Effects of sex and gender on adaptation to space: behavioral health

This article is part of a larger body of work entitled, "The Impact of Sex and Gender on Adaptation to Space." It was developed in response to a recommendation from the 2011 National Academy of Sciences Decadal Survey, "Recapturing a Future for Space Exploration: Life and Physical Sciences for a New Era," which emphasized the need to fully understand sex and gender differences. In this article, our workgroup-consisting of expert scientists and clinicians from academia and the private sector-investigated and summarized the current body of published and unpublished human research performed to date related to sex- and gender-based differences in behavioral adaptations to human spaceflight. This review identifies sex-related differences in: (1) sleep, circadian rhythms, and neurobehavioral measures; (2) personality, group interactions, and work performance and satisfaction; and (3) stress and clinical disorders. Differences in these areas substantially impact the risks and optimal medical care required by space-faring women. To ensure the health and safety of male and female astronauts during long-duration space missions, it is imperative to understand the influences that sex and gender have on behavioral health changes occurring during spaceflight.

Causality and Causal Inference in Social Work: Quantitative and Qualitative Perspectives

Achieving the goals of social work requires matching a specific solution to a specific problem. Understanding why the problem exists and why the solution should work requires a consideration of cause and effect. However, it is unclear whether it is desirable for social workers to identify cause and effect, whether it is possible for social workers to identify cause and effect, and, if so, what is the best means for doing so. These questions are central to determining the possibility of developing a science of social work and how we go about doing it. This article has four aims: (1) provide an overview of the nature of causality; (2) examine how causality is treated in social work research and practice; (3) highlight the role of quantitative and qualitative methods in the search for causality; and (4) demonstrate how both methods can be employed to support a "science" of social work.

A Mixed Methods Approach to Network Data Collection

There is a growing interest in examining network processes with a mix of qualitative and quantitative network data. Research has consistently shown that free recall name generators entail recall bias and result in missing data that affects the quality of social network data. This study describes a mixed methods approach for collecting social network data, combining a free recall name generator in the context of an online survey with network relations data coded from transcripts of semi-structured qualitative interviews. The combined network provides substantially more information about the network space, both quantitatively and qualitatively. While network density was relatively stable across networks generated from different data collection methodologies, there were noticeable differences in centrality and component structure across networks. The approach presented here involved limited participant burden and generated more complete data than either technique alone could provide. We make suggestions for further development of this method.

Low-income cancer patients in depression treatment: dropouts and completers

This study aims to explore reasons for depression treatment dropout among low-income, minority women with depression and cancer. Semi-structured telephone interviews are conducted with 20, predominately Latina, patients who dropped out of depression treatment and 10 who completed. Transcripts analyzed using techniques rooted in grounded theory. Treatment completion barriers cluster according to Meichenbaum and Turk's (Facilitating treatment adherence: A practitioner's guidebook, Plenum Press, New York, 1987) five adherence dimensions: (a) Barriers to Treatment (informational, instrumental, cultural [language, discrimination]); (b) Disease Features (emotional burden of cancer/depression); (c) Cancer/Depression Treatment Regimens; (d) Provider-Patient Relationship (depression treatment dissatisfaction); and (e) Clinical Setting (hospital organizational issues). Although both groups describe multiple overlapping dimensions of barriers, completers seem more motivated and satisfied with treatment, possibly due to completers experiencing the positive treatment effects after the first several sessions. More research should be conducted to determine the most effective clinical treatment methods for this population.

Yearning to Be Heard

Background: Patients with serious mental illness can be at higher risk for suicide. Most research has focused on determining the risk factors for suicide-related events using quantitative methodologies and psychological autopsies. However, fewer studies have examined patients’ perspectives regarding the experience of suicidal events. Aims: To better understand suicide experiences from the perspective of patients diagnosed with serious mental illness. Method: This study purposively sampled and qualitatively interviewed 23 patients within the Veterans Affairs Hospital who were diagnosed with serious mental illness and who had attempted suicide. Using a phenomenological design, hermeneutic interviews included questions about the precursors, characteristics, and treatment of the suicide events, as well as patients’ recommendations for care. Results: Loneliness, isolation, depression, and hopelessness were commonly described as emotional precursors to the suicide events for all patients, while command hallucinations were reported among patients with schizophrenia-spectrum disorders. When evaluating whether treatments were effective, patients focused primarily on the level of empathy and compassion shown by their providers. Conclusion: The most common recommendation for the improvement of care was to increase clinicians’ empathy, compassion, and listening skills. Additionally, efforts to bolster social supports were highlighted as a means to diminish suicide events.

Exploration and Adoption of Evidence-based Practice by US Child Welfare Agencies

OBJECTIVE

To examine the extent to which child welfare agencies adopt new practices and to determine the barriers to and facilitators of adoption of new practices.

METHODS

Data came from telephone interviews with the directors of the 92 public child welfare agencies that constituted the probability sample for the first National Survey of Child and Adolescent Well-being (NSCAWI). In a semi-structured 40 minute interview administered by a trained Research Associate, agency directors were asked about agency demographics, knowledge of evidence-based practices, use of technical assistance and actual use of evidence-based practices.. Of the 92 agencies, 83 or 90% agreed to be interviewed.

RESULTS

Agencies reported that the majority of staff had a BA degree (53.45%) and that they either paid for (52.6%) or provided (80.7%) continuing education. Although agencies routinely collect standardized child outcomes (90%) they much less frequently collect measures of child functioning (30.9%). Almost all agencies (94%) had started a new program or practice but only 24.8% were evidence-based and strategies used to explore new programs or practices usually involved local or state contracts. Factors that were associated with program success included internal support for the innovation (27.3%), and an existing evidence base (23.5%).

CONCLUSIONS

Directors of child welfare agencies frequently institute new programs or practices but they are not often evidence-based. Because virtually all agencies provide some continuing education adding discussions of evidence-based programs/practices may spur adaption. Reliance on local and state colleagues to explore new programs and practices suggests that developing well informed social networks may be a way to increase the spread of evidence0based practices.

Collaboration, negotiation, and coalescence for interagency-collaborative teams to scale-up evidence-based practice

Implementation and scale-up of evidence-based practices (EBPs) is often portrayed as involving multiple stakeholders collaborating harmoniously in the service of a shared vision. In practice, however, collaboration is a more complex process that may involve shared and competing interests and agendas, and negotiation. The present study examined the scale-up of an EBP across an entire service system using the Interagency Collaborative Team approach. Participants were key stakeholders in a large-scale county-wide implementation of an EBP to reduce child neglect, SafeCare. Semistructured interviews and/or focus groups were conducted with 54 individuals representing diverse constituents in the service system, followed by an iterative approach to coding and analysis of transcripts. The study was conceptualized using the Exploration, Preparation, Implementation, and Sustainment framework. Although community stakeholders eventually coalesced around implementation of SafeCare, several challenges affected the implementation process. These challenges included differing organizational cultures, strategies, and approaches to collaboration; competing priorities across levels of leadership; power struggles; and role ambiguity. Each of the factors identified influenced how stakeholders approached the EBP implementation process. System-wide scale-up of EBPs involves multiple stakeholders operating in a nexus of differing agendas, priorities, leadership styles, and negotiation strategies. The term collaboration may oversimplify the multifaceted nature of the scale-up process. Implementation efforts should openly acknowledge and consider this nexus when individual stakeholders and organizations enter into EBP implementation through collaborative processes.

Client perspectives on design and implementation of a couples-based intervention to reduce sexual and drug risk behaviors among female sex workers and their noncommercial partners in Tijuana and Ciudad Juárez, México

This mixed-methods study examined the acceptability of a hypothetical couples-based HIV prevention program for female sex workers and their intimate (non-commercial) male partners in Mexico. Among 320 participants, 67 % preferred couples-based over individual programs, particularly among men. Reasons cited for preferring couples-based programs included convenience and health benefits for both partners. Participants reported that they would benefit from general health information and services, HIV counseling and testing, job training (particularly for men) and other services. However, qualitative interviews revealed that barriers relating to the environment (i.e., poor access to services), providers (i.e., lack of a therapeutic alliance), and intimate relationships (i.e., mistrust or instability) would need to be addressed before such a program could be successfully implemented. Despite women's concerns about privacy and men's preferences for gender-specific services, couples-based HIV prevention programs were largely acceptable to female sex workers and their intimate male partners.

Organizational capacity for service integration in community-based addiction health services

OBJECTIVES

We examined factors associated with readiness to coordinate mental health, public health, and HIV testing among community-based addiction health services programs.

METHODS

We analyzed client and program data collected in 2011 from publicly funded addiction health services treatment programs in Los Angeles County, California. We analyzed a sample of 14 379 clients nested in 104 programs by using logistic regressions examining odds of service coordination with mental health and public health providers. We conducted a separate analysis to examine the percentage of clients receiving HIV testing in each program.

RESULTS

Motivational readiness and organizational climate for change were associated with higher odds of coordination with mental health and public health services. Programs with professional accreditation had higher odds of coordinating with mental health services, whereas programs receiving public funding and methadone and residential programs (compared with outpatient) had a higher percentage of clients receiving coordinated HIV testing.

CONCLUSIONS

These findings provide an evidentiary base for the role of motivational readiness, organizational climate, and external regulation and funding in improving the capacity of addiction health services programs to develop integrated care.

Behavioral health and disasters: looking to the future

Along with other manmade and natural disasters, oil spills produce profound and long-term impacts on the behavioral health of their survivors. Although previous and ongoing research has focused on producing evidence of the breadth and depth of these impacts, future efforts must begin to translate this evidence into developing and implementing policies, programs, and practices that effectively contribute to their prevention and mitigation. Drawing upon a conceptual framework of the behavioral health impacts of oil spills developed from data collected in the aftermath of the Exxon Valdez oil spill in 1989, this paper examines potential interventions designed to prevent or mitigate biopsychosocial, interpersonal, and intrapersonal impacts on behavioral health. Future efforts to translate behavioral health research into effective practice will require the formation and maintenance of academic-community partnerships for the purpose of building resilience to these impacts and providing targeted services to those most vulnerable to their long-term consequences.

Qualitative and mixed methods in mental health services and implementation research

Qualitative and mixed methods play a prominent role in mental health services research. However, the standards for their use are not always evident, especially for those not trained in such methods. This article reviews the rationale and common approaches to using qualitative and mixed methods in mental health services and implementation research based on a review of the articles included in this special series along with representative examples from the literature. Qualitative methods are used to provide a "thick description" or depth of understanding to complement breadth of understanding afforded by quantitative methods, elicit the perspective of those being studied, explore issues that have not been well studied, develop conceptual theories or test hypotheses, or evaluate the process of a phenomenon or intervention. Qualitative methods adhere to many of the same principles of scientific rigor as quantitative methods but often differ with respect to study design, data collection, and data analysis strategies. For instance, participants for qualitative studies are usually sampled purposefully rather than at random and the design usually reflects an iterative process alternating between data collection and analysis. The most common techniques for data collection are individual semistructured interviews, focus groups, document reviews, and participant observation. Strategies for analysis are usually inductive, based on principles of grounded theory or phenomenology. Qualitative methods are also used in combination with quantitative methods in mixed-method designs for convergence, complementarity, expansion, development, and sampling. Rigorously applied qualitative methods offer great potential in contributing to the scientific foundation of mental health services research.

Influence network linkages across implementation strategy conditions in a randomized controlled trial of two strategies for scaling up evidence-based practices in public youth-serving systems

BACKGROUND

Given the importance of influence networks in the implementation of evidence-based practices and interventions, it is unclear whether such networks continue to operate as sources of information and advice when they are segmented and disrupted by randomization to different implementation strategy conditions. The present study examines the linkages across implementation strategy conditions of social influence networks of leaders of youth-serving systems in 12 California counties participating in a randomized controlled trial of community development teams (CDTs) to scale up use of an evidence-based practice.

METHODS

Semi-structured interviews were conducted with 38 directors, assistant directors, and program managers of county probation, mental health, and child welfare departments. A web-based survey collected additional quantitative data on information and advice networks of study participants. A mixed-methods approach to data analysis was used to create a sociometric data set (n = 176) to examine linkages between treatment and standard conditions.

RESULTS

Of those network members who were affiliated with a county (n = 137), only 6 (4.4%) were directly connected to a member of the opposite implementation strategy condition; 19 (13.9%) were connected by two steps or fewer to a member of the opposite implementation strategy condition; 64 (46.7%) were connected by three or fewer steps to a member of the opposite implementation strategy condition. Most of the indirect steps between individuals who were in different implementation strategy conditions were connections involving a third non-county organizational entity that had an important role in the trial in keeping the implementation strategy conditions separate. When these entities were excluded, the CDT network exhibited fewer components and significantly higher betweenness centralization than did the standard condition network.

CONCLUSION

Although the integrity of the RCT in this instance was not compromised by study participant influence networks, RCT designs should consider how influence networks may extend beyond boundaries established by the randomization process in implementation studies.

TRIAL REGISTRATION

NCT00880126.

Overweight and obesity among Hispanic children entering foster care: a preliminary examination of polyvictimization

This retrospective medical chart review examined the prevalence of overweight/obesity (≥85th percentile) and obesity (≥95th percentile) in Hispanic foster children aged 2-18 years in Los Angeles, California. Logistic regression was used for boys and girls separately to analyze polyvictimization (i.e., one vs. two or more types of maltreatment), type of maltreatment (abuse vs. neglect), and age-group as risk factors for overweight and obesity. Almost 40% of participants were overweight/obese, with the highest prevalence (47.7%) observed among children aged 12-18. Children aged 6-18 were at an increased risk of overweight/obesity and obesity compared with children aged 2-5. Although polyvictimization has been shown to have adverse health effects, in this study, it was related to slightly lower odds of obesity for boys but was unrelated to high weight for girls. Addressing the obesity epidemic among Hispanic foster children is vital to preventing continued obesity and the development of obesity-related health problems, especially by focusing on important community and family influences.

Continued use of evidence-based treatments after a randomized controlled effectiveness trial: a qualitative study

OBJECTIVE This study examined the extent to which therapists who participated in a randomized controlled trial (RCT) of evidence-based treatments continued to use them with nonstudy clients after the trial as well as the types of treatment used and the reasons for their continued use. METHODS Semistructured interviews and focus groups were conducted with 38 therapists, three clinical supervisors, and eight clinic directors three months after an RCT of evidence-based treatments for depression, anxiety, and conduct disorders among children and adolescents. The therapists had been assigned randomly to one of three conditions: modular (N=15), allowing flexible use and informed adaptations of treatment components; standard (N=13), using full treatment manuals; and usual care (N=10). Grounded-theory analytic methods were used to analyze interview transcripts. RESULTS Twenty-six therapists (93%) assigned to the modular or standard condition used the treatments with nonstudy cases. Of those, 24 (92%) therapists, including all but two assigned to the standard condition, reported making some adaptation or modification, including using only some modules with all clients or all modules with some clients; changing the order or presentation of the modules to improve the flow or to work around more immediate issues; and using the modules with others, including youths with co-occurring disorders, youths who did not meet the age criteria, and adults. CONCLUSIONS The results provide insight into the likely sustainability of evidence-based treatments, help to explain why the outcomes of the RCT favored a modular approach, and highlight the strengths and limitations of use of evidence-based treatments.

Variation in the implementation of California's Full Service Partnerships for persons with serious mental illness

OBJECTIVE

This study examined variation in the implementation of California's Full Service Partnerships (FSPs), which are supported housing programs that do "whatever it takes" to improve outcomes among persons with serious mental illness who are homeless or at risk of homelessness.

DATA SOURCES/SETTING

Ninety-three FSPs in California.

STUDY DESIGN

A mixed methods approach was selected to develop a better understanding of the complexity of the FSP programs. The design structure was a combined explanatory and exploratory sequential design (qual→QUAN→qual) where a qualitative focus group was used to develop a quantitative survey that was followed by qualitative site visits. The survey was used to describe the breadth of variation based on fidelity to the Housing First model, while the site visits were used to provide a depth of information on high- versus low-fidelity programs.

PRINCIPAL FINDINGS

We found substantial variation in implementation among FSPs. Fidelity was particularly low along domains related with housing and service philosophy, indicating that many FSPs implemented a rich array of services but applied housing readiness requirements and did not adhere to consumer choice in housing.

CONCLUSIONS

There remains room for improvement in the recovery-orientation of FSPs. Fortunately, we have identified several processes by which program managers and counties can increase the fidelity of their programs.

Long-term outcomes for the Child STEPs randomized effectiveness trial: a comparison of modular and standard treatment designs with usual care

OBJECTIVE

This article reports outcomes from the Child STEPs randomized effectiveness trial conducted over a 2-year period to gauge the longer term impact of protocol design on the effectiveness of evidence-based treatment procedures.

METHOD

An ethnoracially diverse sample of 174 youths ages 7- 13 (N = 121 boys) whose primary clinical concerns involved diagnoses or clinical elevations related to anxiety, depression, or disruptive behavior were treated by community therapists randomly assigned to 1 of 3 conditions: (a) standard, which involved the use of 1 or more of 3 manualized evidence-based treatments, (b) modular, which involved a single modular protocol (Modular Approach to Treatment of Children With Anxiety, Depression, or Conduct Problems; MATCH) having clinical procedures similar to the standard condition but flexibly selected and sequenced using a guiding clinical algorithm, and (c) usual care.

RESULTS

As measured with combined Child Behavior Checklist and Youth Self-Report Total Problems, Internalizing, and Externalizing scales, the rate of improvement for youths in the modular condition was significantly better than for those in usual care. On a measure of functional impairment (Brief Impairment Scale), no significant differences were found among the 3 conditions. Analysis of service utilization also showed no significant differences among conditions, with almost half of youths receiving some additional services in the 1st year after beginning treatment, and roughly one third of youths in the 2nd year.

CONCLUSIONS

Overall, these results extend prior findings, supporting incremental benefits of MATCH over usual care over a 2-year period.

A mixed methods multiple case study of implementation as usual in children's social service organizations: study protocol

BACKGROUND

Improving quality in children's mental health and social service settings will require implementation strategies capable of moving effective treatments and other innovations (e.g., assessment tools) into routine care. It is likely that efforts to identify, develop, and refine implementation strategies will be more successful if they are informed by relevant stakeholders and are responsive to the strengths and limitations of the contexts and implementation processes identified in usual care settings. This study will describe: the types of implementation strategies used; how organizational leaders make decisions about what to implement and how to approach the implementation process; organizational stakeholders' perceptions of different implementation strategies; and the potential influence of organizational culture and climate on implementation strategy selection, implementation decision-making, and stakeholders' perceptions of implementation strategies.

METHODS/DESIGN

This study is a mixed methods multiple case study of seven children's social service organizations in one Midwestern city in the United States that compose the control group of a larger randomized controlled trial. Qualitative data will include semi-structured interviews with organizational leaders (e.g., CEOs/directors, clinical directors, program managers) and a review of documents (e.g., implementation and quality improvement plans, program manuals, etc.) that will shed light on implementation decision-making and specific implementation strategies that are used to implement new programs and practices. Additionally, focus groups with clinicians will explore their perceptions of a range of implementation strategies. This qualitative work will inform the development of a Web-based survey that will assess the perceived effectiveness, relative importance, acceptability, feasibility, and appropriateness of implementation strategies from the perspective of both clinicians and organizational leaders. Finally, the Organizational Social Context measure will be used to assess organizational culture and climate. Qualitative, quantitative, and mixed methods data will be analyzed and interpreted at the case level as well as across cases in order to highlight meaningful similarities, differences, and site-specific experiences.

DISCUSSION

This study is designed to inform efforts to develop more effective implementation strategies by fully describing the implementation experiences of a sample of community-based organizations that provide mental health services to youth in one Midwestern city.

"Eyes that don't see, heart that doesn't feel": coping with sex work in intimate relationships and its implications for HIV/STI prevention

Partner communication about HIV sexual risk behaviors represents a key area of epidemiologic and social importance in terms of infection acquisition and potential for tailored interventions. Nevertheless, disclosing sexual risk behaviors often presents myriad challenges for marginalized couples who engage in stigmatized behaviors. Using qualitative data from a social epidemiology study of risk for HIV and other sexually transmitted infections (STIs) among female sex workers and their intimate, non-commercial male partners along the Mexico-U.S. border, we examined both partners' perspectives on sex work and the ways in which couples discussed associated HIV/STI risks in their relationship. Our thematic analysis of individual and joint interviews conducted in 2010 and 2011 with 44 couples suggested that broader contexts of social and economic inequalities profoundly shaped partner perspectives of sex work. Although couples accepted sex work as an economic contribution to the relationship in light of limited alternatives and drug addiction, it exacted an emotional toll on both partners. Couples employed multiple strategies to cope with sex work, including psychologically disconnecting from their situation, telling "little lies," avoiding the topic, and to a lesser extent, superficially discussing their risks. While such strategies served to protect both partners' emotional health by upholding illusions of fidelity and avoiding potential conflict, non-disclosure of risk behaviors may exacerbate the potential for HIV/STI acquisition. Our work has direct implications for designing multi-level, couple-based health interventions.

'Where sex ends and emotions begin': love and HIV risk among female sex workers and their intimate, non-commercial partners along the Mexico-US border

This study explores the affective dimensions of female sex workers' relationships with their intimate, non-commercial partners and assesses how emotions shape each partner's sexual and drug-related risk within their relationship. We draw on qualitative data from a study of HIV, sexually transmitted infections and high-risk behaviours among female sex workers and their non-commercial partners in Tijuana and Ciudad Juárez, Mexico, to illustrate that these couples share relationships based on love, trust, respect and emotional and material support. These relationships range in emotional intensity, which shapes partners' decisions not to use condoms with each other. Drugs were important in most couples' relationships. Among injectors, syringe sharing was common and represented both a sign of care and a pragmatic reaction to conditions of material scarcity. Our findings suggest that couple-based HIV interventions to address dual sexual and drug-related risks should be tailored to the emotional dynamics of sex workers' intimate relationships.

Acceptability of vaginal microbicides among female sex workers and their intimate male partners in two Mexico-US border cities: a mixed methods analysis

Female sex workers (FSWs) may benefit from pre-exposure prophylaxis (PrEP) including microbicides for HIV prevention. Since adherence is a key factor in PrEP efficacy, we explored microbicide acceptability and potential barriers to use within FSWs' intimate relationships in Tijuana and Ciudad Juárez, Mexico, where HIV prevalence is increasing. FSWs and their verified intimate (non-commercial) male partners completed quantitative and qualitative interviews from 2010 to 2012. Our complementary mixed methods design followed an iterative process to assess microbicide acceptability, explore related relationship dynamics and identify factors associated with concern about male partners' anger regarding microbicide use. Among 185 couples (n=370 individuals), interest in microbicides was high. In qualitative interviews with 28 couples, most participants were enthusiastic about microbicides for sex work contexts but some explained that microbicides could imply mistrust/infidelity within their intimate relationships. In the overall sample, nearly one in six participants (16%) worried that male partners would become angry about microbicides, which was associated with higher self-esteem among FSWs and lower self-esteem and past year conflicts causing injury within relationships among men. HIV prevention interventions should consider intimate relationship dynamics posing potential barriers to PrEP acceptability and adherence, involve male partners and promote risk communication skills.

Ethnic differences in the prevalence and predictors of restless legs syndrome between Hispanics of Mexican descent and non-Hispanic Whites in San Diego county: a population-based study

STUDY OBJECTIVES

To investigate the prevalence and predictors of RLS in Hispanics of Mexican descent (HMD) and non-Hispanic whites (NHW).

DESIGN

A population-based random digit dialing telephone questionnaire.

SETTING

San Diego County California

PARTICIPANTS

1,754 HMD and 1,913 NHW adults ≥ 18 years of age able to participate in a telephone interview in English or Spanish.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

RLS was defined by the presence of all 4 criteria of the International Restless Legs Study Group. Sleepiness was measured by the Epworth Sleepiness Scale. Acculturation was evaluated using the Short Acculturation Scale for Hispanics. Risk factors for RLS were by self-report. The survey was conducted in the subject's language of choice. RLS prevalence was significantly lower in HMD than in NHW (14.4% vs.18.3%, p = 0.002). High acculturation HMD had a significantly greater RLS prevalence than the low acculturation group (17.4% vs. 12.8%, p = 0.008). Predictors of RLS varied between HMD and NHW. Female gender (OR 1.40, 95% CI 1.04, 1.90, p = 0.027), smoking (OR 1.82, 95% CI 1.27, 2.61, p = 0.001), and acculturation (OR 1.47, 95% CI 1.10, 1.97, p = 0.009) were independent predictors of RLS in HMD, while only older age (OR 1.01, 95% CI 1.0, 1.02) was an independent predictor of RLS for NHW.

CONCLUSION

The prevalence of RLS was significantly lower in HMD than in NHW, and significantly greater in high acculturation HMD. Our data suggest that risk factors for RLS vary by race/ethnicity and acculturation is an independent risk for RLS in HMD.

Putting families in the center: family perspectives on decision making and ADHD and implications for ADHD care

OBJECTIVE

To examine components of family-centered care in families' stories about treatment decision making for their child with ADHD.

METHOD

Twenty-eight families participated in qualitative interviews that addressed families' perspectives on (a) the treatment decision-making process, (b) the cause and impact of their child's symptoms, and (c) treatment goals and preferences.

RESULTS

The majority of families preferred to be primary or shared decision makers regarding treatment decisions. Families' perspectives on the cause of the child's symptoms varied and often were not consistent with a biomedical framework. Families described multiple areas of impairment on child, family relationships, and family functioning. Perspectives toward evidence-based treatments were mixed, with families also expressing interest in and pursuing interventions not delineated in current treatment guidelines.

CONCLUSION

These findings reinforce the importance of eliciting families' perspectives and involving these important stakeholders in shared decision making as critical components of family-centered care for children with ADHD.

Implementation of an efficacious intervention for high risk women in Mexico: protocol for a multi-site randomized trial with a parallel study of organizational factors

BACKGROUND

Studies of implementation of efficacious human immunodeficiency virus (HIV) prevention interventions are rare, especially in resource-poor settings, but important, because they have the potential to increase the impact of interventions by improving uptake and sustainability. Few studies have focused on provider and organizational factors that may influence uptake and fidelity to core intervention components. Using a hybrid design, we will study the implementation of an efficacious intervention to reduce sexually transmitted infections (STIs) among female sex workers (FSWs) in 12 cities across Mexico. Our protocol will test a 'train-the-trainer' implementation model for transporting the Mujer Segura (Healthy Woman) intervention into community-based organizations (CBOs).

METHODS

We have partnered with Mexican Foundation for Family Planning (Mexfam), a non-governmental organization that has CBOs throughout Mexico. At each CBO, trained ethnographers will survey CBO staff on characteristics of their organization and on their attitudes toward their CBO and toward the implementation of evidence-based interventions (EBIs). Then, after CBO staff recruit a sample of 80 eligible FSWs and deliver a standard-care, didactic intervention to 40 women randomly selected from that pool, a Mexfam staff person will be trained in the Mujer Segura intervention and will then train other counselors to deliver Mujer Segura to the 40 remaining participating FSWs. FSW participants will receive a baseline behavioral assessment and be tested for HIV and STIs (syphilis, gonorrhea, and chlamydia); they will be reassessed at six months post-intervention to measure for possible intervention effects. At the same time, both qualitative and quantitative data will be collected on the implementation process, including measures of counselors' fidelity to the intervention model. After data collection at each CBO is complete, the relative efficacy of the Mujer Segura intervention will be analyzed, and across CBOs, correlations will be examined between individual and organizational provider characteristics and intervention efficacy.

DISCUSSION

This cooperative, bi-national research study will provide critical insights into barriers and facilitating factors associated with implementing interventions in CBOs using the 'train the trainer' model. Our work builds on similar scale-up strategies that have been effective in the United States. This study has the potential to increase our knowledge of the generalizability of such strategies across health issues, national contexts, and organizational contexts.

TRIAL REGISTRATION

NCT01465607.

The Caregiver as Gatekeeper for Accessing Health Care for Children in Foster Care: A Qualitative Study of Kinship and Unrelated Caregivers

The objective of this qualitative study was to examine issues that unrelated and kinship foster caregivers in Los Angeles, CA, have in seeking help and accessing and using health care for children in foster care. There were four themes identified for all caregivers: (1) "Doing Our Best" (caregivers advocated persistently and creatively for health care); (2) "Support from Others Helped" (caregivers relied on caseworkers, organizations, and their social network); (3) "Child has Complicated, Serious, Chronic Health Problems" (caregivers had difficulty securing specialty services and with Medicaid insurance to meet health care needs); and (4) "Caregiver Competence in Meeting Health Needs" (caregivers noted their ability to attend health appointments and understand instructions). An additional theme of "Differences between Unrelated and Kinship Foster Caregivers" highlighted more difficulties among kinship caregivers in finding and using primary health care services and more financial stress, whereas unrelated caregivers were less satisfied with child welfare caseworker help. Despite wide-ranging stressors and serious frustrations with the child welfare and health care systems, caregivers emerged as powerful drivers of health care for foster children. National adoption of a medical home model would ameliorate some of the access barriers identified by foster caregivers in this study.

Therapist perspectives on community mental health services for children with autism spectrum disorders

This mixed methods study examined therapist perspectives on serving children with autism spectrum disorders (ASD) in community mental health (CMH) clinics. One hundred therapists completed a survey about their experiences with this population and 17 participated in subsequent focus groups to clarify and expand survey results. Results indicate that CMH therapists serve many children with ASD for behavior or other psychiatric problems and perceive serving this population as challenging and frustrating due to their limited training. Therapists are highly motivated for comprehensive ASD training on ASD characteristics and intervention strategies. These data were used to tailor and package evidence-based intervention strategies for delivery in CMH services.

Ethnic Differences in Symptoms of Post-traumatic Stress after the Exxon Valdez Oil Spill

Introduction:

Previous studies have reported ethnic differences in the prevalence of post-traumatic stress disorder (PTSD), but the reasons for these differences remain unclear.

Hypothesis:

Ethnic differences in the prevalence of PTSD may reflect ethnic differences in (1) exposure to traumatic events; (2) appraisal of such event as traumatic; and (3) culturally-determined responses to standardized diagnostic instruments, reflecting differences in cultural meanings associated with physical symptoms and idioms of distress.

Methods:

Ethnic differences in risk factors and factor structures of PTSD symptoms were examined in 188 Alaskan Natives and 371 Euro-Americans exposed to the Exxon-Valdez oil spill in 1989.

Results:

High levels of social disruption were associated with PTSD one year after the oil spill in both ethnic groups. However, low family support, participation in spill clean-up activities, and a decline in subsistence activities were significantly associated with PTSD in Alaskan Natives, but not in Euro-Americans. Factor analysis of the Diagnostic Interview Schedule PTSD subscale revealed five factors for both ethnic groups. However, the items comprising these factors were dissimilar.

Conclusions:

These results suggest that social disruption is sufficiently traumatic to be associated with symptoms of post-traumatic stress, but that a diagnosis of PTSD must take into consideration local interpretations of these symptoms.

Community and Individual Factors Associated with Cigarette Smoking Among Young Men Who Have Sex With Men

Young men who have sex with men (YMSM) have higher rates of cigarette smoking than their heterosexual counterparts, yet few studies have examined factors associated with cigarette smoking among YMSM. The present study sought to understand how different types of gay community connection (i.e., gay community identification and involvement, gay bar/club attendance) were associated with smoking among YMSM recruited through venue-based sampling in Los Angeles, California (N = 526). Structural equation modeling was used to isolate direct and indirect effects of gay community connection on smoking through cognitive and psychological mediators (i.e., psychological distress, health values, internalized homophobia). Findings indicate YMSM cigarette smoking prevention and intervention must be tailored to address the direct and indirect influences of the gay community.

Dynamic adaptation process to implement an evidence-based child maltreatment intervention

Background

Adaptations are often made to evidence-based practices (EBPs) by systems, organizations, and/or service providers in the implementation process. The degree to which core elements of an EBP can be maintained while allowing for local adaptation is unclear. In addition, adaptations may also be needed at the system, policy, or organizational levels to facilitate EBP implementation and sustainment. This paper describes a study of the feasibility and acceptability of an implementation approach, the Dynamic Adaptation Process (DAP), designed to allow for EBP adaptation and system and organizational adaptations in a planned and considered, rather than ad hoc, way. The DAP involves identifying core elements and adaptable characteristics of an EBP, then supporting implementation with specific training on allowable adaptations to the model, fidelity monitoring and support, and identifying the need for and solutions to system and organizational adaptations. In addition, this study addresses a secondary concern, that of improving EBP model fidelity assessment and feedback in real-world settings.

Methods

This project examines the feasibility, acceptability, and utility of the DAP; tests the degree to which fidelity can be maintained using the DAP compared to implementation as usual (IAU); and examines the feasibility of using automated phone or internet-enabled, computer-based technology to assess intervention fidelity and client satisfaction. The study design incorporates mixed methods in order to describe processes and factors associated with variations in both how the DAP itself is implemented and how the DAP impacts fidelity, drift, and adaptation. The DAP model is to be examined by assigning six regions in California (USA) to either the DAP (n = 3) or IAU (n = 3) to implement an EBP to prevent child neglect.

Discussion

The DAP represents a data-informed, collaborative, multiple stakeholder approach to maintain intervention fidelity during the implementation of EBPs in the field by providing support for intervention, system, and organizational adaptation and intervention fidelity to meet local needs. This study is designed to address the real-world implications of EBP implementation in public sector service systems and is relevant for national, state, and local service systems and organizations.

Assessing needs for mental health and other services among transition-age youths, parents, and providers

OBJECTIVES

This qualitative study assessed the needs for mental health and other services among transition-age youths who were receiving services in youth-specific programs.

METHODS

Thirteen focus groups were conducted between June 2008 and January 2009. The purposefully sampled participants included transition-age youths age 18 to 24 who were receiving services in youth-specific programs (N=75, eight groups), parents of transition-age youths (N=14, two groups), and providers in the youth-specific programs (N=14, three groups). The qualitative analysis used an inductive approach in which investigators focused on generating themes and identifying relationships between themes. Through a process of repeated comparisons, the categories were further condensed into broad themes illustrating service needs.

RESULTS

Youths expressed needs for improved scheduling of services, stronger patient-provider relationships, and group therapies that address past experiences of violence, loss, and sexual abuse and that provide skills for developing and nurturing healthy relationships. Parents and providers expressed needs for increased community-based and peer-led services. Youths, parents, and providers all expressed needs for more housing options and for mentors with similar life experiences who could serve as role models, information brokers, and sources of social support for youths who were pursuing education and employment goals.

CONCLUSIONS

Findings from the focus groups suggest that there is room for improvement in the provision of services that are relevant to the current needs and life experiences of transition-age youths. Even within age-specific programs, improvements in services are needed to foster transitions to independence.

Deportation experiences of women who inject drugs in Tijuana, Mexico

Deportation from the United States for drug offenses is common, yet the consequences of deportation for women drug users are poorly documented. In 2008, in Tijuana, Mexico, we conducted an exploratory qualitative study of migration, deportation, and drug abuse by interviewing 12 Mexican injection-drug-using women reporting U.S. deportation. Women reported heavy drug use before and after deportation, but greater financial instability and physical danger following deportation than when in the United States. We identified an unmet need for health and social services among deported drug-using women, including HIV prevention, drug treatment, physical and mental health services, and vocational training. Binational coordination is needed to help deported women resettle in Mexico.

Perspectives on schizophrenia over the lifespan: a qualitative study

Longitudinal data suggest heterogeneity in the long-term course of schizophrenia. It is unclear how older adults with schizophrenia perceive changes in their experience of schizophrenia over the lifespan. We interviewed 32 adults aged 50 years and older diagnosed with schizophrenia (mean duration 35 years) about their perceived changes in the symptoms of schizophrenia and functioning over the lifespan. Interview transcripts were analyzed using grounded theory techniques of coding, consensus, co-occurrence, and comparison. The study was conducted by a research partnership involving a multidisciplinary team of academic researchers, community members, and mental health clients engaged in all aspects of study design, interviewing, and analysis and interpretation of data. Results revealed that, in regard to early course of illness, participants experienced confusion about diagnosis, active psychotic symptoms, and withdrawal/losses in social networks. Thereafter, nearly all participants believed that their symptoms had improved, which they attributed to increased skills in self-management of positive symptoms. In contrast to consistency among participants in describing illness course, there was marked heterogeneity in perceptions about functioning. Some participants were in despair about the discrepancy between their current situations and life goals, others were resigned to remain in supported environments, and others working toward functional attainments and optimistic about the future. In conclusion, middle-aged and older adults with schizophrenia believed that their symptoms had improved over their lifespan, yet there was substantial variability among participants in how they perceived their functioning. Functional rehabilitation may need to be tailored to differences in perceptions of capacity for functional improvement.

Mixed methods for implementation research: application to evidence-based practice implementation and staff turnover in community-based organizations providing child welfare services

Many public sector service systems and provider organizations are in some phase of learning about or implementing evidence-based interventions. Child welfare service systems represent a context where implementation spans system, management, and organizational concerns. Research utilizing mixed methods that combine qualitative and quantitative design, data collection, and analytic approaches are particularly well suited to understanding both the process and outcomes of dissemination and implementation efforts in child welfare systems. This article describes the process of using mixed methods in implementation research and provides an applied example of an examination of factors impacting staff retention during an evidence-based intervention implementation in a statewide child welfare system. The authors integrate qualitative data with previously published quantitative analyses of job autonomy and staff turnover during this statewide implementation project in order to illustrate the utility of mixed method approaches in providing a more comprehensive understanding of opportunities and challenges in implementation research.

A conceptual framework for understanding the mental health impacts of oil spills: lessons from the Exxon Valdez oil spill

This paper introduces a conceptual framework for understanding and responding to the currently unfolding social and psychological impacts of the Deepwater Horizon oil spill. Drawing from the concept of corrosive communities and its relationship to theories of conservation of resources, cognitive activation, and risk and resilience, the conceptual model identifies three levels or tiers of impacts: biopsychosocial impacts that are direct consequences of the contamination of the physical environment; interpersonal impacts that are direct consequences of the biopsychosocial impacts; and intrapersonal or psychological impacts that are consequences of both the biopsychosocial and the interpersonal impacts. The model is then evaluated in light of research conducted in the aftermath of the Exxon Valdez oil spill as well as studies of other manmade disasters, and offers a set of testable hypotheses that predict likely impacts of the Deepwater Horizon oil spill. The conceptual framework may be used to identify strategies to develop community resilience and target specific services to prevent and mitigate these adverse effects.

Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: a randomized effectiveness trial

CONTEXT

Decades of randomized controlled trials have produced separate evidence-based treatments for depression, anxiety, and conduct problems in youth, but these treatments are not often used in clinical practice, and they produce mixed results in trials with the comorbid, complex youths seen in practice. An integrative, modular redesign may help.

OBJECTIVE

Standard/separate and modular/integrated arrangements of evidence-based treatments for depression, anxiety, and conduct problems in youth were compared with usual care treatment, with the modular design permitting a multidisorder focus and a flexible application of treatment procedures.

DESIGN

Randomized effectiveness trial.

SETTING

Ten outpatient clinical service organizations in Massachusetts and Hawaii.

PARTICIPANTS

A total of 84 community clinicians were randomly assigned to 1 of 3 conditions for the treatment of 174 clinically referred youths who were 7 to 13 years of age (70% of these youths were boys, and 45% were white). The study was conducted during the period from January 12, 2005 to May 8, 2009.

INTERVENTIONS

Standard manual treatment (59 youths [34% of the sample]; cognitive behavioral therapy for depression, cognitive behavioral therapy for anxiety, and behavioral parent training for conduct problems), modular treatment (62 youths [36%]; integrating the procedures of the 3 separate treatments), and usual care (53 youths [30%]).

MAIN OUTCOME MEASURES

Outcomes were assessed using weekly youth and parent assessments. These assessments relied on a standardized Brief Problem Checklist and a patient-generated Top Problems Assessment (ie, the severity ratings on the problems that the youths and parents had identified as most important). We also conducted a standardized diagnostic assessment before and after treatment.

RESULTS

Mixed effects regression analyses showed that modular treatment produced significantly steeper trajectories of improvement than usual care and standard treatment on multiple Brief Problem Checklist and Top Problems Assessment measures. Youths receiving modular treatment also had significantly fewer diagnoses than youths receiving usual care after treatment. In contrast, outcomes of standard manual treatment did not differ significantly from outcomes of usual care.

CONCLUSIONS

The modular approach outperformed usual care and standard evidence-based treatments on multiple clinical outcome measures. The modular approach may be a promising way to build on the strengths of evidence-based treatments, improving their utility and effectiveness with referred youths in clinical practice settings. Trial Registration  clinicaltrials.gov Identifier: NCT01178554.

Social networks and implementation of evidence-based practices in public youth-serving systems: a mixed-methods study

Background

The present study examines the structure and operation of social networks of information and advice and their role in making decisions as to whether to adopt new evidence-based practices (EBPs) among agency directors and other program professionals in 12 California counties participating in a large randomized controlled trial.

Methods

Interviews were conducted with 38 directors, assistant directors, and program managers of county probation, mental health, and child welfare departments. Grounded-theory analytic methods were used to identify themes related to EBP adoption and network influences. A web-based survey collected additional quantitative information on members of information and advice networks of study participants. A mixed-methods approach to data analysis was used to create a sociometric data set (n = 176) for examination of associations between advice seeking and network structure.

Results

Systems leaders develop and maintain networks of information and advice based on roles, responsibility, geography, and friendship ties. Networks expose leaders to information about EBPs and opportunities to adopt EBPs; they also influence decisions to adopt EBPs. Individuals in counties at the same stage of implementation accounted for 83% of all network ties. Networks in counties that decided not to implement a specific EBP had no extra-county ties. Implementation of EBPs at the two-year follow-up was associated with the size of county, urban versus rural counties, and in-degree centrality. Collaboration was viewed as critical to implementing EBPs, especially in small, rural counties where agencies have limited resources on their own.

Conclusions

Successful implementation of EBPs requires consideration and utilization of existing social networks of high-status systems leaders that often cut across service organizations and their geographic jurisdictions.

Trial Registration

NCT00880126

The influence of the perceived consequences of refusing to share injection equipment among injection drug users: balancing competing risks

Injection drug users (IDUs) are at risk for HIV and other bloodborne pathogens through receptive syringe sharing (RSS) and receptive paraphernalia sharing (RPS). Research into the influence of the perceived risk of HIV infection on injection risk behavior has yielded mixed findings. One explanation may be that consequences other than HIV infection are considered when IDUs are faced with decisions about whether or not to share equipment. We investigated the perceived consequences of refusing to share injection equipment among 187 IDUs recruited from a large syringe exchange program in Los Angeles, California, assessed their influence on RSS and RPS, and evaluated gender differences. Two sub-scales of perceived consequences were identified: structural/external consequences and social/internal consequences. In multiple linear regression, the perceived social/internal consequences of refusing to share were associated with both RSS and RPS, after controlling for other psychosocial constructs and demographic variables. Few statistically significant gender differences emerged. Assessing the consequences of refusing to share injection equipment may help explain persistent injection risk behavior, and may provide promising targets for comprehensive intervention efforts designed to address both individual and structural risk factors.

Reconciling incongruous qualitative and quantitative findings in mixed methods research: exemplars from research with drug using populations

Mixed methods research is increasingly being promoted in the health sciences as a way to gain more comprehensive understandings of how social processes and individual behaviours shape human health. Mixed methods research most commonly combines qualitative and quantitative data collection and analysis strategies. Often, integrating findings from multiple methods is assumed to confirm or validate the findings from one method with the findings from another, seeking convergence or agreement between methods. Cases in which findings from different methods are congruous are generally thought of as ideal, whilst conflicting findings may, at first glance, appear problematic. However, the latter situation provides the opportunity for a process through which apparently discordant results are reconciled, potentially leading to new emergent understandings of complex social phenomena. This paper presents three case studies drawn from the authors' research on HIV risk amongst injection drug users in which mixed methods studies yielded apparently discrepant results. We use these case studies (involving injection drug users [IDUs] using a Needle/Syringe Exchange Program in Los Angeles, CA, USA; IDUs seeking to purchase needle/syringes at pharmacies in Tijuana, Mexico; and young street-based IDUs in San Francisco, CA, USA) to identify challenges associated with integrating findings from mixed methods projects, summarize lessons learned, and make recommendations for how to more successfully anticipate and manage the integration of findings. Despite the challenges inherent in reconciling apparently conflicting findings from qualitative and quantitative approaches, in keeping with others who have argued in favour of integrating mixed methods findings, we contend that such an undertaking has the potential to yield benefits that emerge only through the struggle to reconcile discrepant results and may provide a sum that is greater than the individual qualitative and quantitative parts.

Mixed-methods designs in mental health services research: a review

OBJECTIVE

Despite increased calls for use of mixed-methods designs in mental health services research, how and why such methods are being used and whether there are any consistent patterns that might indicate a consensus about how such methods can and should be used are unclear.

METHODS

Use of mixed methods was examined in 50 peer-reviewed journal articles found by searching PubMed Central and 60 National Institutes of Health (NIH)-funded projects found by searching the CRISP database over five years (2005-2009). Studies were coded for aims and the rationale, structure, function, and process for using mixed methods.

RESULTS

A notable increase was observed in articles published and grants funded over the study period. However, most did not provide an explicit rationale for using mixed methods, and 74% gave priority to use of quantitative methods. Mixed methods were used to accomplish five distinct types of study aims (assess needs for services, examine existing services, develop new or adapt existing services, evaluate services in randomized controlled trials, and examine service implementation), with three categories of rationale, seven structural arrangements based on timing and weighting of methods, five functions of mixed methods, and three ways of linking quantitative and qualitative data. Each study aim was associated with a specific pattern of use of mixed methods, and four common patterns were identified.

CONCLUSIONS

These studies offer guidance for continued progress in integrating qualitative and quantitative methods in mental health services research consistent with efforts by NIH and other funding agencies to promote their use.

A qualitative view of drug use behaviors of Mexican male injection drug users deported from the United States

Deportees are a hidden yet highly vulnerable and numerous population. Significantly, little data exists about the substance use and deportation experiences of Mexicans deported from the United States. This pilot qualitative study describes illicit drug use behaviors among 24 Mexico-born male injection drug users (IDUs), ≥ 18 years old, residing in Tijuana, Mexico who self-identified as deportees from the United States. In-person interviews were conducted in Tijuana, Mexico in 2008. Content analysis of interview transcripts identified major themes in participants' experiences. Few participants had personal or family exposures to illicit drugs prior to their first U.S. migration. Participants reported numerous deportations. Social (i.e., friends/family, post-migration stressors) and environmental factors (e.g., drug availability) were perceived to contribute to substance use initiation in the U.S. Drugs consumed in the United States included marijuana, heroin, cocaine, methamphetamine, and crack. More than half of men were IDUs prior to deportation. Addiction and justice system experiences reportedly contributed to deportation. After deportation, several men injected new drugs, primarily heroin or methamphetamine, or a combination of both drugs. Many men perceived an increase in their substance use after deportation and reported shame and loss of familial social and economic support. Early intervention is needed to stem illicit drug use in Mexican migrant youths. Binational cooperation around migrant health issues is warranted. Migrant-oriented programs may expand components that address mental health and drug use behaviors in an effort to reduce transmission of blood-borne infections. Special considerations are merited for substance users in correctional systems in the United States and Mexico, as well as substance users in United States immigration detention centers. The health status and health behaviors of deportees are likely to impact receiving Mexican communities. Programs that address health, social, and economic issues may aid deportees in resettling in Mexico.

The perceived consequences of safer injection: an exploration of qualitative findings and gender differences

Injection drug users (IDUs) are at a risk for HIV and other bloodborne pathogens via syringe and paraphernalia sharing, with females being at elevated risk. Consequences of injection risk behavior such as the risk of becoming infected with HIV have been relatively well studied, though less is known about the consequences of refusing to share injection equipment. We conducted indepth qualitative interviews with 26 IDUs recruited from a syringe exchange program in Los Angeles, California, USA, to understand the consequences of refusing to share injection equipment and to determine whether these perceived consequences differ by gender. Perceived consequences were organized into four domains using a social ecological framework: microsystem (perceived risk for HIV, drug withdrawal or forgoing drug use), exosystem (trust and social norms), mesosystem (precarious housing and shelter policies), and macrosystem (syringe access/inconvenience, economic and legal consequences). Gender differences were identified in some, but not in all areas. Effective public health interventions among IDUs will benefit from a holistic perspective that considers the environmental and social rationality (Kowalewski, M., Henson, K.D., & Longshore, D. (1997). Rethinking perceived risk and health behavior: A critical review of HIV prevention research. Health Education and Behavior, 24(3), 313-325) of decisions regarding injection risk behavior and assists individuals in addressing the consequences that they perceive to be the most salient.

Cancer patients' perspectives on discontinuing depression treatment: the "drop out" phenomenon

BACKGROUND

Adherence is a critical component of clinical intervention utility, but little is known about how cancer patients with depression, particularly low-income, ethnic minority patients, perceive adherence to and drop out from treatment.

AIM

To explore low-income, minority cancer patient perspectives about not adhering or dropping out of depression treatment.

METHODS

A qualitative substudy was conducted within the Alleviating Depression among Patients with Cancer (ADAPt-C) study. The intervention was an individualized stepped care depression treatment program provided by a clinical social worker in collaboration with a study psychiatrist. Patients randomized to the intervention were offered antidepressant medication and/or 8-10 sessions of problem solving treatment talk therapy. In-depth telephone interviews were conducted with 20 patients who had dropped out of depression treatment, using a grounded theory qualitative methodological approach.

RESULTS

Enrolled intervention patients were predominately Latina, Spanish-speaking, and foreign born. Most patients (12/20) acknowledged they had dropped out of treatment for a variety of reasons, including dissatisfaction with treatment, poor patient-provider relations, logistical and financial barriers, cancer treatment commitments, and language barriers. However, other patients (8/20) denied they had dropped out of treatment and/or became confused about being labeled as a "dropout."

CONCLUSION

A substantial percentage of low-income, ethnic minority patients who drop out of treatment for depression appear not to realize they have dropped out of treatment. Improving treatment adherence requires explanation of what constitutes adherence and the consequences of failing to do so from the perspective of both patient and provider.

Mixed method designs in implementation research

This paper describes the application of mixed method designs in implementation research in 22 mental health services research studies published in peer-reviewed journals over the last 5 years. Our analyses revealed 7 different structural arrangements of qualitative and quantitative methods, 5 different functions of mixed methods, and 3 different ways of linking quantitative and qualitative data together. Complexity of design was associated with number of aims or objectives, study context, and phase of implementation examined. The findings provide suggestions for the use of mixed method designs in implementation research.

Sleep health in U.S. Hispanic population

The importance of sleep on health has only been recently recognized, and the general public and the medical community are not yet fully knowledgeable about this issue. The great majority of sleep research has been performed in whites of European descent and to a lesser extent in African Americans, making generalization of the findings to other ethnic and racial groups difficult. Very little sleep research has been done in U.S. Hispanics. However, based on the available literature and the high prevalence of risk factors in Hispanics, such as obesity, diabetes, living in the inner city, and use of alcohol, the prevalence of such important sleep disorders such as obstructive sleep apnea and sleep habits such as poor sleep hygiene are suspected to be high. There is also some evidence that acculturation to the U.S. life style may lead to worse sleep habits in Hispanics, including fewer hours of sleep. Two current large NIH sponsored studies of sleep in U.S. Hispanics promise to significantly add to the literature on various sleep disorders such as sleep disordered breathing, insomnia, restless legs syndrome, periodic limb movement disorder, and sleep habits such as short sleep duration and sleep hygiene.

Barriers to pharmacy-based syringe purchase among injection drug users in Tijuana, Mexico: a mixed methods study

Injection drug users (IDUs) may be denied purchase of sterile syringes even where purchase without a prescription is legal. This study examined barriers to over-the-counter (OTC) syringe purchase among IDUs in Tijuana, Mexico. A quantitative survey and subsequent focus groups were used to quantify barriers to purchase, identify their correlates and provide in-depth exploration of syringe purchase experiences. Of 627 IDUs, 81% purchased a syringe in the past 6 months and 16% were refused or overcharged. Factors independently associated with refusal/overcharging were homelessness, receptive syringe sharing, >5 uses per syringe, and number of lifetime abscesses. Few pharmacies sold syringes to IDUs, who adapted by limiting purchase attempts to pharmacies known to sell syringes consistently. Failed purchases occurred when drug withdrawal required purchase at unusual times or locations, often following release from jail. IDUs reported syringe sharing, syringe reuse, and searching through unsecured medical waste for syringes in response to failed purchase attempts. Interventions to expand OTC syringe sales to IDUs, particularly near detention facilities, will facilitate safer injection practices.

A randomized placebo-controlled clinical trial of the effectiveness of thyroxine and triiodothyronine and short-term exposure to bright light in prevention of decrements in cognitive performance and mood during prolonged Antarctic residence

OBJECTIVE

We examined the effects of a combined levothyroxine/liothyronine supplement and exposure to bright (10,000 lux) light in euthyroid men and women who spent the austral summer (n = 43) and/or winter (n = 42) in Antarctica.

METHODS

Subjects were randomized to receive 64 nmol of levothyroxine and 16 nmol of liothyronine supplement or a placebo capsule for 93.2 +/- 3.0 days in summer and/or 149.5 +/- 2.2 days in winter. Subjects were further randomized to receive 10,000 lux bright white light or 50 lux dim red light for 14 days at the end of summer and/or winter. Cognitive performance and mood were assessed using the Automatic Neuropsychological Assessment Metric - Isolated and Confined Environments.

RESULTS

In winter, bright light exposure was associated with a significantly greater reduction in TSH and anger (P < 0.05), a significantly greater increase in fT(3) (P < 0.05), and a significantly smaller increase in depressive symptoms (P < 0.001), when compared with dim light. The T4/T3 supplement also led to a significantly greater reduction in TSH (P < 0.05), but a greater reduction in cognitive task efficiency (P < 0.05) as well, when compared with placebo.

CONCLUSION

Administration of bright light leads to a significant reduction in serum TSH and prevents increases in anger and depressive symptoms in winter. However, these associations were not observed in summer, suggesting a seasonal influence of photoperiod over temperature upon this intervention in the polar environment.

Rapid community participatory assessment of health care in post-storm New Orleans

BACKGROUND

Hurricane Katrina and levee failures disrupted healthcare access for hundreds of thousands of New Orleans residents. Few models exist to explain community stakeholders' priorities for post-disaster recovery while building capacity for response. This project engaged community stakeholders in a rapid, participatory assessment of health priorities 1 year post-disaster, to inform the policy process and build capacity for recovery planning among community members.

METHODS

This project combined community-based participatory research methods and rapid assessment procedures to engage diverse community members in design, conduct, data interpretation, and dissemination of results. Thirty stakeholders in the health and healthcare fields were interviewed in Summer 2006, and four grassroots community discussion groups were held in New Orleans neighborhoods to assess perceptions of the disaster's impacts on healthcare access. Interview transcripts were reviewed in Summer 2006, and themes were elicited using methods rooted in grounded theory. Findings were shared at a public community feedback conference, and recovery-relevant community action steps were set in motion.

RESULTS

Three main themes emerged from the data: (1) healthcare access challenges; (2) unmet needs of specific vulnerable populations; (3) opportunities, resources, and community adaptations to improve healthcare access.

CONCLUSIONS

This rapid, community-based participatory assessment provided new information on diverse community members' concerns and priorities, and it produced a sustainable community-academic partnership dedicated to improving both access to care and the public's health following this major disaster.