominantly minority case controlled study?

This case control study of 1,000 birth certificates examined what individual and community factors predicted maternal smoking in Baltimore, Maryland. Conditional multinomial logistic regression results indicated women who were White were more likely to start smoking at a young age, but as they got older, they were less likely to smoke. Minority women were more likely to start smoking at a later age. Also, White women were more likely to smoke as the rate of poverty increased, while for minority women, smoking was unrelated to whether they lived in higher or lower poverty areas. Medical assistance status, community education level, and crime rate were not found to be related to smoking status.

Person-environment interactions contributing to nursing home resident falls.

Although approximately 50% of nursing home residents fall annually, the surrounding circumstances remain inadequately understood. This study explored nursing staff perspectives of person, environment, and interactive circumstances surrounding nursing home falls. Focus groups were conducted at two nursing homes in the mid-Atlantic region with the highest and lowest fall rates among corporate facilities. Two focus groups were conducted per facility: one with licensed nurses and one with geriatric nursing assistants. Thematic and content analysis revealed three themes and 11 categories. Three categories under the Person theme were Change in Residents' Health Status, Decline in Residents' Abilities, and Residents' Behaviors and Personality Characteristics. There were five Nursing Home Environment categories: Design Safety, Limited Space, Obstacles, Equipment Misuse and Malfunction, and Staff and Organization of Care. Three Interactions Leading to Falls categories were identified: Reasons for Falls, Time of Falls, and High-Risk Activities. Findings highlight interactions between person and environment factors as significant contributors to resident falls.

Acceptance and expectations of information technology to support hypertension self-care in African Americans: a qualitative inquiry.

The aim of this study was to explore African American patients' experiences managing their hypertension and to investigate their perspective on how technology might be used to improve hypertension self-management. We conducted and analyzed four focus groups with 32 African American participants diagnosed with hypertension to develop a culturally tailored content for a home-based telecare program aimed at improving hypertension care in African Americans. The discussion about the use of technology was well accepted, demonstrated culturally and gender specific barriers in hypertension care, and generated a comprehensive list of concepts and features to be included to a home-based computerized hypertension telemanagement system.

Inner-city victims of violence and trauma care: the importance of trauma-center discharge and aftercare planning and violence prevention programs.

Inner-city trauma centers often provide care for disproportionately indigent populations who are victims of violence. Many of these victims of violence often return to the trauma center with more violent injuries. Research has shown that a majority of these individuals who return to the trauma center for care are expensive to treat, are uninsured and have significant social problems. Two potential policy approaches are discussed: (1) the use of violence prevention programs to attempt to reduce violence in the immediate community and subsequently reduce the number of victims of violence who are treated in trauma centers and (2) the use of aftercare and discharge models that form an alliance between the trauma center and social service providers in the community. Nontraditional interventions will require the collaboration with hospital departments (emergency medicine, surgery, trauma, social work) and outside agencies, such as the courts and probation and parole. Case management, discharge planning, continuous care treatment teams, and violence intervention models offer positive alternatives to the current method of addressing the multiple problems of victims of violence who frequent the ED.