Implementation strategy in collaboration with people with lived experience of mental illness to reduce stigma among primary care providers in Nepal (RESHAPE): protocol for a type 3 hybrid implementation effectiveness cluster randomized controlled trial.

BACKGROUND: There are increasing efforts for the integration of mental health services into primary care settings in low- and middle-income countries. However, commonly used approaches to train primary care providers (PCPs) may not achieve the expected outcomes for improved service delivery, as evidenced by low detection rates of mental illnesses after training. One contributor to this shortcoming is the stigma among PCPs. Implementation strategies for training PCPs that reduce stigma have the potential to improve the quality of services. DESIGN: In Nepal, a type 3 hybrid implementation-effectiveness cluster randomized controlled trial will evaluate the implementation-as-usual training for PCPs compared to an alternative implementation strategy to train PCPs, entitled Reducing Stigma among Healthcare Providers (RESHAPE). In implementation-as-usual, PCPs are trained on the World Health Organization Mental Health Gap Action Program Intervention Guide (mhGAP-IG) with trainings conducted by mental health specialists. In RESHAPE, mhGAP-IG training includes the added component of facilitation by people with lived experience of mental illness (PWLE) and their caregivers using PhotoVoice, as well as aspirational figures. The duration of PCP training is the same in both arms. Co-primary outcomes of the study are stigma among PCPs, as measured with the Social Distance Scale at 6 months post-training, and reach, a domain from the RE-AIM implementation science framework. Reach is operationalized as the accuracy of detection of mental illness in primary care facilities and will be determined by psychiatrists at 3 months after PCPs diagnose the patients. Stigma will be evaluated as a mediator of reach. Cost-effectiveness and other RE-AIM outcomes will be assessed. Twenty-four municipalities, the unit of clustering, will be randomized to either mhGAP-IG implementation-as-usual or RESHAPE arms, with approximately 76 health facilities and 216 PCPs divided equally between arms. An estimated 1100 patients will be enrolled for the evaluation of accurate diagnosis of depression, generalized anxiety disorder, psychosis, or alcohol use disorder. Masking will include PCPs, patients, and psychiatrists. DISCUSSION: This study will advance the knowledge of stigma reduction for training PCPs in partnership with PWLE. This collaborative approach to training has the potential to improve diagnostic competencies. If successful, this implementation strategy could be scaled up throughout low-resource settings to reduce the global treatment gap for mental illness. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04282915 . Date of registration: February 25, 2020.

Alcohol-Impaired Driving and Perceived Risks of Legal Consequences.

BACKGROUND: Driving while impaired (DWI) is a threat to public health. Codified legal sanctions are a widely implemented strategy to reduce DWI. However, it is unclear that sanctioning affects individual risk perceptions so as to deter alcohol-impaired driving. METHODS: Using survey data collected from individual drivers, police, and defense attorneys specializing in DWI in 8 U.S. cities, we investigated whether risk perceptions about legal consequences for alcohol-impaired driving, both the risk of being stopped if driving while alcohol-impaired and receiving specific penalties following a DWI, deter alcohol-impaired driving. First, we analyzed how different drivers' risk perceptions about being pulled over and facing criminal sanctions related to their self-reported alcohol-impaired driving in the year following the interview at which risk perceptions were elicited. Second, using data from an experimental module in which individual's risk perceptions were randomly updated by the interview, we analyzed how each driver's beliefs about his or her own future alcohol-impaired driving responded to randomly generated increases in the apprehension probability and sanction magnitude. RESULTS: Higher probabilities as estimated by the individuals of being pulled over corresponded to less alcohol-impaired driving in both analyses. Conversely, there was no statistical relationship between perceptions of criminal sanctions for DWI and alcohol-impaired driving with 1 exception-a small significant negative relationship between duration of jail time following a DWI conviction and alcohol-impaired driving. CONCLUSIONS: Perceptions regarding the threat of being apprehended for alcohol-impaired driving were related to actual self-reported driving, while perceived sanctions following a DWI conviction for DWI generally were unrelated to either actual self-reported alcohol-impaired driving or the person's estimate of probability that he or she would drive while alcohol-impaired in the following year. Increasing certainty of apprehension by increasing police staffing and/or conducting sobriety checks is a more effective strategy for reducing alcohol-impaired driving than legislating increased penalties for DWI.

Does the probability of DWI arrest fall following participation in DWI and hybrid drug treatment court programs?

Using North Carolina administrative data, this study examined recidivism following participation in specialty hybrid drug and driving while intoxicated (DWI) court programs. Three court program participation levels were considered-being referred to, enrolling in, and completing a specialty court program. Measures of DWI recidivism were: arrest and total number of arrests for DWI, and being convicted of DWI during follow-up periods of two and, alternatively, four years. Propensity score matching was used to obtain comparable control groups. Using a four-year follow-up, persons convicted of a DWI who completed a specialty court program were associated with a greater reduction in DWI re-arrests and re-convictions than did matched individuals who were never referred to a specialty court program. DWI courts were more effective in reducing re-arrests than hybrid drug courts were. Although promising from the vantage point of participants, few persons convicted of a DWI were referred to either court type, thus limiting this strategy's potential effectiveness in reducing DWI.

Deterring Rearrests for Drinking and Driving.

This study assesses why some individuals are re-arrested for driving while intoxicated (DWI). Using longitudinal data from North Carolina containing information on arrests and arrest outcomes, we test hypotheses that individuals prosecuted and convicted of DWI are less likely to be re-arrested for DWI. We allow for possible endogeneity of prosecution and conviction outcomes by using instrumental variables for the prosecutor's prosecution rate and the judge's conviction rate. With a three-year follow-up, the probability of DWI re-arrest was reduced by 6.6 percent if the person was prosecuted for DWI and, for those prosecuted, by 24.5 percent if convicted on this charge. Prosecution and conviction for DWI deters re-arrest for DWI.

The effects of participation level on recidivism: a study of drug treatment courts using propensity score matching.

BACKGROUND: Empirical evidence has suggested that drug treatment courts (DTCs) reduce re-arrest rates. However, DTC program completion rates are low and little is known about the effectiveness of lower levels of program participation. OBJECTIVES: We examined how DTC program referral, enrollment without completion, and completion, affected re-arrest rates during a two-year follow-up. RESEARCH DESIGN: We used statewide North Carolina data from criminal courts merged with DTC data. Propensity score matching was used to select comparison groups based on demographic characteristics, criminal histories, and drug of choice (when available). Average treatment effects on the treated were computed. MEASURES: DTC participation levels included referral without enrollment, (n = 2,174), enrollment without completion (n = 954), and completion (n = 747). Recidivism measured as re-arrest on a substance-related charge, on a violent offense charge not involving an allegation of substance abuse, and on any charge (excluding infractions) was examined by felony and misdemeanor status during a two-year follow-up period. RESULTS: Re-arrest rates were high, 53-76 percent. In general, re-arrest rates were similar for individuals who were referred but who did not enroll and a matched comparison group consisting of individuals who were not referred. In contrast, enrollees who did not complete had lower re-arrest rates than a matched group of individuals who were referred but did not enroll, for arrests on any charge, on any felony charge, and on substance-related charges (felonies and misdemeanors). Finally, relative to persons who enrolled but did not complete, those who completed had lower re-arrest rates on any charge, any felony charge, any misdemeanor charge, any substance-related charge, any substance-related misdemeanor or felony charge, and any violent felony charge. CONCLUSIONS: Enrolling in a DTC, even without completing, reduced re-arrest rates. Given the generally low DTC completion rate, this finding implies that only examining effects of completion underestimates the benefits of DTC programs.