Enhancing health-care workers' understanding and thinking about people living with co-occurring mental health and substance use issues through consumer-led training

Decrease in provider stigma is associated with improved quality health indicators among individuals receiving methadone in primary care centers in Ukraine

INTRODUCTION

People who inject drugs experience poor health and social outcomes which improve with opioid agonist therapies like methadone, yet provider stigma may influence healthcare utilization. In Ukraine, integrating methadone into primary care centers (PCCs) provides an opportunity to examine provider stigma and its impact on patient outcomes.

METHODS

This sub-analysis included patients randomized to receive methadone in PCCs as part of an implementation trial in which the control group received methadone in specialty addiction clinics in Ukraine. Methadone integration in PCCs was supported through continuous tele-education for providers. Provider stigma towards people who inject drugs, methadone, and attitudes towards evidence-based practices were assessed at baseline, 12, and 24 months using standardized scales (range 1-10). Patient-level outcomes were measured bi-annually over 24 months using a quality health indicator (QHI) score, a percentage of guideline-concordant primary and specialty health services accessed. Linear mixed-effects models examined the changes in provider stigma and attitudes, and the association of these measures with patient outcomes.

RESULTS

The sample included 583 patients and the 112 providers in 24 clinics. Provider fear and stereotypes toward people who inject drugs improved significantly, by 0.6 (95 % CI 0.2-1.1) and 0.4 points (95 % CI 0.1-0.8), respectively, as did preference for methadone over abstinence-based treatment (0.7 points, 95 % CI 0.2-1.1). A 1-point improvement in provider prejudice correlated with a 7.0-point increase (95 % CI: 1.1-13.0) in patient primary care QHI scores at 12 months, while improved attitudes towards evidence-based practices were associated with an 8.3-point increase (95 % CI: 1.1-13.0). Preference for methadone maintenance over abstinence was associated with a 3.7-point increase (95 % CI: 0.6-6.7) in specialty care QHI scores at 12 months, and reduced stereotypes were associated with a 10.9-point increase (95 % CI: 1.2-20.7) at 24 months.

CONCLUSIONS

Integrating methadone into PCCs with the support of provider tele-education may reduce provider stigma, particularly fear and stereotypes, toward people who inject drugs and methadone maintenance. Reducing provider stigma has the potential to improve patient outcomes through increased access to preventive care and screenings.

Transforming Alcohol and Other Drug Education Through Co-Design

Over the past decade, as a broader push to address community needs and improve health outcomes, socially marginalised people have become increasingly involved in co-design research and education. More recently, people with lived experience of substance dependence have co-designed and co-delivered Alcohol and Other Drugs (AOD) education with nurse educators. Evaluations of co-designed AOD education have largely focused on educational and clinical outcomes but not on the process of co-design. Because of this gap, there is a need for research that explores the process of undertaking co-design with people who use substances and clinicians, including facilitators and barriers to the process that are specific to these groups. This research reports on a qualitative study exploring the barriers, facilitators, and perceived value of a co-design process for an AOD clinical education program involving people with lived experience of substance use, nurse clinicians, and academics (nursing and public health). The participants reported that building trusting relationships and skilled facilitation enhanced the co-design process, enabling positive conditions for working in partnership to achieve the project outcomes. However, challenging interpersonal dynamics, lack of adequate resources, and overly directive facilitation could impact team dynamics and undermine the co-design process. Authentic co-design has the potential to transform AOD education, ensuring that it centres the needs of people with lived experience. However, co-design initiatives require adequate resourcing and time to develop equal and respectful relationships for this vision to be realised.

Validity and reliability of the Japanese version of the Substance Use Stigma Mechanism Scale

AIM

Stigma against people who have alcohol and drug problems severely affects their health and well-being. An instrument based on stigma theory assessing individual-level stigma is essential for a comprehensive understanding of their stigma. We evaluated the validity and reliability of the Japanese version of the Substance Use Stigma Mechanism Scale (SU-SMS-J) among a population who had alcohol or drug use problems.

METHODS

Adults with experience in substance use disorders from psychiatry outpatient departments and rehabilitation facilities participated in the self-administered questionnaire survey. Confirmatory factor analysis was conducted to test the structural validity of the 5-factor model proposed in other language versions, and factor loadings and correlation between the subscales were confirmed. The correlations between the SU-SMS-J and psychometric properties related to substance use (e.g., severity of substance use, motivation to change) were investigated to assess concurrent validity. Internal consistency was assessed using Cronbach's alpha coefficients.

RESULTS

Data from 126 participants were analyzed. The 5-factor model was acceptable with good or reasonable model fit indices. The correlations between subscales were weak to moderate, and this result suggested the SU-SMS-J assessed different but related components of stigma: enacted, anticipated, and internalized stigma from different stigma sources (family and healthcare workers). The SU-SMS-J and subscales showed moderate concurrent validity. Internal consistency was mostly sufficient, with Cronbach's alpha coefficients of 0.86 for all items and 0.66-0.93 for subscales.

CONCLUSIONS

The SU-SMS-J is valid and reliable for use among populations with substance use problems in various settings in Japan.

Assessing early feasibility of a novel innovation to increase consumer partnership capability within an Australian health innovation organisation using a mixed-method approach

OBJECTIVE

Engagement-capable health organisations recognise that consumer engagement (also known as patient engagement, consumer engagement, patient and public involvement) must occur at every level of the organisation if it is to be meaningful and genuine. Despite this aspiration, health organisations struggle to adopt, implement, and embody consumer engagement capability in a way that has yielded impact. The Partner Ring (PR) is an embedded model for building staff capability for consumer partnerships. It is hosted by an employed Patient Partner. PR was implemented at the Agency for Clinical Innovation in New South Wales, Australia. The aim of this study was to assess the feasibility (acceptability, demand and practicality) of this innovation to increase consumer engagement capability.

DESIGN

One-group post-intervention mixed methods approach to assess feasibility.

PARTICIPANTS

ACI staff engaged in the PR (n=40 of 89 members).

DATA COLLECTION AND ANALYSIS

Qualitative data was collected through an artificial intelligence (AI)-driven interactive interview, with 40 responses received between 29 June and 12 July 2023. A framework analysis and Generative AI causal mapping were conducted to identify and visualise causal claims within the texts. Cost and session attendance collected from the same point in time supplemented the analysis.

FINDINGS

Findings were categorised by the following feasibility constructs: acceptability, demand and practicality. Almost all the respondents indicated their intent to continue using the PR and outlined personal benefits and professional benefits. For example, (n=23, 57%) reacted positively to the psychological safety of the PR, and professionally people identified attendance increased their knowledge and skills (n=23, 57%).

CONCLUSION

The PR is feasible and likely to be an acceptable innovation for building staff capability and consumer engagement skills across a large health system or organisation. It could be adopted or adapted by other jurisdictions.

Evaluating attitudes among healthcare graduate students following interprofessional education on opioid use disorder

CONTEXT

Provider-enacted stigma is a barrier for people with substance use disorder (SUD) who interface with the healthcare system, and it has been shown to lead to worse healthcare outcomes. This has given urgency to the need for stigma reduction interventions such as education- and contact-based approaches. The positive effect of interprofessional education (IPE) in reducing graduate health students' stigmatizing attitudes on opioids has been examined before, and we contribute to the existing literature by examining the attitudes across the following four health disciplines-osteopathic medicine, physician assistant (PA) studies and public health, pharmacy, and nursing-following a single half-day IPE event focused on opioid use disorder (OUD).

OBJECTIVES

We aimed to determine whether attitudes could be affected by the IPE event by assessing attitudes utilizing an adapted version of the Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ) before and after the IPE event.

METHODS

A total of 647 students across the four previously mentioned health disciplines participated in the IPE event. Attitudes were compared between the pre/post groups utilizing unpaired t tests, and a summative "all-attitudes" score was generated, with higher scores being associated with improved attitudes toward individuals with an OUD. Linear regression was performed controlling for program type, gender, and previous OUD exposure (personal, professional, and education).

RESULTS

We found that the pre/post summative attitudes scores improved an average of 2.81 units (SD 0.87, p=0.001, CI 1.09-4.52) for the entire cohort of graduate health students (56.9 vs. 66.6, p<0.0001) and for all attitudinal subscales (role adequacy, role legitimacy, role support, task-specific self-esteem, and work satisfaction). Students from PA programs had significantly higher attitude scores than other programs, and there were differences in degree type on attitude scores, with an average decrease of 1.89 units in attitude scores (SE 0.38, p<0.0001, CI -2.64 to -1.16). We found that students with previous exposure to OUD had higher pre-IPE event scores than those without, and knowing someone impacted by an SUD was a significant predictor of increased attitude scores, by an average of 3.82 units (SE 0.27, p<0.0001, CI 3.49-4.16). However, students without previous exposure to OUD had equal attitude scores post event to those who had previous exposure to OUD through education, personal experience, or training.

CONCLUSIONS

Our findings suggest that an IPE intervention and panel discussion may improve attitudes toward people with OUD in healthcare trainees, which is consistent with previous research that shows the beneficial effect of education and contact in reducing stigma. Degree type and knowing someone who has been impacted by an SUD are also significant predictors of attitude scores. IPE events are useful in targeting a public health issue by encouraging collaboration between different health professionals at early stages of their training, and preclinical educational efforts can affect therapeutic attitudes.

The Impact of an Online Educational Intervention on Attitudes of Primary Care Clinicians Toward Managing Patients With Substance Use Disorders

BACKGROUND

Negative attitudes of primary care clinicians toward patients with substance use disorders affect the quality and delivery of care in this highly marginalized patient population.

PURPOSE

This project aimed to improve negative attitudes of primary care clinicians toward managing patients with substance use disorders.

METHODS

A pretest-and-posttest design, employing multidimensional online educational interventions, was implemented from June to August 2020. The participants (n = 18) were recruited from a pool of 70 primary care clinicians at two community primary care agencies. The Affect Scale for Substance Users and 15-item Opening Minds Scale for Health Care Providers were administered before, immediately after, and 30 days after the intervention.

RESULTS

There were statistically significant reductions in the immediate postintervention and 30-day postintervention mean scores in the Affect Scale for Substance Users and the disclosure and help-seeking subscale when compared with those of preintervention. The change in attitudes was maintained at 30-day postintervention.

CONCLUSIONS

The project findings support conducting and evaluating future educational programs for substance use disorder management among primary care clinicians. Because of the heterogeneity of the participants and the small sample size, the project results have limited generalizability. Overall, this project is among one of the few aimed at substance use disorder management among primary care clinicians.

Learning that cannot come from a book: An evaluation of an undergraduate alcohol and other drugs subject co-produced with experts by experience

Alcohol and other drugs (AOD) use is a significant public health issue and is associated with high mortality and morbidity rates. Despite this, people who use drugs are often reluctant to seek care due to the lack of trauma-informed treatment and harm reduction treatment options, as well as experiences of stigma and discrimination in health services. Arguably, AOD education that is co-produced with people who use alcohol and drugs can enhance future health professionals' ability to practice in ways that support the needs of this population. This paper reports on a qualitative co-evaluation of a co-produced undergraduate nursing AOD subject. The AOD subject was co-planned, co-designed, co-delivered, and co-evaluated with experts by experience, who have a lived experience of substance dependence and work as advocates and peer workers. Following the delivery of the subject in 2021 and 2022, focus groups were undertaken with 12 nursing students. Focus group data indicate that the co-produced subject supported participants to understand and appreciate how stigma impacts on nursing care and how to recognize and undertake 'good' nursing care that was oriented to the needs of service users. Student participants noted that being co-taught by people who use drugs was particularly powerful for shifting their nursing perspectives on AOD use and nursing care and took learning beyond what could be understood from a book. Findings indicate that co-produced AOD education can shift nursing students' perceptions of AOD use by providing access to tacit knowledge and embodied equitable and collaborative relationships with people who use drugs.

A systematic review of stigma interventions for providers who treat patients with substance use disorders

BACKGROUND

Stigma surrounding substance use disorders (SUDs) is a frequently cited barrier to treatment engagement. Research consistently demonstrates that healthcare professionals' attitudes towards patients with addiction problems are often negative and may adversely impact service delivery. The current study presents a systematic review of stigma interventions for providers who treat patients with SUDs, in order to evaluate the quality of existing studies and potential for implementation in clinical settings.

METHODS

This systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases included PubMed, APA PsycInfo and the Cochrane Database of Systematic Reviews. Of the 1462 records identified between 2011 and 2019, 15 studies were eligible for inclusion. A narrative synthesis of stigma interventions summarized the change in stigmatizing attitudes held by providers.

RESULTS

Studies included heterogeneous and culturally diverse samples of providers (N = 1324), who varied by age, location, discipline, and experience, with the exception of primarily female providers (75%). Results delineated six types of provider stigma interventions with components including online education, in-person education, in-person contact with consumers in recovery, or some combination of these elements. The highest quality studies incorporated motivational interviewing or communication training interventions, and many interventions combined either in-person mentorship or contact with individuals in recovery. Positive effects on provider attitudes occurred at several levels of educational and consumer contact interventions. Interventions with consumer contact demonstrated long-term maintenance of attitudinal shifts. Despite significant methodological limitations and low-quality assessment ratings, several studies utilized real-world providers and patients, as well as practical, innovative, brief, and potentially cost-effective interventions, particularly in locations with limited technological resources.

CONCLUSIONS

Research on provider stigma interventions increased in recent years, indicating greater worldwide attention to the negative impact of stigma. While educational interventions alone can be helpful in attitudinal change, contact with individuals in recovery from SUDs is a vital component of provider stigma interventions, particularly for lasting effects. This review highlights the importance of including implementation outcomes, such as sustainability and cost-effectiveness, in the study of stigma interventions for providers of addiction treatment.

Reducing Opioid Bias is Necessary (ROBIN): An Educational Program to Reduce Addiction Stigma

BACKGROUND

Prescription opioid and heroin use and addiction is a local, national, and worldwide epidemic plaguing over 11 million people. Attitudes toward substance use among the general public were highlighted as an area that needs to be further investigated and addressed. The Reducing Opioid Bias is Necessary (ROBIN) educational project was developed and presented to 21 participants as a one-time, 4-hour pretest and posttest design that included theoretical background, short videos, a documentary film, and writings from individuals and community members affected by opioid use disorder (OUD). Participants were assessed on their familiarity, attitudes, and effectiveness of the ROBIN educational program on their perceptions toward persons with OUD.

METHODS

Quantitative data collection included demographic information, level of familiarity, the Attitudes to Mental Illness Questionnaire, and the Drug and Drug Problems Perceptions Questionnaire. Qualitative measures included reflective writing and focus group discussion 2 months after the program. Quantitative measures were completed using descriptive statistics, and qualitative data were sorted for common themes.

RESULTS

Spearman's rank rho of 0.947 (p < .05) indicated less familiarity and more bias attitudes toward people with OUD. The paired-sample t test on the Drug and Drug Problems Perceptions Questionnaire indicated a significant decrease in participant bias in the posttest (M = 59.33, SD = 16.48) when compared with the pretest (M = 74.86, SD = 19.38), t(20) = 5.17, p = .00002. The qualitative data from the written reflection and focus group indicated strong changes in participants' overall understanding, empathy, and desire for promoting the educational program.

CONCLUSION

The ROBIN program can reduce bias among community and healthcare subjects. Limitations to the study should be addressed in future research on this topic.

Consumer participation in drug treatment: a systematic review

Purpose

It is unclear how consumer participation (CP) can be optimised to transform drug and alcohol treatment services and improve health outcomes. The purpose of this paper is to present the findings of a systematic review examining the types and benefits of activities, and the factors that facilitate CP in drug treatment services.

Design/methodology/approach

A structured search of four databases was undertaken to identify peer reviewed primary research literature in English. Screened articles were appraised. A content analysis was applied to examine the types and outcomes of CP and the associated factors affecting the process. In total, 16 articles were included for review.

Findings

A range of CP activities were identified, and benefits included increased consumer satisfaction, and improved health service delivery. Factors that facilitated the process of CP included positive attitudes of both consumers and providers and employment of people with a lived experience of drug use. However, the lack of consumer and organisational capacity, negative attitudes of providers and power imbalances between consumers and providers constrained CP efforts.

Practical implications

To maximise the benefits of CP in drug and alcohol treatment services, negative attitudes about CP and power dynamics between consumers and health providers need to be addressed. This can be achieved by the strategic use of strengths-based interventions and consumer led education to enhance social capital.

Originality/value

This is the first known review to examine the benefits and facilitators of CP in drug treatment services.

Addressing Unhealthy Substance Use in Primary Care

Unhealthy substance use is common in primary care populations and is a major contributor to morbidity and mortality. Two key strategies to address unhealthy substance use in primary care are the process of screening, brief intervention, and referral to treatment (SBIRT), and integration of treatment for substance use disorders into primary care. Implementation of SBIRT requires buy-in from practice leaders, careful planning, and staff and primary care provider training. Primary care-based treatment of opioid and alcohol use disorders can be effective; more data are needed to better understand the benefits of these models and identify means of treating other substance use disorders in primary care.

Effectiveness of capacity building interventions relevant to public health practice: a systematic review

Background

This systematic review assessed the effectiveness of capacity building interventions relevant to public health practice. The aim is to inform and improve capacity building interventions.

Methods

Four strategies were used: 1) electronic database searching; 2) reference lists of included papers; 3) key informant consultation; and 4) grey literature searching. Inclusion (e.g., published in English) and exclusion criteria (e.g., non-English language papers published earlier than 2005) are outlined with included papers focusing on capacity building, learning plans, or professional development plans within public health and related settings, such as non-governmental organizations, government, or community-based organizations relating to public health or healthcare. Outcomes of interest included changes in knowledge, skill or confidence (self-efficacy), changes in practice (application or intent), and perceived support or supportive environments, with outcomes reported at the individual, organizational or systems level(s). Quality assessment of all included papers was completed.

Results

Fourteen papers were included in this review. These papers reported on six intervention types: 1) internet-based instruction, 2) training and workshops, 3) technical assistance, 4) education using self-directed learning, 5) communities of practice, and 6) multi-strategy interventions. The available literature showed improvements in one or more capacity-building outcomes of interest, mainly in terms of individual-level outcomes. The available literature was moderate in quality and showed a range of methodological issues.

Conclusions

There is evidence to inform capacity building programming and how interventions can be selected to optimize impact. Organizations should carefully consider methods for analysis of capacity building interventions offered; specifically, through which mechanisms, to whom, and for which purpose. Capacity-building interventions can enhance knowledge, skill, self-efficacy (including confidence), changes in practice or policies, behaviour change, application, and system-level capacity. However in applying available evidence, organizations should consider the outcomes of highest priority, selecting intervention(s) effective for the outcome(s) of interest. Examples are given for selecting intervention(s) to match priorities and context, knowing effectiveness evidence is only one consideration in decision making. Future evaluations should: extend beyond the individual level, assess outcomes at organizational and systems levels, include objective measures of effect, assess baseline conditions, and evaluate features most critical to the success of interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5591-6) contains supplementary material, which is available to authorized users.