Reduction in substance use stigma following a peer-recovery specialist behavioral activation intervention.

BACKGROUND: Patients' perceptions and experiences of stigma related to substance use and methadone treatment are barriers to successful treatment of opioid use disorder, particularly among low-income and medically underserved populations. Interventions led by peer recovery specialists (PRSs) may shift stigma-related barriers. This study sought to evaluate shifts in substance use and methadone treatment stigma in the context of an evidence-based behavioral intervention adapted for PRS delivery to support methadone treatment outcomes. METHODS: We recruited patients who had recently started methadone treatment or demonstrated difficulty with adherence from a community-based program (N = 37) for an open-label pilot study of a 12-session behavioral activation intervention led by a PRS interventionist. Participants completed substance use and methadone treatment stigma assessments and the SIP-R, a brief measure of problems related to substance use, at baseline, mid-point (approximately six weeks), and post-treatment (approximately 12 weeks). Generalized estimating equations assessed change in total stigma scores between baseline and post-treatment as well as change in stigma scores associated with change in SIP-R responses. RESULTS: There was a statistically significant decrease in substance use stigma (b(SE)=-0.0304 (0.0149); p = 0.042) from baseline to post-treatment, but not methadone treatment stigma (b(SE)=-0.00531 (0.0131); p = 0.68). Decreases in both substance use stigma (b(SE)=0.5564 (0.0842); p < 0.001) and methadone treatment stigma (b(SE)=0.3744 (0.1098); p < 0.001) were associated with a decrease in SIP-R scores. CONCLUSIONS: PRS-led interventions have potential to shift substance use stigma, which may be associated with decrease in problems related to substance use, and therefore merit further testing in the context of randomized controlled trials.

Mutual capacity building model for adaptation (MCB-MA): a seven-step procedure bidirectional learning and support during intervention adaptation.

Global health reciprocal innovation emphasizes the movement of technologies or interventions between high- and low-income countries to address a shared public health problem, in contrast to unidirectional models of "development aid" or "reverse innovation". Evidence-based interventions are frequently adapted from the setting in which they were developed and applied in a new setting, presenting an opportunity for learning and partnership across high- and low-income contexts. However, few clear procedures exist to guide researchers and implementers on how to incorporate equitable and learning-oriented approaches into intervention adaptation across settings. We integrated theories from pedagogy, implementation science, and public health with examples from experience adapting behavioral health interventions across diverse settings to develop a procedure for a bidirectional, equitable process of intervention adaptation across high- and low-income contexts. The Mutual capacity building model for adaptation (MCB-MA) is made up of seven steps: 1) Exploring: A dialogue about the scope of the proposed adaptation and situational appraisal in the new setting; 2) Developing a shared vision: Agreeing on common goals for the adaptation; 3) Formalizing: Developing agreements around resource and data sharing; 4) Sharing complementary expertise: Group originating the intervention supporting the adapting group to learn about the intervention and develop adaptations, while gleaning new strategies for intervention implementation from the adapting group; 5) Reciprocal training: Originating and adapting groups collaborate to train the individuals who will be implementing the adapted intervention; 6) Mutual feedback: Originating and adapting groups share data and feedback on the outcomes of the adapted intervention and lessons learned; and 7) Consideration of next steps: Discuss future collaborations. This evidence-informed procedure may provide researchers with specific actions to approach the often ambiguous and challenging task of equitable partnership building. These steps can be used alongside existing intervention adaptation models, which guide the adaptation of the intervention itself.

"Early in the morning, there's tolerance and later in the day it disappears" - The intersection of resource scarcity, stress and stigma in mental health and substance use care in South Africa.

Stress is a challenge among non-specialist health workers worldwide, particularly in low-resource settings. Understanding and targeting stress is critical for supporting non-specialists and their patients, as stress negatively affects patient care. Further, stigma toward mental health and substance use conditions also impacts patient care. However, there is little information on the intersection of these factors. This sub-analysis aims to explore how substance use and mental health stigma intersect with provider stress and resource constraints to influence the care of people with HIV/TB. We conducted semi-structured interviews (N=30) with patients (n=15) and providers (n=15, non-specialist health workers) within a low-resource community in Cape Town, South Africa. Data were analyzed using thematic analysis. Three key themes were identified: (1) resource constraints negatively affect patient care and contribute to non-specialist stress; (2) in the context of stress, non-specialists are hesitant to work with patients with mental health or substance use concerns, who they view as more demanding and (3) stress contributes to provider stigma, which negatively impacts patient care. Findings highlight the need for multilevel interventions targeting both provider stress and stigma toward people with mental health and substance use concerns, especially within the context of non-specialist-delivered mental health services in low-resource settings.

Development and Empirical Test of the Research-Informed South African Relationship Functioning Assessment (SARFA).

Intimate partners play an important role in chronic diseases. Despite the chronic disease burden increase in sub-Saharan Africa, very few culturally-relevant quantitative measures of intimate relationship functioning are available. We conducted an empirical investigation evaluating the psychometric properties of the South African Relationship Functioning Assessment (SARFA) assessing healthy relationship functioning in N = 150 community members (50% women; M age = 27.2 years) living in the Vulindlela area of KwaZulu-Natal, South Africa. Item development was based on prior qualitative research from two South African communities. All assessments were conducted in isiZulu, participants' primary language. An exploratory factor analysis was conducted on the initial 39-item measure. The best-fitting model consisted of one factor with 22 items. The SARFA's internal consistency was α = .94. Convergent validity was observed via significant positive associations (all rs ≥ .38, p < .001) between the SARFA's total score and measures of trust, emotional intimacy, constructive communication, sexual satisfaction, and relationship control (women only). Divergent validity was observed for women only. Encouraging initial psychometric properties of a culturally-relevant measure of relationship functioning in KwaZulu-Natal may have relevance to other communities and potential to be used in research involving couples and health in chronic disease-burdened communities.

Piloting Siyakhana: A community health worker training to reduce substance use and depression stigma in South African HIV and TB care.

South Africa has one of the highest rates of HIV/tuberculosis (TB) co-infection, and poor engagement in HIV/TB care contributes to morbidity and mortality. In South Africa, community health workers (CHWs) are tasked with re-engaging patients who have dropped out of HIV/TB care. CHWs have described substantial challenges with substance use (SU) and depression among their patients, while patients have described CHW stigma towards SU and depression as barriers to re-engagement in care. Yet, CHWs receive little-to-no training on SU or depression. Therefore, we piloted Siyakhana, a brief CHW training to reduce stigma related to SU and depression while improving skills for re-engaging these patients in HIV and/or TB care. This study evaluated the preliminary effectiveness (stigma towards SU and depression; clinical competence assessed via roleplay) and implementation (quantitative ratings of feasibility, acceptability, appropriateness, adoption; semi-structured written qualitative feedback) of Siyakhana among CHWs and supervisors (N = 17) at pre- and post-training assessments. SU stigma significantly decreased (F(1,16) = 18.94, p < 0.001, ηp2 = 0.54). Depression stigma was lower than SU stigma at both timepoints and did not significantly decrease after training. CHW clinical competency towards patients with SU/depression significantly improved (t(11) = -3.35, p = 0.007, d = 1.00). The training was rated as feasible, acceptable, appropriate, and likely to be adopted by CHWs and their supervisors. Nonjudgmental communication was commonly described as the most useful training component. Based on this pilot, the training is being refined and evaluated in a larger randomized stepped-wedge clinical trial.

Design and rationale of the Botswana Smoking Abstinence Reinforcement Trial: a protocol for a stepped-wedge cluster randomized trial.

BACKGROUND: With expanded and sustained availability of HIV treatment resulting in substantial improvements in life expectancy, the need to address modifiable risk factors associated with leading causes of death among people living with HIV/AIDS (PLWH), such as tobacco smoking, has increased. Tobacco use is highly prevalent among PLWH, especially in southern Africa, where HIV is heavily concentrated, and many people who smoke would like to quit but are unable to do so without assistance. SBIRT (Screening, Brief Intervention and Referral to Treatment) is a well-established evidence-based approach successful at supporting smoking cessation in a variety of settings. Varenicline is efficacious in supporting smoking cessation. We intend to assess the effectiveness of SBIRT and varenicline on smoking cessation among PLWH in Botswana and the effectiveness of our implementation. METHODS: BSMART (Botswana Smoking Abstinence Reinforcement Trial) is a stepped-wedge, cluster randomized, hybrid Type 2 effectiveness-implementation study guided by the RE-AIM framework, to evaluate the effectiveness and implementation of an SBIRT intervention consisting of the 5As compared to an enhanced standard of care. SBIRT will be delivered by trained lay health workers (LHWs), followed by referral to treatment with varenicline prescribed and monitored by trained nurse prescribers in a network of outpatient HIV care facilities. Seven hundred and fifty people living with HIV who smoke daily and have been receiving HIV care and treatment at one of 15 health facilities will be recruited if they are up to 18 years of age and willing to provide informed consent to participate in the study. DISCUSSION: BSMART tests a scalable approach to achieve and sustain smoking abstinence implemented in a sustainable way. Integrating an evidence-based approach such as SBIRT, into an HIV care system presents an important opportunity to establish and evaluate a modifiable cancer prevention strategy in a middle-income country (MIC) setting where both LHW and non-physician clinicians are widely used. The findings, including the preliminary cost-effectiveness, will provide evidence to guide the Botswanan government and similar countries as they strive to provide affordable smoking cessation support at scale. CLINICAL TRIAL REGISTRATION: NCT05694637 Registered on 7 December 2022 on clinicaltrials.gov, https://clinicaltrials.gov/search?locStr=Botswana&country=Botswana&cond=Smoking%20Cessation&intr=SBIRT.

Global Is Local: Leveraging Global Mental-Health Methods to Promote Equity and Address Disparities in the United States.

Structural barriers perpetuate mental health disparities for minoritized US populations; global mental health (GMH) takes an interdisciplinary approach to increasing mental health care access and relevance. Mutual capacity building partnerships between low and middle-income countries and high-income countries are beginning to use GMH strategies to address disparities across contexts. We highlight these partnerships and shared GMH strategies through a case series of said partnerships between Kenya-North Carolina, South Africa-Maryland, and Mozambique-New York. We analyzed case materials and narrative descriptions using document review. Shared strategies across cases included: qualitative formative work and partnership-building; selecting and adapting evidence-based interventions; prioritizing accessible, feasible delivery; task-sharing; tailoring training and supervision; and mixed-method, hybrid designs. Bidirectional learning between partners improved the use of strategies in both settings. Integrating GMH strategies into clinical science-and facilitating learning across settings-can improve efforts to expand care in ways that consider culture, context, and systems in low-resource settings.

Raising the issue of quality in implementation science reporting in global health: Implications for health planning and practice.

Implementation outcomes, which focus on the barriers to, and facilitators and processes of healthcare delivery, are critical to translating research evidence to health planning and practice and to improving healthcare delivery. This article summarises key quality issues in reporting of implementation science outcomes within global health and describes the ways in which this presents a challenge for shifting health planning and practice across low-resource health systems. This article also suggests that the wider use of reporting guidelines for implementation outcomes could help address this issue.

Community health worker training to reduce mental health and substance use stigma towards patients who have disengaged from HIV/TB care in South Africa: protocol for a stepped wedge hybrid type II pilot implementation trial.

BACKGROUND: South Africa has deployed community health workers (CHWs) to support individuals to enter and stay in HIV/TB care. Although CHWs routinely encounter patients with mental health (particularly depression) and substance use (SU) conditions that impact their engagement in HIV/TB care, CHWs are rarely trained in how to work with these patients. This contributes to mental health and SU stigma among CHWs, a known barrier to patient engagement in care. Mental health and SU training interventions could reduce CHW stigma and potentially improve patient engagement in care, but evidence of the feasibility, acceptability, and preliminary effectiveness of these interventions is scarce. Therefore, we designed a hybrid type 2 effectiveness-implementation pilot trial to evaluate the implementation and preliminary effectiveness of a CHW training intervention for reducing depression and SU stigma in the Western Cape, South Africa. METHODS: This stepped wedge pilot trial will engage CHWs from six primary care clinics offering HIV/TB care. Clinics will be block randomized into three-step cohorts that receive the intervention at varying time points. The Siyakhana intervention involves 3 days of training in depression and SU focused on psychoeducation, evidence-based skills for working with patients, and self-care strategies for promoting CHW wellness. The implementation strategy involves social contact with people with lived experience of depression/SU during training (via patient videos and a peer trainer) and clinical supervision to support CHWs to practice new skills. Both implementation outcomes (acceptability, feasibility, fidelity) and preliminary effectiveness of the intervention on CHW stigma will be assessed using mixed methods at 3- and 6-month follow-up assessments. DISCUSSION: This trial will advance knowledge of the feasibility, acceptability, and preliminary effectiveness of a CHW training for reducing depression and SU stigma towards patients with HIV and/or TB. Study findings will inform a larger implementation trial to evaluate the longer-term implementation and effectiveness of this intervention for reducing CHW stigma towards patients with depression and SU and improving patient engagement in HIV/TB care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05282173. Registered on 7 March 2022.

Barriers, Facilitators, and Strategies to Improve Participation of a Couple-Based Intervention to Address Women's Antiretroviral Therapy Adherence in KwaZulu-Natal, South Africa.

BACKGROUND: Couple-based interventions (CBIs), despite strong efficacy in improving numerous HIV risk behaviors, are not widely available and have not been tested to improve women's antiretroviral therapy (ART) adherence. We examined barriers and facilitators to participation in a CBI based on cognitive behavioral couple therapy for women's ART adherence in KwaZulu-Natal, South Africa. METHODS: Semi-structured interviews were conducted with women with HIV (n = 15) and men of mixed HIV status (n = 15). Thematic analyses were guided by the Consolidated Framework for Implementation Research. RESULTS: Facilitators mostly related to the couple's relationship, including having an existing healthy relationship, men's desire to support their partners, and a potential opportunity for men's HIV disclosure. Barriers included a lack of understanding of how a CBI approach would be useful for women's ART adherence, sole focus on women if male partners were also living with HIV, and men's lack of prior HIV status disclosure to female partners. CONCLUSION: Findings indicate that relationship context and the male partner's HIV status need to be addressed during recruitment, enrolment, and during the intervention to promote uptake.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment.

BACKGROUND: Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment. METHODS: The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis. RESULTS: Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment. CONCLUSION: Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

The Role of Peer Providers to Scale Up Psychological Treatments for Perinatal Populations Worldwide.

PURPOSE OF REVIEW: Psychological treatments remain largely inaccessible to perinatal populations despite their robust effectiveness. This gap is partly due to the limited number of available treatment providers. In this review, we critically evaluate recent literature on task-sharing to peer providers and propose future directions. RECENT FINDINGS: There is a growing evidence base demonstrating that peer providers can effectively deliver psychological treatments for perinatal populations, as well as engage in processes critical to quality assurance, such as measurement-based peer supervision. Findings have also highlighted some benefits of peers over licensed healthcare providers, such as enhanced collaborative relationships, reduced stigma, provision of social comparisons, and increased accessibility. Peer providers may be one solution to improve access to psychological treatments for perinatal populations. However, there is a need to address clinical, professional, and health-system level barriers to effectively leverage this cadre of treatment providers.

Substance Use Outcomes Among Sexual and Gender Minority Individuals Living with HIV Following Residential Substance Use Treatment in Washington, DC.

This study explored how sexual or gender minority (SGM) status influenced substance use (SU) treatment outcomes in a predominantly African American and unemployed sample of people with HIV. N = 60 participants were enrolled in an abstinence-focused inpatient SU treatment center, followed by outpatient treatment sessions. At 12-months follow-up, the survival rate (i.e. those who did not reuse substances) was 37.6% (non-SGM group) vs. 4.8% (SGM group). The impact of SGM status on reuse was .54 log odds, p = .11, which translates to a 71.8% increase in the hazard of reusing substances for SGM vs. non-SGM individuals. For both groups, frequency of reuse remained stable and problems associated with SU decreased over time. Results suggest a potentially clinically relevant finding that SGM individuals have possible heigh-tened risk of SU after a mixed inpatient-outpatient program. ClinicalTrials.gov trial registration number: NCT01351454.

Applying a mutual capacity building model to inform peer provider programs in South Africa and the United States: A combined qualitative analysis.

BACKGROUND: Globally, there is a treatment gap for substance use treatment and harm reduction services. As peer-delivered interventions expand to address this gap in both high-income countries (HICs) and low and middle-income countries (LMICs), they provide an opportunity to examine mutual capacity building, the bidirectional exchange of ideas between distinct settings to address common challenges. METHODS: The aim of this study was to explore the perspectives of patients in Cape Town and Baltimore about the acceptability and feasibility of a peer-delivered intervention using a combined qualitative analysis across a HIC and LMIC. Semi-structured qualitative interviews were conducted with participants in pilot trials in Cape Town, South Africa and Baltimore, USA (n=55). Across both trials, participants received a peer-delivered behavioral intervention focused on problem solving strategies for medication adherence, behavioral activation, and other cognitive-behavioral skills. The datasets from each location were merged and analyzed jointly using thematic analysis to develop codes and themes. Transcripts were coded to theoretical saturation (n=21 from Baltimore, n=16 from Cape Town). RESULTS: Participants highlighted what they valued about the peer-delivered intervention: 1) behavioral skills learned, 2) relationship with the peer, 3) ability to help others based on what they learned, 4) improved adherence to HIV or substance use medications, and 5) changes in substance use behaviors. In Baltimore, participants were typically more focused on their supportive relationship with the peer, which contrasted with many other relationships in their lives. In Cape Town, many participants highlighted the value of the skills they learned, such as mindfulness and activity scheduling. CONCLUSIONS: Across sites, participants valued that the peer could support them to accomplish meaningful life goals beyond substance use recovery, such as building relationships or health. Differences between settings may highlight the importance of tailoring peer interventions to fill context-specific gaps in available services.

Feasibility and acceptability of peer-delivered interventions using mHealth for PrEP services among adolescent girls and young women in DREAMS program in Botswana.

BACKGROUND: Adolescent girls and young women accounted for 25% of all new HIV infections despite representing only 10% of the population in Sub Saharan Africa. PEPFAR has launched the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative, a comprehensive HIV prevention program including PrEP services. Among adolescent girls and young women, PrEP adherence is currently sub-optimal. Tailored strategies for adolescent girls and young women to improve access and use of PrEP delivery are urgently needed to maximise its potential. Recommended interventions include peer-delivered interventions using mobile technology. However, data on the feasibility and acceptability of this approach is limited for SSA. OBJECTIVES: We assessed the feasibility and perceived acceptability of providing mHealth peer-delivered interventions to support PrEP services among adolescent girls and young women in Botswana. METHODS: This cross-sectional study included HIV-negative women aged 18-24 years old seeking health services at DREAMS-supported facilities. Participants completed a survey assessing the feasibility and perceived acceptability of the mHealth peer-delivered interventions, which included the Acceptability of Intervention Measure (AIM). Descriptive analyses were performed. RESULTS: A total of 131 participated in the study. Overall, 89% owned a mobile phone (feasibility). There was no difference in cell phone ownership between participants from rural and urban settings. Among participants, 85% reported interest in participating in a mHealth peer-delivered intervention if it was available to them. Regarding perceived acceptability for mHealthpeer support groups for PrEP, the average score on the AIM was 3.8 out of 5 (SD = 0.8). CONCLUSION: mHealthpeer-delivered interventions appear to be feasible and perceived acceptable among adolescent girls and young women in Botswana. This modality should be incorporated into PEPFAR's programmatic toolkit of implementation strategies to improve PrEP services.

Efficacy of alcohol reduction interventions among people with HIV as evaluated by self-report and a phosphatidylethanol (PEth) outcome: protocol for a systematic review and individual participant data meta-analysis.

INTRODUCTION: Unhealthy alcohol use is associated with a range of adverse outcomes among people with HIV (PWH). Testing the efficacy and promoting the availability of effective interventions to address unhealthy alcohol use among PWH is thus a priority. Alcohol use outcomes in intervention studies are often measured by self-report alone, which can lead to spurious results due to information biases (eg, social desirability). Measuring alcohol outcomes objectively through biomarkers, such as phosphatidylethanol (PEth), in addition to self-report has potential to improve the validity of intervention studies. This protocol outlines the methods for a systematic review and individual participant data meta-analysis that will estimate the efficacy of interventions to reduce alcohol use as measured by a combined categorical self-report/PEth variable among PWH and compare these estimates to those generated when alcohol is measured by self-report or PEth alone. METHODS AND ANALYSIS: We will include randomised controlled trials that: (A) tested an alcohol intervention (behavioural and/or pharmacological), (B) enrolled participants 15 years or older with HIV; (C) included both PEth and self-report measurements, (D) completed data collection by 31 August 2023. We will contact principal investigators of eligible studies to inquire about their willingness to contribute data. The primary outcome variable will be a combined self-report/PEth alcohol categorical variable. Secondary outcomes will include PEth alone, self-report alone and HIV viral suppression. We will use a two-step meta-analysis and random effects modelling to estimate pooled treatment effects; I2 will be calculated to evaluate heterogeneity. Secondary and sensitivity analyses will explore treatment effects in adjusted models and within subgroups. Funnel plots will be used to explore publication bias. ETHICS AND DISSEMINATION: The study will be conducted with deidentified data from completed randomised controlled trials and will be considered exempt from additional ethical approval. Results will be disseminated through peer-reviewed publications and international scientific meetings. PROSPERO REGISTRATION NUMBER: CRD42022373640.

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment.

Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 23-31.].

Behavioral Activation Disseminated by Non-Mental Health Professionals, Paraprofessionals, and Peers: A Systematic Review.

There is a striking disparity between the number of individuals with significant mental health concerns and those who are able to access care globally. One promising solution to expanding the mental health taskforce is task-sharing, or employing nonspecialists in the delivery of evidence-based interventions. Behavioral activation (BA), a brief intervention that focuses on scheduling rewarding activities into one's daily life, may have promise for delivery using task-sharing approaches due to its straightforward, flexible nature. The aim of this systematic review was to examine the current state of the literature on non-specialist-delivered BA and evaluate the evidence base of this approach. Three databases (Pubmed, PsycInfo, and Cochrane) were searched, and all articles were screened for inclusion criteria by two research assistants, included the review of titles, abstracts, and full-text. The final dataset consisted of 13 research studies, represented through 15 articles. A meta-analysis was conducted to examine the overall pooled effects of peer-delivered BA on depressive symptoms (the most widely examined clinical outcome). Studies reported on effectiveness and implementation outcomes of non-specialist-delivered BA for depression, substance use, loneliness, trauma survivors, and individuals with comorbid physical health conditions. Results provide initial support for the effectiveness of BA utilizing a task-sharing approach, and highlight the feasibility and acceptability of using nonspecialists to deliver BA in a variety of contexts, including low-resource settings.

Psychosocial challenges affecting patient-defined medication for opioid use disorder treatment outcomes in a low-income, underserved population: Application of the social-ecological framework.

INTRODUCTION: Successful engagement with medication treatment for opioid use disorder is an important focus in reducing mortality associated with the opioid crisis. Mortality remains at unacceptably high levels, pointing to a need for improved understanding of factors that affect medication for opioid use disorder outcomes. This study aims to understand how barriers co-occur and interact to interfere with outcomes in methadone treatment for a low-income, underserved patient population with opioid use disorder. METHODS: This study was conducted at a community-based drug treatment center that serves a predominately low-income, racially diverse population. Guided by the social-ecological framework, we analyzed semi-structured interviews and focus groups with patients and providers working in opioid use disorder care and recovery across Baltimore City (N = 32) to assess factors that influence methadone treatment outcomes, and how barriers co-occur and interact to worsen treatment outcomes. The study used patient-centered definitions to describe successful treatment outcomes. RESULTS: Barriers described by both patients and providers fit into several broad levels: individual, interpersonal, institutional, community, and stigma. Participants described co-occurrence of many barriers. Further, the study identified potential interactive effects, such that interrelated barriers were seen as fueling one another and having a deleterious effect on treatment outcomes. Specifically, interrelationships between barriers were described for 1) unstable housing with social influences and mental health factors; 2) transportation with poor physical health and other competing responsibilities; 3) treatment program policies and schedule with competing responsibilities; and 4) stigma with poor physical and mental health. CONCLUSIONS: Understanding barriers to successful medication for opioid use disorder outcomes and considering their co-occurrence may help to identify and promote interventions to mitigate their impact. This work is intended to guide future research to adapt conceptual frameworks for understanding psychosocial and structural barriers affecting opioid use disorder treatment and ultimately intervention efforts to improve treatment outcomes.

"Sometimes you have to take the person and show them how": adapting behavioral activation for peer recovery specialist-delivery to improve methadone treatment retention.

BACKGROUND: Despite efficacy of medication for opioid use disorder, low-income, ethno-racial minoritized populations often experience poor opioid use disorder treatment outcomes. Peer recovery specialists, individuals with lived experience of substance use and recovery, are well-positioned to engage hard-to-reach patients in treatment for opioid use disorder. Traditionally, peer recovery specialists have focused on bridging to care rather than delivering interventions. This study builds on research in other low-resource contexts that has explored peer delivery of evidence-based interventions, such as behavioral activation, to expand access to care. METHODS: We sought feedback on the feasibility and acceptability of a peer recovery specialist-delivered behavioral activation intervention supporting retention in methadone treatment by increasing positive reinforcement. We recruited patients and staff at a community-based methadone treatment center and peer recovery specialist working across Baltimore City, Maryland, USA. Semi-structured interviews and focus groups inquired about the feasibility and acceptability of behavioral activation, recommendations for adaptation, and acceptability of working with a peer alongside methadone treatment. RESULTS: Participants (N = 32) shared that peer recovery specialist-delivered behavioral activation could be feasible and acceptable with adaptations. They described common challenges associated with unstructured time, for which behavioral activation could be particularly relevant. Participants provided examples of how a peer-delivered intervention could fit well in the context of methadone treatment, emphasizing the importance of flexibility and specific peer qualities. CONCLUSIONS: Improving medication for opioid use disorder outcomes is a national priority that must be met with cost-effective, sustainable strategies to support individuals in treatment. Findings will guide adaptation of a peer recovery specialist-delivered behavioral activation intervention to improve methadone treatment retention for underserved, ethno-racial minoritized individuals living with opioid use disorder.