The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness

IntroductionCompared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH.MethodsWe used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions).ResultsIn step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing.DiscussionThe research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing

Tobacco use among non-elderly adults with and without criminal justice involvement in the past year: United States, 2008–2016

Abstract Background Tobacco use remains the leading cause of preventable disease and death in the United States and is concentrated among disadvantaged populations, including individuals with a history of criminal justice involvement. However, tobacco use among individuals with a history of criminal justice involvement has been understudied in the United States, and data are needed to inform policy and practice. Methods We used data from the 2008–2016 National Survey on Drug Use and Health (unweighted N = 330,130) to examine trends in tobacco use, categories of tobacco use, characteristics of cigarette use, and health care utilization and tobacco use screening among individuals (aged 18–64) with and without a history of criminal justice involvement in the past year. We used multiple logistic and Poisson regression models with predictive margins to provide adjusted prevalence estimates. Results The weighted sample in each year was, on average, representative of 8,693,171 individuals with a history of criminal justice involvement in the past year and 182,817,228 individuals with no history of criminal justice involvement in the past year. Tobacco use was significantly more common among individuals with a history of criminal justice involvement compared with individuals with no criminal justice involvement, and disparities increased over time (Difference in adjusted relative differences: − 10.2% [95% CI − 17.7 to − 2.7]). In 2016, tobacco use prevalence was more than two times higher among individuals with a history of criminal justice involvement (62.9% [95% CI 59.9–66.0] vs. 27.6% [95% CI 26.9–28.3]). Individuals with a history of criminal justice involvement who smoked reported a significantly earlier age of cigarette initiation, more cigarettes used per day, and higher levels of nicotine dependence and chronic obstructive pulmonary disease. Individuals with a history of criminal justice involvement were less likely to report an outpatient medical visit in the past year and, among those reporting an outpatient medical visit, were less likely to be asked about tobacco use, but paradoxically, more likely to report being advised to quit. Conclusions Novel programs and tobacco control policies are needed to address persistently high rates of tobacco use and reduce cardiovascular morbidity and mortality among individuals with a history of criminal justice involvement

Pilot trial results of D-HOMES: a behavioral-activation based intervention for diabetes medication adherence and psychological wellness among people who have been homeless

IntroductionPeople living with type 2 diabetes who experience homelessness face a myriad of barriers to engaging in diabetes self-care behaviors that lead to premature complications and death. This is exacerbated by high rates of comorbid mental illness, substance use disorder, and other physical health problems. Despite strong evidence to support lay health coach and behavioral activation, little research has effectively engaged people living with type 2 diabetes who had experienced homelessness (DH).MethodsWe used community engaged research and incremental behavioral treatment development to design the Diabetes HOmeless MEdication Support (D-HOMES) program, a one-on-one, 3 month, coaching intervention to improve medication adherence and psychological wellness for DH. We present results of our pilot randomized trial (with baseline, 3 mo., 6 mo. assessments) comparing D-HOMES to enhanced usual care (EUC; brief diabetes education session and routine care; NCT05258630). Participants were English-speaking adults with type 2 diabetes, current/recent (<24 mo.) homelessness, and an HbA1c‗7.5%. We focused on feasibility (recruitment, retention, engagement) and acceptability (Client Satisfaction Questionnaire, CSQ-8). Our primary clinical outcome was glycemic control (HbA1c) and primary behavioral outcome was medication adherence. Secondary outcomes included psychological wellness and diabetes self-care.ResultsThirty-six eligible participants enrolled, 18 in each arm. Most participants identified as Black males, had high rates of co-morbidities, and lived in subsidized housing. We retained 100% of participants at 3-months, and 94% at 6-months. Participants reported high satisfaction (mean CSQ-8 scores=28.64 [SD 3.94] of 32). HbA1c reduced to clinically significant levels in both groups, but we found no between group differences. Mean blood pressure improved more in D-HOMES than EUC between baseline and 6 mo. with between group mean differences of systolic -19.5 mmHg (p=0.030) and diastolic blood pressure -11.1 mmHg (p=0.049). We found no significant between group differences in other secondary outcomes.ConclusionWe effectively recruited and retained DH over 6 months. Data support that the D-HOMES intervention was acceptable and feasible. We observe preliminary blood pressure improvement favoring D-HOMES that were statistically and clinically significant. D-HOMES warrants testing in a fully powered trial which could inform future high quality behavioral trials to promote health equity.Clinical trial registrationhttps://clinicaltrials.gov/study/NCT05258630?term=D-HOMES&rank=1, identifier NCT05258630

The development and pilot testing of a behavioral activation-based treatment for depressed mood and multiple health behavior change in patients with recent acute coronary syndrome.

BackgroundPatients with acute coronary syndrome (ACS) with depressed mood demonstrate poor cardiovascular behavioral risk profiles and elevated risk for recurrent ACS and mortality. Behavioral Activation (BA) offers an intervention framework for an integrated treatment targeting both depression and critical health behaviors post-ACS. Behavioral Activation for Health and Depression (BA-HD) was developed and pilot tested in a multiphase iterative process.MethodsFirst, an initial treatment manual was conceptualized based on the team's prior work, as well as the extant literature. Second, qualitative interviews were conducted with target patients and target providers on the proposed BA-HD treatment rationale, content, and structure. Framework matrix analyses were used to summarize and aggregate responses. Third, an expert panel was convened to elicit additional manual refinements. Finally, patients with post-ACS depression and health behavior non-adherence were recruited to complete an open pilot trial to evaluate acceptability (Client Satisfaction Questionnaire [CSQ], exit interview) and treatment engagement (number of sessions attended; treatment completion was considered completion of 8 out of 10 possible sessions).ResultsThe initial BA-HD treatment manual expanded an existing treatment manual for post-ACS BA-based mood management and smoking cessation to target four health behaviors relevant to post-ACS patients (e.g., smoking cessation, medication adherence, physical activity, and diet). After the initial conceptualization, ten post-ACS patients and eight cardiac rehabilitation professionals completed qualitative interviews. Patients endorsed bi-directional interactions between mood and health behaviors post-ACS. Both patients and providers expressed general support of the proposed treatment rationale and values-guided, collaborative goal-setting approach. Patients, providers, and experts provided feedback that shaped the iterative manual development. After the BA-HD manual was finalized, eight participants were enrolled in a single-arm pilot trial. The mean CSQ score was 30.57 ± 2.23, indicating high satisfaction. Seven out of eight (88%) completed treatment. Pre- to post treatment improvements in depressed mood and health behaviors were promising.ConclusionsBA-HD treatment is an acceptable approach to target both mood and health behaviors in post-ACS patients with depression. A future larger, controlled trial is needed to evaluate the efficacy of the BA-HD treatment.Trial registrationClinicalTrials.gov Identifier: NCT04158219

Bringing Lived Experience to Research on Health and Homelessness: Perspectives of Researchers and Lived Experience Partners.

Improving health and healthcare for people experiencing homelessness (PEH) has become a national research priority. It is critical for research related to homelessness to be guided by input from PEH themselves. We are a group of researchers and individuals who have personally experienced homelessness collaborating on a study focused on homelessness and housing. In this Fresh Focus, we describe our partnership, lessons learned from our work together, what we have gained from our collaboration, and considerations for future homelessness research-lived experience partnerships

sj-docx-1-hpp-10.1177_15248399231221731 – Supplemental material for Disseminating Community-Engaged Research Involving People Experiencing Homelessness and Diabetes Using Participatory Theater

Supplemental material, sj-docx-1-hpp-10.1177_15248399231221731 for Disseminating Community-Engaged Research Involving People Experiencing Homelessness and Diabetes Using Participatory Theater by Preethiya Sekar, Maren Ward, Susan Gust, Becky R. Ford, Moncies Franco, Edward Adair, Annette Bryant, Denita Ngwu, Jonathan M. Cole, Lelis Brito, Marcia Barnes, Tahiti Robinson, Ali ‘Cia Anderson-Campbell, Joel Gray, Esther Ouray, Alphonse Carr and Katherine Diaz Vickery in Health Promotion Practice</p