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1.  Enhancing screening, brief intervention, and referral to treatment among socioeconomically disadvantaged patients: study protocol for a knowledge exchange intervention involving patients and physicians 
Background
Screening, Brief Intervention, and Referral for Treatment (SBIRT) is an effective approach for managing alcohol and other drug misuse in primary care; however, uptake into routine care has been limited. Uptake of SBIRT by healthcare providers may be particularly problematic for disadvantaged populations exhibiting alcohol and other drug problems, and requires creative approaches to enhance patient engagement. This knowledge translation project developed and evaluated a group of patient and health care provider resources designed to enhance the capacity of health care providers to use SBIRT and improve patient engagement with health care.
Methods/Design
A nonrandomized, two-group, pre-post, quasi-experimental intervention design was used, with baseline, 6-, and 12-month follow-ups. Low income patients using alcohol and other drugs and who sought care in family medicine and emergency medicine settings in Edmonton, Canada, along with physicians providing care in these settings, were recruited. Patients and physicians were allocated to the intervention or control condition by geographic location of care. Intervention patients received a health care navigation booklet developed by inner city community members and also had access to an experienced community member for consultation on health service navigation. Intervention physicians had access to online educational modules, accompanying presentations, point of care resources, addiction medicine champions, and orientations to the inner city. Resource development was informed by a literature review, needs assessment, and iterative consultation with an advisory board and other content experts. Participants completed baseline and follow-up questionnaires (6 months for patients, 6 and 12 months for physicians) and administrative health service data were also retrieved for consenting patients. Control participants were provided access to all resources after follow-up data collection was completed. The primary outcome measure was patient satisfaction with care; secondary outcome measures included alcohol and drug use, health care and addiction treatment use, uptake of SBIRT strategies, and physician attitudes about addiction.
Discussion
Effective knowledge translation requires careful consideration of the intended knowledge recipient’s context and needs. Knowledge translation in disadvantaged settings may be optimized by using a community-based participatory approach to resource development that takes into account relevant patient engagement issues.
Trial registration
Northern Alberta Clinical Trials and Research Centre #30094
doi:10.1186/1472-6963-13-108
PMCID: PMC3610268  PMID: 23517813
Addiction; Screening; Brief intervention; Family medicine; Emergency medicine; Underserved patients; Patient engagement
2.  Ultra-Brief Intervention for Problem Drinkers: Results from a Randomized Controlled Trial 
PLoS ONE  2012;7(10):e48003.
Background
There are a number of evidence-based, in-person clinical inteventions for problem drinkers, but most problem drinkers will never seek such treatments. Reaching the population of non-treatment seeking problem drinkers will require a different approach. Accordingly, this randomized clinical trial evaluated an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as an indicated public health intervention (i.e., targeting the population of non-treatment seeking problem drinkers).
Methodology/Principal Findings
Problem drinkers (N = 1767) completed a baseline population telephone survey and then were randomized to one of three conditions – a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions were sent their respective interventions by postal mail addressed to ‘Check Your Drinking.’ Changes in drinking were assessed post intervention at three-month and six-month follow-ups. The follow-up rate was 86% at three-months and 76% at six-months. There was a small effect (p = .04) in one of three outcome variables (reduction in AUDIT-C, a composite measure of quantity and frequency of drinking) observed for the personalized feedback pamphlet compared to the no intervention control. No significant differences (p>.05) between groups were observed for the other two outcome variables – number of drinks consumed in the past seven days and highest number of drinks on one occasion.
Conclusions/Significance
Based on the results of this study, we tentatively conclude that a brief intervention, modified to an ultra-brief, public health format can have a meaningful impact.
Trial Registration
ClinicalTrials.gov NCT00688584.
doi:10.1371/journal.pone.0048003
PMCID: PMC3480504  PMID: 23110157
3.  Who uses online interventions for problem drinkers? 
The goal of this research was to understand why some people use online interventions for drinking problems while others with comparable access to the interventions do not. As part of a randomized controlled trial, 92 participants in the experimental condition were provided access to a password protected version of a web-based personalized feedback intervention (the Check Your Drinking screener; CYD; www.CheckYourDrinking.net). Information collected at baseline was compared between those who accessed the website and those who did not. Those who accessed the website tended to be more frequent users of the Internet, to drink less, and to perceive that others of the same age and sex drank less as compared to those who did not access the intervention. Some of these results are troubling as the preferred target of this type of intervention would be those who drink more and perceive that others are also heavy alcohol consumers.
doi:10.1016/j.jsat.2011.03.003
PMCID: PMC3166539  PMID: 21632197
Alcohol; Internet; brief intervention; adherence
4.  Normative Misperceptions about Alcohol Use in a General Population Sample of Problem Drinkers from a Large Metropolitan City 
Aims: Heavy drinkers tend to overestimate how much others drink (normative fallacy), at least in college samples. Little research has been conducted to evaluate whether normative misperceptions about drinking extend beyond the college population. The present study explored normative misperceptions in an adult general population sample of drinkers. Methods: As part of a larger study, in Toronto, Canada, a random digit dialling telephone survey was conducted with 14,009 participants who drank alcohol at least once per month. Respondents with Alcohol Use Disorders Identification Test of eight or more (n = 2757) were asked to estimate what percent of Canadians of their same sex: (a) drank more than they do; (b) were abstinent and (c) drank seven or more drinks per week. Respondents' estimates of these population drinking norms were then compared with the actual levels of alcohol consumption in the Canadian population. Results: A substantial level of normative misperception was observed for estimates of levels of drinking in the general population. Estimates of the proportion of Canadians who were abstinent were fairly accurate. There was some evidence of a positive relationship between the respondents' own drinking severity and the extent of normative misperceptions. Little evidence was found of a relationship between degree of normative misperceptions and age. Conclusion: Normative misperceptions have been successfully targeted in social norms media campaigns as well as in personalized feedback interventions for problem drinkers. The present research solidifies the empirical bases for extending these interventions more widely into the general population.
doi:10.1093/alcalc/agr125
PMCID: PMC3243438  PMID: 22028458
5.  Barriers to accessing highly active antiretroviral therapy by HIV-positive women attending an antenatal clinic in a regional hospital in western Uganda 
Background
The aim of this study was to describe barriers to accessing and accepting highly active antiretroviral therapy (HAART) by HIV-positive mothers in the Ugandan Kabarole District's Programme for the Prevention of Mother to Child Transmission-Plus (PMTCT-Plus).
Methods
Our study was a qualitative descriptive exploratory study using thematic analysis. Individual in-depth interviews (n = 45) were conducted with randomly selected HIV-positive mothers who attended this programme, and who: (a) never enrolled in HAART (n = 17); (b) enrolled but did not come back to receive HAART (n = 2); (c) defaulted/interrupted HAART (n = 14); and (d) are currently adhering to HAART (n = 12). A focus group was also conducted to verify the results from the interviews.
Results
Results indicated that economic concerns, particularly transport costs from residences to the clinics, represented the greatest barrier to accessing treatment. In addition, HIV-related stigma and non-disclosure of HIV status to clients' sexual partners, long waiting times at the clinic and suboptimal provider-patient interactions at the hospital emerged as significant barriers.
Conclusions
These barriers to antiretroviral treatment of pregnant and post-natal women need to be addressed in order to improve HAART uptake and adherence for this group of the population. This would improve their survival and, at the same time, drastically reduce HIV transmission from mother to child.
doi:10.1186/1758-2652-13-37
PMCID: PMC2954932  PMID: 20863399
6.  Twelve-Month Follow-up Results from a Randomized Controlled Trial of a Brief Personalized Feedback Intervention for Problem Drinkers 
Aims: To examine the impact of a web-based personalized feedback intervention, the Check Your Drinking (CYD; www.CheckYourDrinking.net) screener at 12-month follow-up.
Methods: Respondents (N = 185) were recruited from a general population telephone survey of Ontario, Canadian adults (≥18 years) by asking risky drinkers if they were willing to help develop and evaluate Internet-based interventions for drinkers. Those randomly assigned to the intervention condition were provided with the web address and a unique password to a study-specific copy of the CYD. Respondents assigned to the control condition were sent a written description of the different components of the CYD and asked how useful they thought each of the components might be. Respondents were followed up at 3, 6 and 12 months.
Results: By the 12-month follow-up, the impact of the intervention previously reported at 3 and 6 months of CYD on problem drinkers’ alcohol consumption was no longer apparent (P > 0.05).
Conclusions: Recognizing that many people with alcohol concerns will never seek treatment, recent years have seen an increase in efforts to find ways to take treatment to problem drinkers. The CYD is one such intervention that has a demonstrated effect on reducing alcohol consumption in the short term (i.e. 6 months). Other more intensive Internet-based interventions or interventions via other modalities may enhance this positive outcome over the short and long term among problem drinkers who would be otherwise unlikely to access treatment for their alcohol concerns.
www.ClinicalTrials.gov registration #NCT00367575.
doi:10.1093/alcalc/agq009
PMCID: PMC2857148  PMID: 20150170
7.  A randomized controlled trial of an Internet-based intervention for alcohol abusers 
Addiction (Abingdon, England)  2009;104(12):2023-2032.
Objective
Misuse of alcohol imposes a major public health cost, yet few problem drinkers are willing to access in-person services for alcohol abuse. The development of brief, easily accessible ways to help problem drinkers who are unwilling or unable to seek traditional treatment services could therefore have significant public health benefit. The objective of this project is to conduct a randomized controlled evaluation of the Internet-based Check Your Drinking (CYD) screener (www.CheckYourDrinking.net).
Method
Participants (N = 185) recruited through a general telephone population survey were randomly assigned to receive access to the CYD, or to a no intervention control group.
Results
Follow-up rates were excellent (92%). Problem drinkers provided access to the CYD displayed a six to seven drinks reduction in their weekly alcohol consumption (a 30% reduction in typical weekly drinking) at both the three-and six-month follow-ups as compared to a one drink per week reduction among control group respondents.
Conclusions
The CYD is one of a growing number of Internet-based interventions with research evidence supporting its efficacy to reduce alcohol consumption. The Internet could increase the range of help seeking options available because it takes treatment to the problem drinker rather than making the problem drinker come to treatment.
doi:10.1111/j.1360-0443.2009.02726.x
PMCID: PMC2779998  PMID: 19922569
8.  Risk factors for methamphetamine use in youth: a systematic review 
BMC Pediatrics  2008;8:48.
Background
Methamphetamine (MA) is a potent stimulant that is readily available. Its effects are similar to cocaine, but the drug has a profile associated with increased acute and chronic toxicities. The objective of this systematic review was to identify and synthesize literature on risk factors that are associated with MA use among youth.
More than 40 electronic databases, websites, and key journals/meeting abstracts were searched. We included studies that compared children and adolescents (≤ 18 years) who used MA to those who did not. One reviewer extracted the data and a second checked for completeness and accuracy. For discrete risk factors, odds ratios (OR) were calculated and when appropriate, a pooled OR with 95% confidence intervals (95% CI) was calculated. For continuous risk factors, mean difference and 95% CI were calculated and when appropriate, a weighted mean difference (WMD) and 95% CI was calculated. Results were presented separately by comparison group: low-risk (no previous drug abuse) and high-risk children (reported previous drug abuse or were recruited from a juvenile detention center).
Results
Twelve studies were included. Among low-risk youth, factors associated with MA use were: history of heroin/opiate use (OR = 29.3; 95% CI: 9.8–87.8), family history of drug use (OR = 4.7; 95% CI: 2.8–7.9), risky sexual behavior (OR = 2.79; 95% CI: 2.25, 3.46) and some psychiatric disorders. History of alcohol use and smoking were also significantly associated with MA use. Among high-risk youth, factors associated with MA use were: family history of crime (OR = 2.0; 95% CI: 1.2–3.3), family history of drug use (OR = 4.7; 95% CI: 2.8–7.9), family history of alcohol abuse (OR = 3.2; 95% CI: 1.8–5.6), and psychiatric treatment (OR = 6.8; 95% CI: 3.6–12.9). Female sex was also significantly associated with MA use.
Conclusion
Among low-risk youth, a history of engaging in a variety of risky behaviors was significantly associated with MA use. A history of a psychiatric disorder was a risk factor for MA for both low- and high-risk youth. Family environment was also associated with MA use. Many of the included studies were cross-sectional making it difficult to assess causation. Future research should utilize prospective study designs so that temporal relationships between risk factors and MA use can be established.
doi:10.1186/1471-2431-8-48
PMCID: PMC2588572  PMID: 18957076
9.  Ultra-brief intervention for problem drinkers: research protocol 
BMC Public Health  2008;8:298.
Background
Helping the large number of problem drinkers who will never seek treatment is a challenging issue. Public health initiatives employing educational materials or mass media campaigns have met with mixed success. However, clinical research has developed effective brief interventions to help problem drinkers. This project will employ an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as a public health intervention. The major objective of this study is to conduct a randomized controlled trial to establish the effectiveness of an ultra-brief, personalized feedback intervention for problem drinkers.
Methods/design
Problem drinkers recruited on a baseline population telephone survey conducted in a major metropolitan city in Canada will be randomized to one of three conditions – a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions will be sent their respective pamphlets. Changes in drinking will be assessed post intervention at three-month and six-month follow-ups. Drinking outcomes will be compared between experimental conditions using Structural Equation Modeling. The primary hypothesis is that problem drinkers from households who receive the personalized feedback pamphlet intervention will display significantly improved drinking outcomes at three and six-month follow-ups as compared to problem drinkers from households in the no intervention control condition. Secondary hypotheses will test the impact of the intervention on help seeking, and explore the mediating or moderating role of perceived drinking norms, perceived alcohol risks and the problem drinker's social reasons for drinking.
Discussion
This trial will provide information on the effectiveness of a pamphlet-based personalized feedback intervention for problem drinkers in a community setting.
Trial registration
ClinicalTrials.gov registration #NCT00688584.
doi:10.1186/1471-2458-8-298
PMCID: PMC2528012  PMID: 18727823
10.  Socio-economic status and types of childhood injury in Alberta: a population based study 
BMC Pediatrics  2006;6:30.
Background
Childhood injury is the leading cause of mortality, morbidity and permanent disability in children in the developed world. This research examines relationships between socio-economic status (SES), demographics, and types of childhood injury in the province of Alberta, Canada.
Methods
Secondary analysis was performed using administrative health care data provided by Alberta Health and Wellness on all children, aged 0 to 17 years, who had injuries treated by a physician, either in a physician's office, outpatient department, emergency room and/or as a hospital inpatient, between April 1st. 1995 to March 31st. 1996. Thirteen types of childhood injury were assessed with respect to age, gender and urban/rural location using ICD9 codes, and were related to SES as determined by an individual level SES indicator, the payment status of the Alberta provincial health insurance plan. The relationships between gender, SES, rural/urban status and injury type were determined using logistic regression.
Results
Twenty-four percent of Alberta children had an injury treated by physician during the one year period. Peak injury rates occurred about ages 2 and 13–17 years. All injury types except poisoning were more common in males. Injuries were more frequent in urban Alberta and in urban children with lower SES (receiving health care premium assistance). Among the four most common types of injury (78.6% of the total), superficial wounds and open wounds were more common among children with lower SES, while fractures and dislocations/sprains/strains were more common among children receiving no premium assistance.
Conclusion
These results show that childhood injury in Alberta is a major health concern especially among males, children living in urban centres, and those living on welfare or have Treaty status. Most types of injury were more frequent in children of lower SES. Analysis of the three types of the healthcare premium subsidy allowed a more comprehensive picture of childhood injury with children whose families are on welfare and those of Treaty status presenting more frequently for an injury-related physician's consultation than other children. This report also demonstrates that administrative health care data can be usefully employed to describe injury patterns in children.
doi:10.1186/1471-2431-6-30
PMCID: PMC1687186  PMID: 17094808
11.  Illicit opioid use in Canada: Comparing social, health, and drug use characteristics of untreated users in five cities (OPICAN study) 
Most of the estimated 125,000 injection drug users (IDUs) in Canada use illicit opioids and are outside treatment (i.e., methadone maintenance treatment). Empirical data suggest that illicit opioid users outside treatment are characterized by various health and social problem characteristics, including polydrug use, physical and mental morbidity, social marginalization, and crime. Although required for evidence-based programming, systematic information on this specific substance-user population is sparse in Canada to date. This article presents and compares key characteristics of population of illicit opioid users outside treatment in five cities across Canada (OPICAN cohort). Overall, the majority of OPICAN participants regularly used both a variety of illicit opioids and cocaine or crack, reported physical and mental health (e.g., mood disorder) problems, lacked permanent housing, were involved in crime, and had their “ideal” treatment not available to them. However, key local sample differences were shown, including patterns of heroin versus prescription opioid use and levels of additional cocaine versus crack use as well as indicators of social marginalization. Illicit opioid user population across Canada differ on key social, health, and drug use indicators that are crucial for interventions and are often demonstrated between larger and smaller city sites. Differentiated interventions are required.
doi:10.1093/jurban/jti049
PMCID: PMC3456573  PMID: 15872194
Canada; Comorbidity; Dependence; Health; Heroin use; Illicit opioid use; Infectious disease; Methadone treatment; Polydrug use; Treatment
12.  Understanding why adolescents decide to visit family physicians 
Canadian Family Physician  2005;51(12):1661.
OBJECTIVE
To understand why Canadian adolescents go or do not go to see family physicians for annual checkups using the Theory of Planned Behavior as a conceptual framework.
DESIGN
Qualitative analysis of small group discussions.
SETTING
Edmonton, Alta, a large Canadian city.
PARTICIPANTS
Seventeen adolescents (6 male, 11 female) recruited from a medical clinic and an organized youth group.
METHOD
Two small group discussions and one validation focus group were held. A combination of category coding and thematic analysis was used to analyze the data transcribed.
MAIN FINDINGS
Adolescents reported that regular checkups, although uncomfortable, are a good idea. They also reported that going to a family doctor for a checkup is out of their control because of numerous barriers (eg, lack of time, not knowing how to set it up, or lack of transportation). Participants thought their parents’ opinions on going for routine checkups were more important than the opinions of their peers.
CONCLUSION
Family physicians should recognize adolescents’ attitudes toward visiting family physicians’ offices and understand the potential barriers adolescents face in coming in for checkups in order to make visits to their offices more comfortable and beneficial.
PMCID: PMC1479494  PMID: 16926945
13.  Determinants of overdose incidents among illicit opioid users in 5 Canadian cities 
Background
Drug overdose is a major cause of death and illness among illicit drug users. Previous research has indicated that most illicit drug users experience nonfatal overdoses and has suggested a variety of factors that are associated with risk of overdose. In this study, we examined the occurrence of and the factors associated with nonfatal overdoses within a Canadian sample of illicit opioid users not enrolled in treatment at the time of study recruitment.
Methods
Interviewers used a standard questionnaire to collect data on sociodemographic characteristics, drug use, health and health care, experience in the criminal justice system and treatment for drug problems; they also performed standard assessments for mental health and infectious disease. The association between overdose and sociodemographic and drug-use factors was examined with χ2 and t test analyses; marginally significant variables were examined with logistic regression to determine independent effects.
Results
A total of 679 subjects were interviewed; 651 provided answers sufficient for this analysis. One hundred and twelve (17.2%) of the 651 respondents reported an overdose episode in the previous 6 months. In the logistic regression analysis (after adjustment for sociodemographic factors), homelessness, noninjection use of hydromorphone in the past 30 days and involvement in drug treatment in the past 12 months were predictors of overdose (p < 0.05).
Interpretation
Overdose poses a considerable health risk for illicit opioid users. We found that a diverse set of factors was associated with overdose episodes. Prevention efforts will likely be more effective if they can be directed to specific causal factors.
doi:10.1503/cmaj.1031416
PMCID: PMC490072  PMID: 15289420
14.  A randomized controlled trial of an internet-based intervention for alcohol abusers 
Addiction (Abingdon, England)  2009;104(12):2023-2032.
Objective
Misuse of alcohol imposes a major public health cost, yet few problem drinkers are willing to access in-person services for alcohol abuse. The development of brief, easily accessible ways to help problem drinkers who are unwilling or unable to seek traditional treatment services could therefore have significant public health benefit. The objective of this project is to conduct a randomized controlled evaluation of the internet-based Check Your Drinking (CYD) screener (http://www.CheckYourDrinking.net).
Method
Participants (n = 185) recruited through a general telephone population survey were assigned randomly to receive access to the CYD, or to a no-intervention control group.
Results
Follow-up rates were excellent (92%). Problem drinkers provided access to the CYD displayed a six to seven drinks reduction in their weekly alcohol consumption (a 30% reduction in typical weekly drinking) at both the 3- and 6-month follow-ups compared to a one drink per week reduction among control group respondents.
Conclusions
The CYD is one of a growing number of internet-based interventions with research evidence supporting its efficacy to reduce alcohol consumption. The internet could increase the range of help-seeking options available because it takes treatment to the problem drinker rather than making the problem drinker come to treatment.
doi:10.1111/j.1360-0443.2009.02726.x
PMCID: PMC2779998  PMID: 19922569
Alcohol; brief intervention; internet; problem drinking; randomized controlled trial

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