Aims To test the feasibility and effectiveness of Brief Counseling Intervention (BCI) and Naltrexone integrated into tuberculosis (TB) care in Tomsk, Russia. Design Using factorial randomized controlled trial design, patients were randomized into: Naltrexone, Brief Behavioral Compliance Enhancement Therapy (BBCET), treatment as usual (TAU); BCI, TAU; Naltrexone, BBCET, BCI, TAU; TAU. Setting and Participants In the Tomsk Oblast, hospitalized TB patients diagnosed with Alcohol Use Disorders (AUDs) by the DSM-IV were referred upon the start of TB treatment. Of the 196 cohort, the mean age was 41 years and 82% were male. Severe TB (84.7% had cavitary disease), and smoking (92.9%) were common. The majority had a diagnosis of an AUD (63.0%). 27.6% reported nearly daily drinking and consumed a median of 16 standard drinks per day. Measurements Primary outcomes were “favorable” TB outcome (cured, completed treatment) and change in mean number of abstinent days in the last month of study compared with baseline. Change in mean number of heavy drinking days, defined as 4 drinks per day and 5 drinks per day for women and men respectively, and TB adherence, measured as percent of doses taken as prescribed under direct observation, were secondary outcomes. Analysis based on “intention to treat” was performed for multivariable analysis. Findings Primary TB and alcohol endpoints between naltrexone and no-naltrexone or BCI and no-BCI groups did not differ significantly. TB treatment adherence and change in number of heavy drinking days also did not differ significantly among treatment arms. Among individuals with a prior quitting attempt (n=111), naltrexone use was associated with an increased likelihood of favorable TB outcomes (92.3% versus 75.9%, P=0.02). Conclusions In Tomsk Oblast, Russia, tuberculosis patients with severe Alcohol Use Disorders who were not seeking alcohol treatment did not respond to naltrexone or behavioral counselling integrated into tuberculosis care; however, those patients with past attempts to quit drinking had improved tuberculosis outcomes.

BackgroundStrengthening Community Health Worker systems has been recognized to improve access to chronic disease prevention and management efforts in low-resource communities. The Community Outreach and Patient Empowerment (COPE) Program is a Native non-profit organization with formal partnerships with both the Navajo Nation Community Health Representative (CHR) Program and the clinical facilities serving the Navajo Nation. COPE works to better integrate CHRs into the local health care system through training, strengthening care coordination, and a standardized culturally appropriate suite of health promotion materials for CHRs to deliver to high-risk individuals in their homes.MethodsThe objective of this mixed methods, cross sectional evaluation of a longitudinal cohort study was to explore how the COPE Program has effected CHR teams over the past 6 years. COPE staff surveyed CHRs in concurrent years (2014 and 2015) about their perceptions of and experience working with COPE, including potential effects COPE may have had on communication among patients, CHRs, and hospital-based providers. COPE staff also conducted focus groups with all eight Navajo Nation CHR teams.ResultsCHRs and other stakeholders who viewed our results agree that COPE has improved clinic-community linkages, primarily through strengthened collaborations between Public Health Nurses and CHRs, and access to the Electronic Health Records. CHRs perceived that COPE’s programmatic support has strengthened their validity and reputation with providers and clients, and has enhanced their ability to positively effect health outcomes among their clients. CHRs report an improved ability to deliver health coaching to their clients. Survey results show that 80.2% of CHRs feel strongly positive that COPE trainings are useful, while 44.6% of CHRs felt that communication and teamwork had improved because of COPE.ConclusionsThese findings suggest that CHRs have experienced positive benefits from COPE through training. COPE may provide a useful programmatic model on how best to support other Community Health Workers through strengthening clinic-community linkages, standardizing competencies and training support, and structuring home-based interventions for high-risk individuals.

Background: Community Health Representatives (CHRs) overcome health disparities in Native communities by delivering home care, health education, and community health promotion. The Navajo CHR Program partners with the non-profit Community Outreach and Patient Empowerment (COPE), to provide home-based outreach to Navajo clients living with diabetes. COPE has created an intervention (COPE intervention) focusing on multiple levels of improved care including trainings for CHRs on Motivational Interviewing and providing CHRs with culturallyappropriate education materials. The objective of this research is to understand the participant perspective of the CHR-COPE collaborative outreach through exploring patient-reported outcomes (PROs) of clients who consent to receiving the COPE intervention (COPE clients) using a qualitative methods evaluation. Methods: Seven COPE clients were selected to participate in semi-structured interviews one year after finishing COPE to explore their perspective and experiences. Qualitative interviews were recorded, transcribed, and coded to identify themes. Results: Clients revealed that health education delivered by CHRs facilitated lifestyle changes by helping them understand key health indicators and setting achievable goals through the use of accessible material and encouragement. Clients felt comfortable with CHRs who respected traditional practices and made regular visits. Clients also appreciated when CHRs educated their family members, who in turn were better able to support the client in their health management. Finally, CHRs who implemented the COPE intervention helped patients who were unable to regularly see a primary care doctor for critical care and support in their disease management. Conclusion: The COPE-CHR collaboration facilitated trusting client-CHR relationships and allowed clients to better understand their diagnoses. Further investment in materials that respect traditional practices and aim to educate clients' families may foster these relationships and improve health outcomes. Trial registration: clinicaltrials.gov: NCT03326206. Registered 9/26/2017 (retrospectively registered).

BackgroundNavajo Nation Community Health Representatives (CHR) are trained community health workers (CHWs) who provide crucial services for patients and families. The success of the CHRs’ interventions depends on the interactions between the CHRs and their clients. This research investigates the culturally specific factors that build and sustain the CHR-client interaction.MethodsIn-depth interviews were conducted with 16 CHRs on Navajo Nation. Interviews were transcribed and coded according to relevant themes. Code summaries were organized into a narrative using grounded theory techniques.ResultsThe analysis revealed four findings critical to the development of a CHR-client relationship. Trust is essential to this relationship and provides a basis for providing quality services to the client. The ability to build and maintain trust is defined by tradition and culture. CHRs must be respectful of the diverse traditional and social practices. Lastly, the passing of clients brings together the CHR, the client’s family, and the community.ConclusionUnderstanding the cultural elements of the CHR-client relationship will inform the work of community partners, clinical providers, and other indigenous communities working to strengthen CHR programs and obtain positive health outcomes among marginalized communities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1956-7) contains supplementary material, which is available to authorized users.

Russian Federation’s (RF) HIV epidemic is the fastest growing of any country. This study explores factors associated with high HIV risk behavior in tuberculosis (TB) patients with alcohol use disorders in Tomsk, RF. This analysis was nested within the Integrated Management of Physician-delivered Alcohol Care for TB Patients (IMPACT, trial number NCT00675961) randomized controlled study of integrating alcohol treatment into TB treatment in Tomsk. Demographics, HIV risk behavior (defined as participant report of high-risk intravenous drug use and/or multiple sexual partners with inconsistent condom use in the last six months), clinical data, alcohol use, depression and psychosocial factors were collected from 196 participants (161 male and 35 female) at baseline. Forty-six participants (23.5%) endorsed HIV risk behavior at baseline. Incarceration history(Odds Ratio (OR)3.93, 95% confidence interval (CI) 1.95, 7.95), age under 41 (OR:2.97, CI:1.46, 6.04), drug addiction(OR: 3.60 CI:1.10, 11.77), history of a sexually transmitted disease(STD)(OR 2.00 CI:1.02, 3.90), low social capital (OR:2.81 CI:0.99, 8.03) and heavier alcohol use (OR:2.56 CI: 1.02, 6.46) were significantly more likely to be associated with HIV risk behavior at baseline. In adjusted analysis, age under 41(OR: 4.93, CI: 2.10, 11.58), incarceration history(OR: 3.56 CI:1.55, 8.17) and STD history (OR: 3.48, CI: 1.5, 8.10) continued to be significantly associated with HIV risk behavior. Understanding HIV transmission dynamics in Russia remains an urgent priority to inform strategies to address the epidemic. Larger studies addressing sex differences in risks and barriers to protective behavior are needed.

Background The Doris and Howard Hiatt Residency in Global Health Equity and Internal Medicine at Brigham and Women's Hospital provides global health training during residency, but little is known about its effect on participants' selection of a global health career. Objective We assessed the perceptions of residency graduates from the first 7 classes to better understand the outcomes of this education program, and the challenges faced by participants. Methods We interviewed 27 of 31 physicians (87%) who graduated from the program between 2003 and 2013 using a convergent mixed-methods design and a structured interview tool that included both open-ended and forced-choice questions. We independently coded and analyzed qualitative data using a case study design, and then wove together the qualitative and quantitative data at the interpretation phase using a parallel convergent mixed-methods design. Results Entering a career focused on social justice was cited as the most common motivator for selecting to train in global health. Most respondents (83%, 20 of 24) reported they were able to achieve this goal despite structural barriers, such as lower salaries compared with peers, a lack of mentors in the field, poorly structured and undersupported career pathways at their institutions, and unique work-life challenges. Conclusions A majority of graduates from 1 dedicated residency program in global health and internal medicine reported they were able to continue to engage in global health activities after graduation and, despite identified challenges, reported that they planned long-term careers in global health.

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