Critical Dialogue and Capacity-Building Projects Reduced Alcohol and Substance Use in a Randomized Clinical Trial Among Formerly Incarcerated Men.

Background: Rates of alcohol and/or substance use (ASU) among residents of predominantly Black and marginalized communities are similar to ASU rates in White communities. Yet ASU has worse consequences in predominantly Black and marginalized communities (e.g., higher incarceration). Objective: We randomized participants to one of 16 intervention conditions using a 24 full factorial design to optimize a multilevel intervention reducing ASU among 602 formerly incarcerated men with substance-use-disorders (SUD). Candidate intervention components included (1) critical dialogue (CD; six weekly 2-hour-long group sessions vs. no CD sessions), (2) Quality of Life Wheel (QLW; six weekly 1-hour-long group sessions vs. no QLW sessions), (3) capacity building projects (CBP; six weekly 1-hour-long group sessions vs. no CBP sessions), and (4) delivery by a trained peer versus licensed facilitators. Outcome was percentage of days in which participants used alcohol, cocaine, opioid, and/or cannabis in previous 30 days. Results: Intent-to-treat analysis did not meet a priori component selection criteria due to low intervention attendance. After controlling for intervention group attendance (percentage of sessions attended), peer-delivered CD and CBP produced statistically and clinically significant main and interaction effects in ASU over 5 months. Per the multiphase optimization strategy framework, we selected peer-delivered CD and CBP for inclusion as the optimized version of the intervention with a cost of US$1,380 per 10 individuals. No adverse intervention effects occurred. Conclusion: CD and CBP were identified as the only potentially effective intervention components. Future research will examine strategies to improve attendance and test the optimized intervention against standard of care in a randomized-controlled-trial.

Linking critical consciousness and health: The utility of the critical reflection about social determinants of health scale (CR_SDH).

INTRODUCTION: Critical consciousness (CC) theory has been proposed as a framework to inform health interventions targeting a wide variety of health conditions. Unfortunately, methodological limitations have made it difficult to test CC as a mediator of health outcomes. Specifically, standardized and widely accepted measures of health-related CC are needed. The goal of this study was to develop and test a measure of critical reflection on social determinants of health (SDH). This measure focused on critical reflection, an essential dimension of CC. METHODS: Community-based participatory research principles and a mixed methods design were used with three samples: (1) experts in SDH and CC, (2) 502 individuals completing online surveys, and (3) 602 men with histories of substance use disorder and incarceration. All participants were over 18 years of age. Analysis included descriptive frequencies, exploratory factor analyses (EFA), confirmatory factor analysis (CFA), generalized linear regression models, correlations, and Cronbach's alpha calculations. RESULTS: The Critical Reflection about SDH scale (CR_SDH) is a short, unidimensional, and reliable scale (α = 0.914). Construct validity was supported and known-groups validity showed that the scale discriminated different levels of CR_SDH based on political views, educational level, knowledge of health inequities, and gender. CONCLUSION: The CR_SDH is a standardized measure that can assess critical reflection about the impact of SDH on health among providers and consumers of health care. The CR_SDH can be used to identify critical reflection related training needs and inform decisions about development and testing of critical reflection related health interventions and health care policy.

Enhancing behavioral intervention science: using community-based participatory research principles with the multiphase optimization strategy.

Innovative methodological frameworks are needed in intervention science to increase efficiency, potency, and community adoption of behavioral health interventions, as it currently takes 17 years and millions of dollars to test and disseminate interventions. The multiphase optimization strategy (MOST) for developing behavioral interventions was designed to optimize efficiency, efficacy, and sustainability, while community-based participatory research (CBPR) engages community members in all research steps. Classical approaches for developing behavioral interventions include testing against control interventions in randomized controlled trials. MOST adds an optimization phase to assess performance of individual intervention components and their interactions on outcomes. This information is used to engineer interventions that meet specific optimization criteria focused on effectiveness, cost, or time. Combining CBPR and MOST facilitates development of behavioral interventions that effectively address complex health challenges, are acceptable to communities, and sustainable by maximizing resources, building community capacity and acceptance. Herein, we present a case study to illustrate the value of combining MOST and CBPR to optimize a multilevel intervention for reducing substance misuse among formerly incarcerated men, for under $250 per person. This integration merged experiential and cutting-edge scientific knowledge and methods, built community capacity, and promoted the development of efficient interventions. Integrating CBPR and MOST principles yielded a framework of intervention development/testing that is more efficient, faster, cheaper, and rigorous than traditional stage models. Combining MOST and CBPR addressed significant intervention science gaps and speeds up testing and implementation of interventions.

Interprofessional collaboration associated with frequency of life-saving links to HIV continuum of care services in the urban environment of Newark, New Jersey.

BACKGROUND: HIV continuum of care has been used as a strategy to reduce HIV transmission rates, with timely engagement in HIV testing being the first and most critical step. This study examines interprofessional-collaboration (IPC) after controlling for agency/ provider demographics, provider training and self-efficacy as a significant predictor of how frequently HIV service providers link their clients to HIV testing. METHODS: Multilevel binary logistic regression analysis was conducted to examine the effects of IPC on links to HIV testing while controlling for demographic and agency information, provider training, and standardized measures of providers' feelings, attitudes, and opinions about IPC. Cross-sectional data from 142 providers in 13 agencies offering treatment and prevention services for HIV and substance-use disorders were collected via a survey. RESULTS: Those who scored higher on the IPC scale reported significantly higher rates of linkages to HIV testing. Compared to the null model (i.e., no predictor model), the final multilevel binary logistic regression model showed a significantly improved likelihood of linkage to HIV testing by 11.4%, p. < .05. The final model correctly classified 90.2% of links to HIV testing. Providers in agencies with smaller budgets and in agencies offering substance use disorder services were more likely to link clients to HIV testing. Younger providers who received HIV training were also more likely to link clients to HIV testing. CONCLUSIONS: Findings suggest IPC training as a potential strategy to improve linkages to HIV testing for clients at risk for HIV infection. Future research is recommended to identify specific areas of IPC that might have differential effects on links to HIV testing.

Optimizing a community-engaged multi-level group intervention to reduce substance use: an application of the multiphase optimization strategy.

BACKGROUND: Rates of alcohol and illicit drug use (AIDU) are consistently similar across racial groups (Windsor and Negi, J Addict Dis 28:258-68, 2009; Keyes et al. Soc Sci Med 124:132-41, 2015). Yet AIDU has significantly higher consequences for residents in distressed communities with concentrations of African Americans (DCAA - i.e., localities with high rates of poverty and crime) who also have considerably less access to effective treatment of substance use disorders (SUD). This project is optimizing Community Wise, an innovative multi-level behavioral-health intervention created in partnership with service providers and residents of distressed communities with histories of SUD and incarceration, to reduce health inequalities related to AIDU. METHODS: Grounded in critical consciousness theory, community-based participatory research principles (CBPR), and the multiphase optimization strategy (MOST), this study employs a 2 × 2 × 2 × 2 factorial design to engineer the most efficient, effective, and scalable version of Community Wise that can be delivered for US$250 per person or less. This study is fully powered to detect change in AIDU in a sample of 528 men with a histories of SUD and incarceration, residing in Newark, NJ in the United States. A community collaborative board oversees recruitment using a variety of strategies including indigenous field worker sampling, facility-based sampling, community advertisement through fliers, and street outreach. Participants are randomly assigned to one of 16 conditions that include a combination of the following candidate intervention components: peer or licensed facilitator, group dialogue, personal goal development, and community organizing. All participants receive a core critical-thinking component. Data are collected at baseline plus five post-baseline monthly follow ups. Once the optimized Community Wise intervention is identified, it will be evaluated against an existing standard of care in a future randomized clinical trial. DISCUSSION: This paper describes the protocol of the first ever study using CBPR and MOST to optimize a substance use intervention targeting a marginalized population. Data from this study will culminate in an optimized Community Wise manual; enhanced methodological strategies to develop multi-component scalable interventions using MOST and CBPR; and a better understanding of the application of critical consciousness theory to the field of health inequalities related to AIDU. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02951455 . Registered on 1 November 2016.

Community Wise: paving the way for empowerment in community reentry.

Theoretical approaches traditionally applied in mental health and criminal justice interventions fail to address the historical and structural context that partially explains health disparities. Community Wise was developed to address this gap. It is a 12week group intervention informed by Critical Consciousness Theory and designed to prevent substance abuse, related health risk behaviors, psychological distress, and reoffending among individuals with a history of incarceration and substance abuse. This paper reports findings from the first implementation and pilot evaluation of Community Wise in two community-based organizations. This pre-posttest evaluation pilot-tested Community Wise and used findings to improve the intervention. Twenty-six participants completed a phone and clinical screening, baseline, 6- and 12-week follow-ups, and a focus group at the end of the intervention. Measures assessed participants' demographic information, psychological distress, substance use, criminal offending, HIV risk behaviors, community cohesion, community support, civic engagement, critical consciousness, ethnic identification, group cohesion, client satisfaction, and acquired treatment skills. Research methods were found to be feasible and useful in assessing the intervention. Results indicated that while Community Wise is a promising intervention, several changes need to be made in order to enhance the intervention. Community Wise is a new approach where oppressed individuals join in critical dialogue, tap into existing community resources, and devise, implement and evaluate their own community solutions to structural barriers.

Community Wise: A formative evaluation of a community based health intervention.

Individuals with histories of incarceration and substance abuse residing in distressed communities often receive suboptimal services partly due to a lack of empirically supported substance abuse treatments targeting this population. Grounded in community-engaged research, we developed Community Wise, a manualized, 12-week, group behavioral intervention. The intervention aims to reduce substance use frequency, HIV/HCV risk behaviors, and reoffending among individuals with histories of substance abuse and incarceration. Thirty six individuals were recruited to participate in a formative evaluation of Community Wise processes and outcomes. Analysis showed significantly lower post-intervention number of cigarettes smoked per day, days using an illicit drug, money spent on illegal drugs, and rearrests. Based on the evaluation, the research team made the following changes: 1) added a session on sexuality; 2) increased the number of sessions from 12 to 15; and 3) modified strategies to help participants develop and implement capacity building projects.

Using Concept Mapping in Community-Based Participatory Research: A Mixed Methods Approach.

Community-based participatory research (CBPR) has been identified as a useful approach to increasing community involvement in research. Developing rigorous methods in conducting CBPR is an important step in gaining more support for this approach. The current article argues that concept mapping, a structured mixed methods approach, is useful in the initial development of a rigorous CBPR program of research aiming to develop culturally tailored and community-based health interventions for vulnerable populations. A research project examining social dynamics and consequences of alcohol and substance use in Newark, New Jersey, is described to illustrate the use of concept mapping methodology in CBPR. A total of 75 individuals participated in the study.

From the Individual to the Community: Perspectives about Substance Abuse Services.

This paper argues that substance abuse interventions in distressed African-American communities must be culturally-tailored and incorporate a framework targeting changes in both individual behavior and the community. The current study employed Concept Mapping in conjunction with Community-Based Participatory Research (CBPR) principles to involve 100 community members, substance users, and service providers to examine the role of alcohol and other drugs in distressed African-American communities. Findings reveal the way participants understand the role of drugs and alcohol in their community and their perceptions of substance abuse services. The paper describes a collaborative approach to engage the community in addressing substance abuse.

Surviving oppression under the rock: the intersection of New York's drug, welfare, and educational polices in the lived experiences of low-income African Americans.

Drawing on standpoint and intersectionality theories, this study explores the degree to which interactions among New York State's Rockefeller Drug Laws and educational and welfare policies have contributed to the maintenance of a culture of surveillance in which the lives of impoverished African Americans are overseen and influenced by oppressive policies and governmental institutions. Qualitative secondary analysis of longitudinal ethnographic data was conducted. Findings demonstrate multiple disadvantages that impoverished African American families struggling with substance use or sale experience. These disadvantages accumulated intergenerationally, in a snowball effect, making it difficult for participants to maintain stable lives. Findings explored the tension between participants' lived experiences and the multiple ways they either assimilated or resisted their oppression. New sensitive policies informed by standpoint, intersectionality, and Afrocentric perspectives must be developed to increase the availability of meaningful employment and strengthening impoverished African American communities.

Challenging controlling images, oppression, poverty and other structural constraints: Survival strategies among African American women in distressed households.

Powerful controlling images perpetuate misguided messages about impoverished African American women that contribute to the oppression these women endure. These images inform policies and behavior that create and maintain structural barriers such as lack of access to education and meaningful employment further marginalizing oppressed individuals. This article uses in-depth interview data to analyze interlocking oppressions in the lived experience of impoverished African American women. The authentic women's voices presented serve as a counter narrative of resistance. Our larger goal in writing this paper is to encourage the public, policy makers, service providers and impoverished African American women themselves to fight against controlling images by deconstructing personal biases, educating the public, and developing culturally congruent interventions to social problems.

Dimensions of oppression in the lives of impoverished black women who use drugs.

Oppression against Black women continues to be a significant problem in the United States. The purpose of this study is to use grounded theory to identify multiple dimensions of oppression experienced by impoverished Black women who use drugs by examining several settings in which participants experience oppression. Three case studies of drug using, impoverished Black women were randomly selected from two large scale consecutive ethnographic studies conducted in New York City from 1998 to 2005. Analysis revealed five dimensions of oppression occurring within eight distinct settings. While dimensions constitute different manifestations of oppression, settings represented areas within participants' lives or institutions with which participants interact. Dimensions of oppression included classism, sexism, familism, racism, and drugism. Settings included the school system, correction system, welfare system, housing and neighborhood, relationship with men, family, experiences with drug use, and employment. Findings have important implications for social justice, welfare, drug, and justice system policy.

Spiritual change in drug treatment: utility of the Christian Inventory of Spirituality.

The current study used data from reliability testing of the Christian Inventory of Spirituality (CIS) to (1) assess the utility of CIS in detecting differences in level of spirituality in residents of residential Christian faith-based substance abuse programs (RCFBSAPs); (2) test the hypothesis that residents who have been in the program for longer periods of time will have significantly higher levels of spirituality after controlling for relevant demographic characteristics; and (3) test the hypothesis that residents of programs that only use unlicensed staff and place higher importance on spirituality will have significantly higher levels of spirituality. A purposive sample of the cross-sectional data from the reliability testing of the CIS was used (n = 253). Analysis supported the hypothesis. Demographic characteristics were not associated with level of spirituality. The CIS proved to be useful in discriminating levels of spirituality. Further research is needed to examine spiritual change using randomized pre-post test designs.

What is substance use about? Assumptions in New York's drug policies and the perceptions of African Americans who are low-income and using drugs.

The current article uses intersectionality and standpoint theories to examine the social impact of solely relying on Eurocentric worldviews when developing drug policies that affect low-income African American communities. It is argued that low-income African Americans share a unique cultural and historical background that must be taken into account in the development and implementation of policies and interventions that effect this population. Analysis of longitudinal qualitative data will compare the assumptions informing New York's Rockefeller Drug Laws with the worldviews of drug using and low-income African Americans in New York City, New York, while examining the impact of these policies in participants' lived experiences.

Systematic assessment of culturally competent chemical dependence treatment services for African Americans.

This project aimed to develop a tool for assessing and planning culturally competent and relevant chemical dependence treatment services for African American clients and their families. Focus groups were conducted with experts in African American culture and chemical dependence in eight substance abuse programs serving adult and adolescent African Americans and their families. Seventy-five statements were developed describing characteristics of culturally competent and relevant organizations. Concept mapping was used to produce a conceptual map displaying dimensions of culturally competent and relevant organizations and Cronbach's alpha was calculated to assess the internal consistency of each dimension. Analysis resulted in six reliable dimensions: Family Involvement (alpha = .81), Staff and Program Cultural Diversity (alpha = .98), Counselor Traits (alpha = .99), Linkage (alpha = .94), Community/Faith Services (alpha = .96), and Agency Culture (alpha = .97). The resulting instrument enables agencies to evaluate culturally competent and relevant services, set goals, and identify resources needed to implement desired services for both individual organizations and within networks of regional service providers.

Assessing culturally competent chemical dependence treatment services for Mexican Americans.

Mexican Americans struggling with chemical dependence are greatly underserved. Barriers to treatment include language, lack of culturally relevant services, lack of trust in programs, uninviting environments, and limited use and linkage with cultural resources in the community. This project aimed to develop a tool for assessing and planning culturally competent/relevant chemical dependence treatment services for Mexican Americans. Focus groups were conducted with experts in Mexican-American culture and chemical dependence from six substance abuse programs serving adult and adolescent Mexican Americans and their families. Sixty-two statements were developed describing characteristics of culturally competent/relevant organizations. Concept mapping was used to produce a conceptual map displaying dimensions of culturally competent/relevant organizations and Cronbach's alpha was calculated to assess the internal consistency of each dimension. Analysis resulted in seven reliable subscales: Spanish language (alpha = 0.84), counselor characteristics (alpha = 0.82), environment (alpha = 0.88), family (alpha = 0.84), linkage (alpha = 0.92), community (alpha = 0.86), and culture (alpha = 0.89). The resulting instrument based on these items and dimensions enable agencies to evaluate culturally competent/relevant services, set goals, and identify resources needed to implement desired services for both individual organizations and networks of regional services.

Substance abuse and dependence among low income African Americans: using data from the national survey on drug use & health to demystify assumptions.

The media has portrayed African Americans as drug users and criminals. The purpose of this study is to test the assumption that low-income African Americans use more alcohol, nicotine, marijuana, and illicit drugs than other racial groups using data from the 2005 National Survey on Drug Use and Health to compare drug abuse and dependence across low income racial groups (N = 20,172). Most respondents were white, female, and older than 26 years of age. The majority completed high school and reported annual family incomes between $10,000 and $19,000. Few participants reported receiving public assistance. Drug abuse and dependence rates varied across drug type and across race. Drug dependence and abuse were measured using the Nicotine Dependence Syndrome Scale and criteria from the Diagnostic and Statistical Manual of Mental Disorders. Hierarchical regression was conducted to examine the level of association between racial background and drug abuse and dependence after controlling for age and gender. Results reveal that the assumption of high drug and alcohol use and abuse rates among low-income African Americans should be, at best, reexamined. This study has significant implications for both policy and social work practice because it breaks down normalized and biased assumptions of low-income African American drug use.

Educating Homeless Youth in Texas: The McKinney-Vento Homeless Education Assistance Improvements Act of 2001.

This paper discusses homeless youth in the US focusing on educational issues addressed by the implementation of the McKinney-Vento Homeless Education Assistance Improvements Act of 2001. This law requires that states ensure each homeless child has equal access to public education. Moreover, the law requires states to identify and remove barriers to homeless children's education, such as requirements for previous school records and proof of residency. Following description of homelessness, educational issues, and barriers for homeless youth, the McKinney-Vento Act is described as it is applied in Texas. Finally, the paper concludes that further development, education, and commitment from service providers in schools and other community agencies will be needed to improve outcomes for these highly vulnerable youth.

Contrasting faith-based and traditional substance abuse treatment programs.

This article (a) discusses the definition of faith-based substance abuse treatment programs, (b) juxtaposes Durkheim's theory regarding religion with treatment process model to highlight key dimensions of faith-based and traditional programs, and (c) presents results from a study of seven programs to identify key program dimensions and to identify differences/similarities between program types. Focus group/Concept Mapping techniques yielded a clear "spiritual activities, beliefs, and rituals" dimension, rated as significantly more important to faith-based programs. Faith-based program staff also rated "structure and discipline" as more important and "work readiness" as less important. No differences were found for "group activities/cohesion" and "role modeling/mentoring," "safe, supportive environment," and "traditional treatment modalities." Programs showed substantial similarities with regard to core social processes of treatment such as mentoring, role modeling, and social cohesion. Implications are considered for further research on treatment engagement, retention, and other outcomes.