Evaluation of an Education Strategy versus Usual Care to Implement the STEADI Algorithm in Primary Care Clinics in an Academic Medical Center.

BACKGROUND: Although falls are the leading cause of morbidity and mortality in the US in the older adult population, there is little information regarding implementation of evidence-based fall prevention guidelines within primary care settings. The objective of this study was to address this gap in the literature by determining the effectiveness of the use of education and written materials as implementation strategies. METHODS: Using a prospective, mixed methods, controlled before-and-after study design, we studied the effect of the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) education and written materials on knowledge and intention to use in primary care clinics as well as test the screening, assessment, and intervention behaviors. This manuscript details the quantitative findings of the study, using STEADI Knowledge Test, Continuing Professional Development (CPD) Reaction Questionnaire, and EMR Reports. We compared data between the study arms (usual implementation versus education implementation) using descriptive statistics, paired t-tests, and factorial ANOVAs. RESULTS: In total, data from 29 primary care staff, including physicians, APRNs, RNs, and medical assistants, were analyzed. Although we found a statistically significant difference within the education arm between immediate pretests and posttests/surveys mean scores, there was no statistically significant difference between the study arms' knowledge, intent to use STEADI, or use behaviors. The pre/immediate post education mean knowledge score increased by 1.19 (p= 0.02) and the pre/immediate post education intent to use mean increased by 0.64 (p 0.01). There was no statistically significant change between the study arms over time. CONCLUSION: Educational strategies, particularly written materials and an online module, did not increase the long-term use of the STEADI toolkit. Implementation research is needed to identify the strategies that are most effective for promoting the adoption of STEADI in primary care.

Factors Associated With Nurses' Acceptance of the Electronic Intensive Care Unit.

BACKGROUND: Telemedicine intensivist-led intensive care (electronic intensive care unit [eICU]) is recommended when on-site intensivist-led intensive care is not available. Although the effects of eICU on patient outcomes are comparable with bedside intensivist-led care, not all implementations of eICU are successful in improving patient outcomes. Therefore, the aims of this study were to (1) examine the associations of perceived usefulness, perceived ease of use, nurses' attitudes toward eICU, and intention to use and (2) determine which participant characteristics were associated with these four dependent variables. METHODS: This cross-sectional, correlational study asked bedside registered nurses to complete an anonymous online survey to explore their acceptance of eICU. RESULTS: Nurses' attitude toward eICU and intention-to-use eICU demonstrated the strongest association, r(120) = 0.83, p < .001. The most significant variable associated with perceived usefulness, perceived ease of use, nurses' attitudes toward eICU, and intention to use was support from nurses. In addition, support from physicians was significantly associated with perceived usefulness, perceived ease of use, and nurses' attitudes toward eICU. CONCLUSIONS: Support from both bedside physicians and registered nurses in the intensive care unit had the most association with acceptance of the eICU service. Gaining their support to use an eICU service is essential.

Veterans' experiences initiating VA-based mental health care.

Military veterans who could benefit from mental health services often do not access them. Research has revealed a range of barriers associated with initiating United States Department of Veterans Affairs (VA) care, including those specific to accessing mental health care (e.g., fear of stigmatization). More work is needed to streamline access to VA mental health-care services for veterans. In the current study, we interviewed 80 veterans from 9 clinics across the United States about initiation of VA mental health care to identify barriers to access. Results suggested that five predominant factors influenced veterans' decisions to initiate care: (a) awareness of VA mental health services; (b) fear of negative consequences of seeking care; (c) personal beliefs about mental health treatment; (d) input from family and friends; and (e) motivation for treatment. Veterans also spoke about the pathways they used to access this care. The four most commonly reported pathways included (a) physical health-care appointments; (b) the service connection disability system; (c) non-VA care; and (d) being mandated to care. Taken together, these data lend themselves to a model that describes both modifiers of, and pathways to, VA mental health care. The model suggests that interventions aimed at the identified pathways, in concert with efforts designed to reduce barriers, may increase initiation of VA mental health-care services by veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Veterans' Attitudes Toward Smartphone App Use for Mental Health Care: Qualitative Study of Rurality and Age Differences.

BACKGROUND: Mental health smartphone apps provide support, skills, and symptom tracking on demand and come at minimal to no additional cost to patients. Although the Department of Veterans Affairs has established itself as a national leader in the creation of mental health apps, veterans' attitudes regarding the use of these innovations are largely unknown, particularly among rural and aging populations who may benefit from increased access to care. OBJECTIVE: The objective of our study was to examine veterans' attitudes toward smartphone apps and to assess whether openness toward this technology varies by age or rurality. METHODS: We conducted semistructured qualitative interviews with 66 veterans from rural and urban areas in Maine, Arkansas, and California. Eligible veterans aged 18 to 70 years had screened positive for postraumatic stress disorder (PTSD), alcohol use disorder, or major depressive disorder, but a history of mental health service utilization was not required. Interviews were digitally recorded, professionally transcribed, and coded by a research team using an established codebook. We then conducted a thematic analysis of segments pertaining to smartphone use, informed by existing theories of technology adoption. RESULTS: Interviews revealed a marked division regarding openness to mental health smartphone apps, such that veterans either expressed strongly positive or negative views about their usage, with few participants sharing ambivalent or neutral opinions. Differences emerged between rural and urban veterans' attitudes, with rural veterans tending to oppose app usage, describe smartphones as hard to navigate, and cite barriers such as financial limitations and connectivity issues, more so than urban populations. Moreover, rural veterans more often described smartphones as being opposed to their values. Differences did not emerge between younger and older (≥50) veterans regarding beliefs that apps could be effective or compatible with their culture and identity. However, compared with younger veterans, older veterans more often reported not owning a smartphone and described this technology as being difficult to use. CONCLUSIONS: Openness toward the use of smartphone apps in mental health treatment may vary based on rurality, and further exploration of the barriers cited by rural veterans is needed to improve access to care. In addition, findings indicate that older patients may be more open to integrating technology into their mental health care than providers might assume, although such patients may have more trouble navigating these devices and may benefit from simplified app designs or smartphone training. Given the strong opinions expressed either for or against smartphone apps, our findings suggest that apps may not be an ideal adjunctive treatment for all patients, but it is important to identify those who are open to and may greatly benefit from this technology.

Reducing Risky Sex among Rural African American Cocaine Users: A Controlled Trial.

Rural African American cocaine users experience high rates of STIs/HIV. This NIDA-funded trial tested an adapted evidence-based risk reduction program versus an active control condition. Participants were 251 African American cocaine users in rural Arkansas recruited from 2009-2011. Outcomes included condom use skills and self-efficacy, sexual negotiation skills, peer norms, and self-reported risk behavior. The intervention group experienced greater increases in condom use skills and overall effectiveness in sexual negotiation skills. Both groups reported reductions in trading sex, improvements in condom use self-efficacy, and increased use of specific negotiation skills. Implications and limitations are discussed.

Trajectory of substance use after an HIV risk reduction intervention.

BACKGROUND: Research assessments can confound the results of treatment outcome studies and can be themselves an intervention or form of aftercare. OBJECTIVE: To determine the trajectory of substance use and substance severity in a sample of African American cocaine users participating in a community-based sexual risk reduction trial. METHODS: Out-of-treatment participants were recruited using Respondent-Driven Sampling in two African American majority counties in rural Arkansas. They participated in either the sexual risk reduction condition or an active control focused on access to social services. They were interviewed at baseline, post-intervention, and 6 and 12 months post-intervention. Substance use outcome measures were use of crack cocaine, powder cocaine, marijuana, alcohol, and the Addiction Severity Index Alcohol and Drug Severity composites. A random sample of participants completed qualitative interviews post-12-month interview. RESULTS: 251 were enrolled. Substance use outcomes did not differ among the two conditions at any point in the study. Use of measured substances and the ASI composites significantly decreased between baseline and post-intervention (p < 0.01), decreases that persisted at the 12-month assessment period compared to baseline. Qualitative findings suggested that many participants identified increased awareness of their drug use and need to control it through the programs. Participants also noted strong bonding with interviewers. CONCLUSION: Clinical trials may have positive unexpected outcomes in terms of reduced substance use even though the trial is not substance use focused. Behavioral interventions for drug users that are not focused specifically on reducing drug use may nonetheless have unanticipated positive associations with reductions in drug use.

Correlates of HIV testing among rural African American cocaine users.

Andersen's Revised Behavioral Model of Health Services Use (RBM) was used as a framework in this correlational cross-sectional study to examine factors associated with HIV testing among a sample of 251 rural African American cocaine users. All participants reported using cocaine and being sexually active within the past 30 days. Independent variables were categorized according to the RBM as predisposing, enabling, need, or health behavior factors. Number of times tested for HIV (never, one time, two to four times, five or more times) was the outcome of interest. In ordered logistic regression analyses, HIV testing was strongly associated with being female, of younger age (predisposing factors); having been tested for sexually transmitted diseases or hepatitis, ever having been incarcerated in jail or prison (enabling factors); and having had one sex partner the past 30 days (health behavior factor). Other sexual risk behaviors, drug use, health status, and perception of risk were not associated with HIV testing. Our findings confirm the importance of routine testing in all healthcare settings rather than risk-based testing.

Sexual sensation seeking, transactional sex, and rural African American cocaine users.

The purpose of this study was to explore correlates of sexual sensation seeking (SSS) in a sample of rural African American cocaine users. Respondent-driven sampling was used to recruit 251 participants from two impoverished rural counties in eastern Arkansas. Consistent with previous investigations, SSS scores were associated with being younger, being male, having more sexual partners, and having more unprotected sexual encounters in the previous 30 days. Multiple regression revealed that SSS was correlated with a number of oral sex acts, transactional sex (exchanging sex for food, shelter, drugs, money, or other commodities), and Addiction Severity Index drug composite. SSS continues to demonstrate a strong association with sexual risk behaviors in diverse populations, including vulnerable groups like this community. Interventions to reduce unsafe sexual behaviors among high-risk groups, including drug users and individuals who engage in transactional sex, should incorporate approaches that include high sensation seekers' needs for novelty and variety.

Risky sex in rural America: longitudinal changes in a community-based cohort of methamphetamine and cocaine users.

BACKGROUND AND OBJECTIVES: This study examined the longitudinal associations between stimulant use and sexual behaviors. METHODS: Data are from a 3-year community-based study of 710 rural stimulant users. Past 30-day crack cocaine, powder cocaine, and methamphetamine use and sexual behaviors (any sex, inconsistent condom use, and multiple sexual partners) were assessed through in-person interviews every 6 months. RESULTS: GEE analyses revealed that the odds of having sex remained steady over time, with crack cocaine and methamphetamine use positively associated with having sex. The odds of multiple sexual partners declined, but the odds of inconsistent condom use remained steady over time. Crack cocaine use was positively associated with multiple sexual partners, whereas powder cocaine use was negatively associated with inconsistent condom use. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Many rural stimulant users could potentially benefit from safe sex educational programs. Such efforts could reduce the incidence of HIV and other STIs in rural America.

A qualitative analysis of provider barriers and solutions to HIV testing for substance users in a small, largely rural southern state.

PURPOSE: Integrating HIV testing programs into substance use treatment is a promising avenue to help increase access to HIV testing for rural drug users. Yet few outpatient substance abuse treatment facilities in the United States provide HIV testing. The purpose of this study was to identify barriers to incorporating HIV testing with substance use treatment from the perspectives of treatment and testing providers in Arkansas. METHODS: We used purposive sampling from state directories to recruit providers at state, organization, and individual levels to participate in this exploratory study. Using an interview guide, the first and second authors conducted semistructured individual interviews in each provider's office or by telephone. All interviews were recorded, transcribed verbatim, and entered into ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). We used constant comparison and content analysis techniques to identify codes, categories, and primary patterns in the data. FINDINGS: The sample consisted of 28 providers throughout the state, 18 from the substance use system and 10 from the public/ community health system. We identified 7 categories of barriers: environmental constraints, policy constraints, funding constraints, organizational structure, limited inter- and intra-agency communication, burden of responsibility, and client fragility. CONCLUSIONS: This study presents the practice-based realities of barriers to integrating HIV testing with substance use treatment in a small, largely rural state. Some system and/or organization leaders were either unaware of or not actively pursuing external funds available to them specifically for engaging substance users in HIV testing. However, funding does not address the system-level need for coordination of resources and services at the state level.

A Qualitative Study of Barriers to the Utilization of HIV Testing Services Among Rural African American Cocaine Users.

This qualitative study is about barriers to the utilization of HIV testing as perceived by African Americans who have recently used cocaine and who live in the rural Delta region of Arkansas. Affordability, physical accessibility, and geographic availability were not perceived as barriers to HIV testing in this sample, yet acceptability was still perceived as poor. Acceptability due to social mores and norms was a major barrier. Many said testing was unacceptable because of fear of social costs. Many were confident of being HIV-negative based on risky assumptions about testing and the notification process. Small-town social and sexual networks added to concerns about reputation and risk. System approaches may fail if they focus solely on improving access to HIV services but do not take into consideration deeply internalized experiences of rural African Americans as well as involvement of the community in developing programs and services.

The "translators": engaging former drug users as key research staff to design and implement a risk reduction program for rural cocaine users.

This manuscript describes lessons learned in the development and implementation of a clinical behavioral trial to reduce sexual risk among African-American cocaine users in rural Arkansas, from the perspectives of a multidisciplinary investigative team and community staff members with a history as local drug users who served as "translators." Recommendations for investigators doing community-based research with active substance users are provided in the following domains: (a) engaging the community during formative research, (b) establishing bidirectional trust, (c) ensuring community voices are heard, and (d) managing conflict. The "translator's" role is critical to the success of such projects.

"We as drug addicts need that program": Insight from rural African American cocaine users on designing a sexual risk reduction intervention for their community.

This focused ethnographic study examines data collected in 2007 from four gender- and age-specific focus groups (FGs) (N = 31) to inform the development of a sexual risk reduction intervention for African American cocaine users in rural Arkansas. A semi-structured protocol was used to guide audio-recorded FGs. Data were entered into Ethnograph and analyzed using constant comparison and content analysis. Four codes with accompanying factors emerged from the data and revealed recommendations for sexual risk reduction interventions with similar populations. Intervention design implications and challenges, study limitations, and future research are discussed. The study was supported by funds from the National Institute of Nursing Research (P20 NR009006-01) and the National Institute on Drug Abuse (1R01DA024575-01 and F31 DA026286-01).

Stages of change, decisional balance, and self-efficacy in condom use among rural African-American stimulant users.

This pilot study (a) examined the stages of change (SOC) for condom use with primary and casual partners among rural heterosexual African American stimulant users, (b) identified gender differences in variables associated with SOC, and (c) assessed the association of SOC with decisional balance and self-efficacy. A total of 72 participants completed the study. SOC with a primary partner were much lower than with a casual partner, indicating more consistent condom use with casual partners. Significant gender differences existed in decisional balance for condom use for both primary (p = .02) and casual partners (p =.03), with women having higher decisional balance scores than men. Women also reported higher self-efficacy scores for condom use with casual partners than men. In regression models, age, decisional balance, and self-efficacy were significantly associated with SOC for condom use with a primary partner; however, only self-efficacy was significantly associated with SOC with casual partners. The results provide support for the development of interventions that promote the advantages of and increase self-efficacy for condom use.

HIV risk behaviors among rural stimulant users: variation by gender and race/ethnicity.

We examined data from a community sample of rural stimulant users (n = 691) in three diverse states to identify gender and racial/ethnic differences in HIV risk behaviors. Bivariate and logistic regression analyses were conducted with six risk behaviors as dependent variables: injecting drugs, trading sex to obtain money or drugs, trading money or drugs to obtain sex, inconsistent condom use, multiple sex partners, and using drugs with sex. Controlling for state, income, age, heavy drinking, and type of stimulant used, men had lower odds than women for trading sex to obtain money or drugs (adjusted odds ratio [AOR] =0.4, confidence interval [CI] = 0.28-0.59; p < .0001), greater odds than women for trading money or drugs to obtain sex (AOR = 44.4, CI = 20.30-97.09; p < .0001), greater odds than women of injecting drugs (adjusted odds ratio (AOR =1.6, CI = 1.11-2.42; p = .01), and lower odds than women of using condoms inconsistently (AOR = 0.6, CI = 0.35-0.92; p = .02); African Americans had lower odds than Whites of injecting drugs (AOR = .08, CI = 0.04-0.16; p < .0001), greater odds than Whites for trading sex to obtain money or drugs (AOR = 1.7, CI = 1.01-2.85; p = .04) and for trading money or drugs to obtain sex (AOR = 2.9, CI = 1.53-5.59; p = .001), and greater odds than Whites of using drugs with sex (AOR = 3.9, CI = 1.47-10.09; p = .006). These findings indicate HIV prevention efforts should be tailored to address gender and racial/ethnic differences in risk behaviors among rural stimulant users.

Kentucky rural stimulant use: a comparison of methamphetamine and other stimulant users.

Population based surveys suggest that methamphetamine use is increasing. However, little is known about stimulant use in rural areas. Given the lack of data regarding rural stimulant use, particularly methamphetamine use, and the continuing problems associated with stimulant drug use, the purpose of this study was to examine rural stimulant use in Kentucky. Of 225 rural stimulant-using participants surveyed, 76% (n = 170) reported lifetime use of methamphetamine. Rural methamphetamine users differed from other rural stimulant users on demographic characteristics, health, and drug use histories. These results suggest that differences exist between rural stimulant users and that clinicians may need to consider these differences when planning treatment and rehabilitation strategies.