Implementation of medication for opioid use disorder treatment in Indian health clinics in California: A qualitative evaluation.

INTRODUCTION: American Indians and Alaska Native (AIAN) populations are disproportionately affected by opioid misuse. Medication for opioid use disorder (MOUD) is essential to decrease overdose events and overdose deaths. AIAN communities can benefit from MOUD programs that are housed within primary care clinics to improve treatment accessibility. This study aimed to gather information on the needs, barriers, and successes related to implementing MOUD programs in Indian health clinics (IHCs) offering primary care. METHODS: The study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) evaluation framework to structure key informant interviews with clinic staff who received technical assistance for MOUD program implementation. The study incorporated RE-AIM dimensions into a semi-structured interview guide. We developed the coding approach for analyzing interview data using Braun and Clarke's (2006) reflexive thematic analysis in qualitative research. RESULTS: Eleven clinics participated in the study. The research team conducted twenty-nine interviews with clinic staff. We found that inadequate education about MOUD, scant resources, and limited availability of AIAN providers adversely impacted reach. Challenges with integrating medical and behavioral care, patient-level barriers (e.g., rural conditions, geographical dispersion), and limited workforce capacity impacted MOUD effectiveness. Stigma at the clinic level was detrimental to MOUD adoption. Implementation was challenging due to a limited number of waivered providers, and the need for technical assistance and MOUD policies and procedures. Staff turnover and restricted physical infrastructure negatively influenced MOUD maintenance. CONCLUSIONS: Clinical infrastructure should be strengthened. The integration of culture into clinic services must be embraced by staff to support MOUD adoption. Increased representation from AIAN clinical staff is needed to appropriately represent the population being served. Stigma at various levels must be addressed, and the multiple barriers that AIAN communities face must be considered in understanding MOUD program implementation and outcomes.

American Indian and Alaska Native substance use treatment: Barriers and facilitators according to an implementation framework.

INTRODUCTION: Substance use disorder (SUD) and overdose deaths are higher in the American Indian and Alaska Native (AIAN) population than in other racial/ethnic groups. Multi-level gaps hinder SUD treatment for AIAN patients. Few studies have engaged front-line clinicians and administrators of SUD treatment programs serving AIAN patients to identify barriers and facilitators to improve the implementation of effective treatment. METHODS: We conducted key informant interviews with a diverse sample of providers and administrators of SUD treatment programs across California regarding barriers and facilitators to treatment for AIAN patients. An AIAN-majority community advisory board (CAB) guided the development of an interview guide and helped to recruit respondents from five types of SUD programs statewide. Using ATLAS.ti, the research team coded interviews and classified emergent themes as barriers and facilitators related to Outer, Inner, and Individual domains of the Consolidated Framework for Implementation Research (CFIR). RESULTS: Representatives of 13 of 15 invited SUD treatment programs participated and 9 of the 13 interviewed self-identified as AIAN. Related to Outer Setting barriers from coded interviews, a dominant barrier was policies that defund or underfund SUD treatment, especially detoxification centers. Outer Setting facilitators included consistent Indian Health Service (IHS) eligibility criteria, judicial system connections for direct treatment access, and community programs advocating SUD treatment. Key themes related to barriers for the Inner Setting were limited bed capacity, poor coordination of intake and care, and lack of telehealth technology. Facilitators integrated mental health, linkage to external resources, and culturally centered care. Individual-level barriers were negative attitudes such as SUD stigma, distrust of governmental programs, and lack of transportation while individual engagement was facilitated by programs addressing negative attitudes and providing telemedicine for remote care. CONCLUSION: The public health threat of SUD for the AIAN population mandates the implementation of interventions and policies that facilitate care. This qualitative study with primarily AIAN clinical leaders of SUD treatment highlights opportunities to improve care at multiple CFIR levels, focusing on capacity, coordination, culturally congruent care, and community initiatives to promote engagement.

Project SUN: Pilot Study of a Culturally Adapted Smoking Cessation Curriculum for American Indian Youth.

American Indian Alaska Native (AIAN) youth have disproportionately higher rates of commercial tobacco product use compared to other racial and ethnic groups in the U.S. These rates underscore a need for commercial tobacco product cessation interventions that are culturally informed. This project studied the development, implementation, and some impact data of an adapted version of Project EX, an evidence-based intervention for teen smoking cessation. Implementation challenges resulted in a change from a three-arm to a single-arm trial with 37 AIAN youth who participated in an eight-week curriculum. Intent-to-treat analysis with biochemical validation results indicated that 32% (N = 12/37) of youth quit smoking at the three-month follow-up. Participants reported being satisfied with the program overall and enjoying the culturally adapted activities. This study detailed the program's adaptation and lessons learned during implementation.

Substance and Behavioral Addictions among American Indian and Alaska Native Populations.

OBJECTIVE: This paper examines substance and behavioral addictions among American Indian and Alaska Natives (AIAN) to identify the structural and psychosocial risk and cultural protective factors that are associated with substance use and behavioral addictions. METHODS: Five databases were used to search for peer reviewed articles through December 2021 that examined substance and behavioral addictions among AIANs. RESULTS: The literature search identified 69 articles. Numerous risk factors (i.e., life stressors, severe trauma, family history of alcohol use) and protective factors (i.e., ethnic identity, family support) influence multiple substance (i.e., commercial tobacco, alcohol, opioid, stimulants) and behavioral (e.g., gambling) addictions. CONCLUSIONS: There is a dearth of research on behavioral addictions among AIANs. Unique risk factors in AIAN communities such as historical trauma and socioeconomic challenges have interfered with traditional cultural resilience factors and have increased the risk of behavioral addictions. Future research on resilience factors and effective prevention and treatment interventions could help AIANs avoid behavioral addictions.

Evaluation of a Program to Help Low-Income, Latina Mothers Help Their Children Cope With Stress.

This paper describes the evaluation of a program that provides low-income Latina mothers with skills to help their children cope with stress. Based on focus groups with mothers and their school-aged children in two locations, we developed a five-week program for helping mothers identify signs of stress in their children, learn effective emotion-coaching skills, and learn how to effectively encourage their children to use coping strategies that match the controllability of the situation. We conducted a randomized controlled trial in an urban (n = 13) and rural (n = 78) location in which we randomly assigned mothers to either an intervention or a no-treatment control condition. We completed eight implementations of the program (2 in the urban sample and 6 in the rural one). To evaluate the program, we collected pre- and post-assessments of mothers' coping knowledge, emotion coaching, strategies for helping their children cope with stress, maternal self-efficacy in helping their children cope, general parenting practices, and general parenting self-efficacy. Observers assessed the fidelity of program delivery. Mothers who received the intervention, in contrast to those in the control condition, showed significant increases in their knowledge of strategies to help their children cope with stress, in reported emotion-coaching skills, and in the reported use of positive strategies for helping their children manage their behavior and emotions in stressful situations (i.e., helping their children relax and calm down, talking with their children about feelings, helping their children problem-solve, encouraging distraction, and helping their children improve their self-esteem). Post intervention, mothers reported increases in their efficacy for helping their children cope with stress. Analyses revealed no significant effects of the program on general parenting or general parenting self-efficacy, but did have the hypothesized effects on maternal knowledge, attitudes, and reported behavior. Subsequent research should examine the degree to which the program has effects over a longer time period and on children's approaches to coping with stress.

Emotion regulation strategies and childhood obesity in high risk preschoolers.

The current study examined the relationships between the specific strategies that preschool children use to regulate their emotions and childhood weight status to see if emotion regulation strategies would predict childhood weight status over and above measures of eating self-regulation. 185 4- to 5-year-old Latino children were recruited through Head Start centers in a large city in the southeastern U.S. Children completed both a delay of gratification task (emotion regulation) and an eating in the absence of hunger task (eating regulation). Eating regulation also was assessed by maternal reports. Four emotion regulation strategies were examined in the delay of gratification task: shut out stimuli, prevent movement, distraction, and attention to reward. Hierarchical linear regressions predicting children's weight status showed that both measures of eating regulation negatively predicted child obesity, and the use of prevent movement negatively predicted child obesity. Total wait time during the delay of gratification tasks was not a significant predictor. The current findings are consistent with studies showing that for preschool children, summary measures of emotion regulation (e.g., wait time) are not concurrently associated with child obesity. In contrast, the use of emotion regulation strategies was a significant predictor of lower child weight status. These findings help identify emotion regulation strategies that prevention programs can target for helping children regulate their emotions and decrease their obesity risk.