Background People experiencing homelessness are at increased risk of COVID-19, but little is known about specific risk factors for infection within homeless shelters. Methods We performed widespread SARS-CoV-2 PCR testing and collected risk factor information at all homeless shelters in Chicago with at least one reported case of COVID-19 (n=21). Multivariable, mixed-effects log-binomial models were built to estimate adjusted prevalence ratios (aPRs) for SARS-CoV-2 infection for both individual and facility-level risk factors. Results During March 1 to May 1, 2020, 1717 shelter residents and staff were tested for SARS-CoV-2; 472 (27%) persons tested positive. Prevalence of infection was higher for residents (431/1435, 30%) than for staff (41/282, 15%) (prevalence ratio [PR] =2.52, 95% CI 1.78–3.58). The majority of residents with SARS-CoV-2 infection (293/406 with available information about symptoms, 72%) reported no symptoms at the time of specimen collection or within the following two weeks.Among residents, sharing a room with a large number of people was associated with increased likelihood of infection (aPR for sharing with >20 people compared to single rooms = 1.76, 95% CI 1.11–2.80), and current smoking was associated with reduced likelihood of infection (aPR=0.71, 95% CI 0.60–0.85). At the facility-level, a higher proportion of residents leaving and returning each day was associated with increased prevalence (aPR=1.08, 95% CI 1.01–1.16), while an increase in the number of private bathrooms was associated with reduced prevalence (aPR for one additional private bathroom per 100 people = 0.92, 95% CI 0.87–0.98). Conclusions We identified a high prevalence of SARS-CoV-2 infections in homeless shelters. Reducing the number of residents sharing dormitories might reduce the likelihood of SARS-CoV-2 infection. When community transmission is high, limiting movement of persons experiencing homelessness into and out of shelters might also be beneficial.

Solving the opioid crisis requires immediate, innovative, and sustainable solutions. A number of promising strategies are being carried out by U.S. states and territories as part of their Opioid State Targeted Response (STR) plans funded through the 21st Century Cures Act, and they provide an opportunity for researchers to assess effectiveness of these interventions using pragmatic approaches. This paper describes a pilot study of Project Planned Outreach, Intervention, Naloxone, and Treatment (POINT), the intervention that served as the basis for Indiana's STR-funded, emergency department (ED)-based peer specialist expansion that was conducted in preparation for a larger, multisite pragmatic trial. Through the pilot, we identified, documented, and corrected for challenges encountered while implementing planned study protocols. Per the project's funding mechanism, the ability to move to the larger trial was determined by the achievement of 3 milestones: (1) successful replication of the intervention; (2) demonstrated ability to obtain the necessary sample size; and (3) observe a higher level of engagement in medication for addiction treatment in the POINT group compared to standard care. Overall implementation of the study protocols was successful, with only minor refinements to proposed procedures being required in light of challenges with (1) data access, (2) recruitment, and (3) identification of the expansion hospitals. All three milestones were reached. Challenges in implementing protocols and reaching milestones resulted in refinements that improved the study design overall. The subsequent trial will add to the limited but growing evidence on ED-based peer supports. Capitalizing on STR efforts to study an already scaling and promising intervention is likely to lead to faster and more sustainable results with greater generalizability than traditional, efficacy-focused clinical research.

Background: Implementation science’s focus on establishing implementation strategy effectiveness has overshadowed the need to understand differential performance of such strategies under various conditions. Methods allowing for assessment between implementation context and process can help address this gap. This article provides a detailed description of a mixed method procedure for assessing factors related to the implementation context and process intersection, which was developed as part of the pilot study of the Housing First Technical Assistance and Training (HFTAT) program, a multifaceted strategy designed to support Housing First model implementation. Methods: The HFTAT was pilot tested among a sample of three organizations. Our mixed method approach combines two tools often used in implementation research—the Stages of Implementation Completion (SIC) and the Consolidated Framework for Implementation Research—in a novel way. Several stages to analysis were completed, starting with a separate analysis of data pertaining to each measure and then two levels of mixed method analysis. Results: The approach provided a better understanding of the issues that impacted the implementation guided by the HFTAT, suggesting (1) individual determinants seemed to have a bigger impact based on the number of SIC phases they affected, (2) implementation context and process were connected through climate-related factors in the inner setting that made the sites more or less responsive to addressing identified barriers, and (3) there is a need to better assess context factors to identify areas where implementation drivers should be better targeted to facilitate change, and this is supported by prior research. Conclusions: Understanding the underlying factors impacting a setting’s performance related to a specific implementation strategy has potential to improve decision-making and optimize future implementation efforts. The approach likely be as successful combining the SIC with other determinant frameworks and should be utilized at the onset of an implementation project to maximize its usefulness. Plain language summary The field of implementation science needs better approaches for understanding how context (i.e., constraints and opportunities in the implementation setting) and process (i.e., the actions and steps taken during implementation) interact over the course of implementation. Such information would be very useful for understanding the success or failure of specific implementation strategies, which are specific techniques used to increase the adoption, implementation, and sustainability of a specific intervention. This article explains a method to assess the intersection of implementation context and implementation process that we developed to better understand issues that could help explain the effectiveness of an implementation strategy for an intervention for housing people who are experiencing chronic homelessness and who have both a diagnosed substance use disorder and serious mental illness. The method combines two popular implementation tools, the Stages of Implementation Completion and the Consolidated Framework for Implementation Research. Using this method resulted in a better understanding of differences in implementation performance at each of the organizations and how we might improve the implementation strategy. This understanding was better than what we had learned from other approaches we had used before this. We provide some suggestions for how the method can be strengthened for use in other studies.

Background Justice-involved youth are especially vulnerable to mental health distress, substance misuse, and risky sexual activity, amplifying the need for evidence-based programs (EBPs). Yet, uptake of EBPs in the justice system is challenging because staff training is costly in time and effort. Hence, justice-involved youth experience increasing health disparities despite the availability of EBPs. Objective To counter these challenges, this study develops and pilot-tests a prototype of a technology-based training tool that teaches juvenile justice staff to deliver a uniquely tailored EBP for justice-involved youth—PHAT (Preventing HIV/AIDS Among Teens) Life. PHAT Life is a comprehensive sex education, mental health, and substance use EBP collaboratively designed and tested with guidance from key stakeholders and community members. The training tool addresses implementation barriers that impede uptake and sustainment of EBPs, including staff training and support and implementation costs. Methods Staff (n=11) from two juvenile justice settings pilot-tested the technology-based training tool, which included five modules. Participants completed measures of HIV and sexually transmitted infection (STI) knowledge, sex education confidence, and implementation outcomes such as training satisfaction, adoption, implementation, acceptability, appropriateness, and sustainability. PHAT Life trainers assessed fidelity through two activity role plays participants submitted upon completing the training modules. Results Participants demonstrated increases in HIV and STI knowledge (t10=3.07; P=.01), and were very satisfied (mean 4.42, SD 0.36) with the training tool and the PHAT Life curriculum. They believed that the training tool and curriculum could be adopted, implemented, and sustained within their settings as an appropriate and acceptable intervention and training. Conclusions Overall, the results from this pilot test demonstrate feasibility and support continuing efforts toward completing the training tool and evaluating it within a fully powered randomized controlled trial. Ultimately, this study will provide a scalable option for disseminating an EBP and offers a more cost-effective and sustainable way to train staff in an EBP.

Justice-Involved youth may experience unique sexual and mental health risks related to both their gender and sexual orientation. Although previous research has revealed important gender and sexual orientation differences in the sexual and mental health of Justice-Involved youth, no study has yet examined gender and sexual orientation differences simultaneously within the same sample. The present study addressed this gap in a sample of 347 probation-involved youth, 13–17 years old, recruited as part of a randomized controlled trial of PHAT Life, an HIV/STI, mental health, and substance use prevention program. On the one hand, female and non-heterosexual youth were less likely than male and heterosexual youth to report having ever had sex and to be considered high sexual risk. On the other hand, female youth were more likely than male youth to test positive for STIs and to report certain mental health problems, but non-heterosexual youth showed no difference from heterosexual youth. Finally, female non-heterosexual youth were more likely to report externalizing problems than youth of other gender and sexual orientation combinations. Findings highlight the need for prevention and intervention efforts that specifically target Justice-involved youth who identify as female, non-heterosexual, or both.