Community Treatment Research Articles

Barriers and facilitators to implement Assertive Community Treatment (ACT) in Japan: a qualitative study protocol using Consolidated Framework for Implementation Research (CFIR)

IntroductionAssertive Community Treatment (ACT), which was developed in the 1970s in the USA, is a programme that supports people with severe mental illness living in the community through a multidisciplinary...

Compulsory treatment at home: an interview study exploring the experiences of an early group of patients, relatives and mental-health workers

BackgroundWhen introduced in 2020, the Netherlands’ Compulsory Mental Healthcare Act included provisions for compulsory community treatment (CCT) and compulsory treatment in patients’ homes (CTH). Although CCT has been incorporated into mental health care in many countries, its effectiveness is debated. We know of no other countries in which CTH has been adopted.The aim of this study is to evaluate how an early group of participants experienced CTH. They were drawn from three stakeholder groups: patients, relatives and mental-health workers.MethodsIn total, 17 open interviews were conducted with six patients, five relatives and six mental-health workers. All had experience with CTH. Thematic analysis was used to analyze the interviews.ResultsFive themes were identified: 1). Reasons for applying for a court order with options for CTH. The reasons included preventing harm, avoiding hospitalization, and providing a safety net. 2.) Participants’ experiences with CTH in practice. The four most noteworthy experiences were related to the process of applying for a court order; compulsory home visits and the compulsory use of medication; the involvement of relatives during treatment; and the influence of CTH on the relationship between patients and relatives. 3.) The advantages and disadvantages of CTH. The most important advantages were avoiding hospitalization; improving medication adherence; facilitating easy access to care; early signaling of deterioration; early intervention; and regained autonomy. The most important disadvantages were restricted autonomy; fewer options for monitoring compared to hospitalization; and problems regarding control of patient behavior. 4.) Participants’ preferences. All preferred CTH to hospitalization. 5.) Participants’ suggestions for improving CTH. These included the need not only to provide patients with better information, but also to improve the involvement of relatives during treatment.ConclusionThe interviewees found that CTH might help to avoid hospitalization by providing stakeholders with more options for arranging effective care at home. Although this suggests that initial experiences of CTH under the new Dutch mental health law were positive, it is still uncertain whether CTH as currently implemented really differs from CCT.

The Epidemiological, Entomological and Socio-Economic Evaluation of Ivermectin Treatment in Imo River Basin, Nigeria

To assess the effectiveness of annual mass ivermectin treatment over 20 years in achieving elimination of onchocerciasis, we conducted a cross-sectional study between May 2021 and March 2022. A total of 540 individuals aged 5 years and above from rural farming communities selected were skin-snipped for dermal microfilariae (mf) by standard technique. Prospection of Simulium black flies was done at Lolo and Ibii Rivers. Structured questionnaires were used for the level of awareness, attitude and perceptions (KAP): onchocerciasis, vectors, treatment, drug compliance, benefits and socio-economy. Results revealed an overall mf prevalence of 12.8% and black fly infection rate (0.7%), infectivity and transmission potentials of (0.0%) indicative of non-transmission. These values contrasted with earlier reports in the range of 22%-68% for mf and 20.2%-48.2% infective rates suggesting the efficacy of mass ivermectin treatment in halting onchocerciasis. Participants had a high level of awareness about drug distribution. Benefits, dislikes and challenges of ivermectin were reported. We concluded that annual mass ivermectin treatment creditably reduced the microfilarial load and treatment in the study communities.

Synthesis, Characterization and Biological Studies of Gemifloxacin Mesylate with Nickel(II) and Copper(II)

Gemifloxacin mesylate, a fourth-generation fluoroquinolone-type antibiotic, is widely used for community treatment of acquired pneumonia and severe bacterial infections. The Cu(II) and Ni(II) complexes of gemifloxacin mesylate were synthesized by refluxing an aqueous solution of the ligand with the required amount of metal(II) salts in a round bottom flask with 2:1 (L:M) ratio in an oil bath at 90 ºC with a continuous stirring for 4 h. The mixture was kept overnight to obtain a coloured solid complex. The synthesized metal(II) complexes were characterized by physico-chemical parameters and spectral analyses, including UV-Vis, FT-IR and 1H NMR. The structures of the complexes were further confirmed by elemental (CHNS) and TG-DTA analyses. The spectral findings revealed that metal-ligand interaction has successfully occurred where the ligand acted as a bidentate chelate in the synthesized metal(II) complexes. The IR studies showed that upon complexation the characteristic carboxylic stretching frequency at 1714 cm-1 disappeared and the pyridone stretching frequency shifted to a lower frequency region. The 1H NMR data of the complexes confirm the effective interaction between the metal and the ligand via 3-carboxyl group and 4-oxo groups. The thermal and elemental analyses data were also in agreement with the proposed interaction. The ligand as well as its metal(II) complexes showed significant activity against all the studied 11 bacterial strains and one of the fungal strains, Candida sp.

Sintered Clays: Application in the Removal of Arsenic from Water by Filter Beds

Objectives: The main objective of the research was to build a ceramic filter bed, using red clay and diatomite, for the removal of arsenic in aqueous media and to propose an environmentally friendly and low-cost technique for rural communities in Peru that consume water contaminated with arsenic. Theoretical framework: Arsenic is a common contaminant in the drinking water of many rural communities in Peru, exceeding the limits allowed by the WHO. Prolonged exposure to arsenic can cause serious health problems. The use of low-cost non-metallic materials, such as thermally activated clay and diatomite, is proposed for its adsorption. Method: A filter bed composed of 5 cm layers of red clay and diatomite with particle sizes of 0.81, 0.31 and 0.20 mm was used. Both materials were thermally activated at 900°C and placed on a stainless steel support. The arsenic removal process was evaluated by passing a synthetic solution with 13.99 ppm of arsenic through the bed. Material characterization analyses were performed before and after the adsorption process, using techniques such as ICP-OES, SEM, FTIR, among others. Results and discussion: The filter bed composed of diatomite (83.31% SiO2) and red clay (8.23% Fe2O3) achieved an arsenic removal of up to 99.99%, highlighting the efficiency of particles with a size of 0.20 mm. This shows that the combination of these materials can be highly effective in removing arsenic in water, which is promising for its implementation in rural areas. Research implications: This research has important implications for water treatment in rural communities facing arsenic contamination problems. The technique developed is low-cost and uses abundant resources, which facilitates its application at the local level and promotes sustainable solutions for access to safe drinking water. Originality/Value: The research provides a novel approach through the use of red clay and diatomite, accessible resources, thermally activated for the removal of arsenic in water. In addition, the high removal effectiveness achieved provides a potentially scalable and replicable solution in other rural communities with similar problems.

Retraction Note: Development and evaluation of rapid data-enabled access to routine clinical information to enhance early recruitment to the national clinical platform trial of COVID-19 community treatments

This article has been retracted. Please see the Retraction Notice for more detail: https://doi.org/10.1186/s13063-021-05965-4.

Clinical outcomes and outcome predictors of two-year assertive community treatment in Norway: an explorative prospective pre–post study

BackgroundAssertive Community Treatment (ACT) teams have become a part of mental health services for people with severe mental illness in many high-income countries. Studies in several countries have investigated the outcomes of ACT, and knowledge is also needed about outcomes of ACT teams in Norway. Our aims were to study clinical outcomes of ACT, how the outcomes were associated with characteristics of patients and treatment, and whether they differed across ACT teams.MethodsOur explorative, prospective, pre–post multicenter study involved 142 patients who received ACT for two years from the first 12 ACT teams established in urban and rural areas of Norway. There was no control group. The primary outcome was change in clinician-rated psychiatric symptoms. Secondary outcomes were clinician-rated change in functioning and engagement and change in community tenure compared with 2 years prior to ACT. We measured fidelity to the ACT model using the Tool for Measurement of Assertive Community Treatment. We performed linear mixed-effects modeling to analyze outcomes and their associations with characteristics of patients and treatment.ResultsAfter two years, psychiatric symptoms were significantly reduced with a small effect size. Negative symptoms, anxiety and depression, and agitation and mania had significant reductions, while positive symptoms had nonsignificant changes. Functioning, engagement, and community tenure all significantly increased with small effect sizes. Age, difficulty to engage, problematic use of alcohol, frequent previous use of inpatient services, total number of sessions, and team’s fidelity to the ACT model were associated with different groups of symptoms. Less improvement in functioning was associated with team fidelity and number of sessions. Change in engagement was not associated with any predictors. Increased community tenure was greater for younger patients and patients who were on community treatment orders at treatment start.ConclusionsACT for two years led to significant positive outcomes with small effect sizes for psychiatric symptoms, functioning, engagement, and community tenure. The outcomes were associated with some potential predictors, and some team-level variance emerged. Positive significant outcomes after two years indicate that larger improvements may be achieved from longer-term treatments by ACT teams.

‘It’s like someone is holding your hand, an invisible hand’: A grounded theory study of participation and personal recovery in Flexible Assertive Community Treatment

Background Participation in everyday life and personal recovery is often adversely affected for individuals with complex mental health needs. Flexible Assertive Community Treatment (FACT) is a recovery-oriented service targeting participation in everyday life and personal recovery and is thus important to understand from the perspectives of service users. Aim To explore how service users experience the care and support they receive from FACT as facilitating processes of participation in everyday life and in their personal recovery process. Materials and Methods A constructivist Grounded Theory approach was employed, involving 14 in-depth interviews conducted from January to November 2023 with FACT service users (9 women, 5 men; 23-55 years) within the Swedish adult general Mental Health Services. Results The process of Building genuine relationships between participants and FACT team members enabled Doing as a way of recovering. This was facilitated by how FACT was organised, promoting continuity and flexibility in care and support. Conclusions and significance This study contributes to a greater understanding of how genuine relationships between FACT service users and team members provide opportunities for participation and doing as a means for personal recovery. The results underscore the significance of incorporating an occupational therapy perspective into recovery-oriented services.

Modulation of gut microbiome in response to the combination of Escherichia coli Nissle 1917 and sugars: a pilot study using host-free system reflecting impact on interpersonal microbiome.

The differential effects of probiotic, prebiotic, and synbiotic formulations on human health are dictated by the inter-individual gut microbial profile. The effects of probiotics such as Escherichia coli Nissle 1917 (ECN) on gut microbiota may vary according to the microbiome profiles of individuals and may be influenced by the presence of certain carbohydrates, which can impact microbial community structure and treatment results. Processed fecal samples from donors having contrasting lifestyles, dietary patterns, and disease histories were mixed with 5 × 106 CFU/mL ECN with or without 1% (w/v) sugars (glucose, galactose, or rice starch) in a host-free system. Post-incubation, 16 s rRNA sequencing was performed. Microbial diversity and taxonomic abundance were computed in relation to the probiotic, prebiotic, and synbiotic treatment effects and interpersonal microbiome variance. Baseline gut microbial profiles showed significant inter-individual variations. ECN treatment alone had a limited impact on the inter-personal gut microbial diversity and abundance. Prebiotics caused a substantial enrichment in Actinobacteria, but there were differences in the responses at the order and genus levels, with enrichment shown in Bifidobacterium, Collinsella, and Megasphaera. Subject B exhibited enrichment in Proteobacteria and Cyanobacteria, but subject A showed more diversified taxonomic alterations as a consequence of the synbiotic treatments. Despite negligible difference in the α-diversity, probiotic, prebiotic, and synbiotic treatments independently resulted in distinct segregation in microbial communities at the β-diversity level. The core microbiota was altered only under prebiotic and synbiotic treatment. Significant correlations primarily for minor phyla were identified under prebiotic and synbiotic treatment. The interindividual microbiome composition strongly influences the effectiveness of personalized diet and treatment plans. The responsiveness to dietary strategies varies according to individual microbiome profiles influenced by health, diet, and lifestyle. Therefore, tailored approaches that consider individual microbiome compositions are crucial for maximizing gut health and treatment results.

Preference of Tooth Extraction Over Root Canal Treatment among Patients Visiting Rural Health Centers—a Cross-Sectional Study

Abstract Background Dental care decision-making is a multifaceted process influenced by various factors such as socioeconomic status, cultural beliefs, and access to healthcare resources. The research aims to elucidate the prevalence and determinants of the preference for tooth extraction over root canal treatment (RCT) in rural communities. Methodology A structured self-administered questionnaire comprising 15 close-ended questions was formulated for the purpose of data collection for this cross-sectional survey and a sample size of 384 was estimated. Following a total enumeration sampling technique, the study was performed on individuals visiting the rural center aged over 18 years and persons who are willing to participate in the study. The data were analyzed using descriptive statistics and subjected to multinomial logistic regression. Results Among the participants, 33.1% had undergone RCT in the past and 63.5% had undergone extraction in the past with decay being the most common reason for seeking treatment. About 60.2% individuals preferred extraction and only 39.8% individuals preferred RCT wherein age, gender, and area of residence had a significant influence on the decision-making. Conclusion Majority of the participants in the study preferred extraction over RCT. Understanding the dynamics driving patient preferences in rural health settings is crucial for tailoring effective oral health interventions. The findings of this study have implications for healthcare practitioners, policymakers, and public health initiatives, providing valuable insights to enhance dental care delivery and promote informed decision-making in rural communities.

Impact of flexible assertive community treatment model (FACT) on community rehabilitation of schizophrenia in Southern China.

Schizophrenia is a group of severe mental illnesses of unknown etiology, most of which are slow or subacute in young adults. 160 adult schizophrenic patients were randomly divided into an intervention group given FACT and a control group given routine mental health follow-up. The scale includes the Positive and Negative Syndrome Scale (PANSS), Social Disability Screening Schedule Scale (SDSS), and the World Health Organization's multicultural quality of life instrument in its brief form Scale(WHOQOL-BREF) were recorded. The average scores of positive scale, negative scale, general psychopathology scale and total score in PANSS scale before intervention(baseline) of the patients in the intervention group were 24.90 ± 5.43, 17.53 ± 3.84, 38.31 ± 4.09 and 80.54 ± 6.75. After 6 months and 12 months of intervention, positive scale, negative scale, general psychopathology scale and total score of the PANSS scale in the intervention group and the total score of SDSS all decreased significantly. The WHOQOL-BREF total score was significantly improved, and the differences were statistically significant (P < 0.05). The FACT intervention model has a significant effect on the rehabilitation of patients with schizophrenia in the community, improves their social function, and improves their quality of life.

Nurse-Led Physical Screening of Patients With Substance Use Disorders: A Cross-Sectional Study.

Somatic comorbidity is the main cause of reduced life expectancy in patients with substance use disorders (SUDs). This study aims to investigate somatic health challenges in patients with SUDs using the USS. Patient self-management of somatic health and quality of life were also assessed. In our study, a stratified random sample of 136 clients who received treatment at a specialist addiction facility was drawn to investigate their physical health and lifestyle behaviours using the Utrecht Somatic Screening 2.0 (USS 2.0). The sample included three subgroups, that is, patients receiving outpatient treatment through Flexible Assertive Community Treatment (FACT), Heroin-Assisted Treatment (HAT) and Opioid Replacement Therapy (ORT). Pain, self-management and quality of life were also measured. Descriptive statistics were used to analyse the data. The findings indicate that many patients experience a large number of somatic health problems, including pain and exhaustion. The most prevalent conditions in this study are cardiovascular disease (25%) and COPD (20%), underweight and poor oral health. Tobacco smoking is prevalent among 88% of patients. Fifty percent of the patients expressed a need for support in managing their physical health. Somatic health care and lifestyle promotion should be tailored to the specific characteristics of patients. Patients with SUDs suffer from poor physical health and show unhealthy lifestyle behaviours, which demand the promotion of tailored somatic health.

Cochrane meta-analysis fuels invalid skepticism about compulsory community treatment effectiveness

BackgroundQuantitative research on non-randomized-samples, focused on statute-mandated-outcomes, has found positive results favoring compulsory-community-treatment (CCT) in jurisdictions fully supporting its implementation. In contrast, three randomized-studies “failed-to-find” a difference between randomly-assigned-CCT and control-groups–each study repeatedly summarized in revisions of a Cochrane-meta-analysis reporting this failure. Considering the potential health and safety threats to people with severe-mental-illness and those with whom they interact, there is a critical need for this investigation to resolve these conflicting results. MethodUsing data and procedural-descriptions from the involved-studies, this validity-focused-analysis addressed six questions. Two external-validity focused-questions addressing generalizability of study findings: 1. Did the Cochrane-meta-analysis select studies focused on the CCT-target population? 2. Assuming valid population focus did the Cochrane meta-analysis enroll individuals from among this population fitting the CCT criteria? Four internal-validity-questions: 1. Did the study-designs address the intervention's purpose? 2. Were the outcome-criteria used in the selected-studies valid-indicators of the intervention's intended-outcomes? 3. Were the studies reviewed in the Cochrane-meta-analysis, controlled-trials? And 4. Were the prescribed-Cochrane-Database-statistical-procedures appropriate for evaluating the reviewed-randomized-trials? ResultsFocused on completing randomized-investigations, two outpatient-commitment and one CTO-study failed to validly represent the CCT-population, failed to enroll qualifying-subjects, conflated their primary outcome-measure with a required-intervention-procedure, failed to control for post-randomization experiences directly related to their primary-outcome-measure, and conflated the study conditions. Two trials continuously misrepresented themselves as “randomized-controlled-trials”. All relied on univariate-contrasts in evaluating their outcomes, while without post-randomization-control the studies required multivariate-controls for contrasting the outcomes of their intervention-groups. The Cochrane-review, while listing the short-comings of these studies, placing an over-emphasis on prescriptive-methodology, without addressing study substantive-validity, has yielded spurious-conclusions suborning an invalid political-narrative regarding CCT-effectiveness. ConclusionsThe “failure-to-find” results from the Cochrane-reviewed-studies can be attributed to research shortcomings rather than intervention-ineffectiveness. The Cochrane-review has promoted undue controversy and skepticism re the use of CCT, a potentially lifesaving-procedure.

The Different Faces of Religion in Therapy: An Exploratory Qualitative Study of a Religion-Based Therapeutic Community for Addiction Recovery in Israel.

This article examines the impact of the integration of religion and psychological treatment in a religion-based therapeutic community for persons in recovery from addiction in Israel. Based on an exploratory qualitative study that includes participant observation in a Jewish forgiveness therapy training course and in-depth interviews with counselors working in the community, we identify three themes that characterize the therapeutic process. First, religion emerges as a challenge in therapy, one that should be addressed with sensitivity. Second, religion can be turned into a spiritual and cultural resource in the recovery process, with a cautious and sensitive approach. Third, religion can offer a remedial experience, without necessarily involving an intensification of faith. We offer principles that can help guide decisions regarding the integration of religion into therapy, with a focus on addiction treatment oriented to clients with a religious background.

Telemedicine-Related Opioid Use Disorder Services in Underserved Populations: A Qualitative Evaluation of the Waiver Era.

Introduction: This pilot study examined access to telemedicine-related opioid use disorder (OUD) treatment in underserved communities in Houston, Texas before July 30, 2023. Methods: Participants, both patients and providers, were recruited in partnership with local substance use treatment clinics. Both groups shared experiences before and after the waiver era. Rapid qualitative analysis was conducted by the research team. Results: Fourteen qualitative interviews were conducted via Zoom with 5 treatment providers and 9 self-identified Black or Hispanic patient participants. Participants generally approved telemedicine for OUD treatment due to its technological accessibility and flexibility. However, concerns about technology, care quality, relationship building, and privacy were common among both patients and providers. Discussion: Our study highlights the underutilization of telemedicine for OUD treatment in underserved Houston communities. Efforts to address current limitations and leverage recent policy changes can help bridge the utilization gap in underserved areas.

Development and feasibility testing of a time-restricted eating intervention for women living with overweight/obesity and HIV in a resource-limited setting of South Africa

BackgroundHuman Immunodeficiency Virus (HIV) and type 2 diabetes (T2D) are amongst the leading causes of death in South Africa. The preferred first-line anti-retroviral treatment contains dolutegravir (DTG), shown to increase body weight, may compound the already high rates of obesity and associated risk for T2D. South Africa has widespread food insecurity, making traditional dietary strategies difficult to implement. Time-restricted eating (TRE) may be an appropriate intervention in resource-limited communities.MethodsThis article outlines the development and feasibility testing of a TRE intervention to inform the design of a TRE randomised controlled trial in women (20–45 years old) living with overweight/obesity and HIV, receiving DTG-based treatment from a resource-limited community in Cape Town, South Africa. Factors influencing TRE adoption were identified using the Capability, Opportunity, Motivation – Behaviour model and the Theoretical Domains Framework, combining in-depth interviews (IDIs) and focus group discussions. Participants from the IDIs went on to participate in a single arm 4-week TRE pilot trial where feasibility was explored in terms of reach, acceptability, applicability, and implementation integrity. An iterative, thematic analysis approach was employed to analyse the qualitative data.ResultsParticipants included 33 isiXhosa-speaking women (mean age 37.1 years, mean BMI 35.9 kg/m2). Thematic analysis identified psychological capability (knowledge of fasting), social influences (cultural preferences, family support), and reflective motivation (awareness of weight, health impact, motivation for TRE) as key factors influencing adoption of TRE for weight management. In a 4-week TRE pilot trial (n = 12), retention was 100%. Positive outcomes perceived included improved energy, appetite control and weight loss. TRE was perceived as acceptable, easy, and enjoyable. Family support facilitated adherence, while habitual and social eating and drinking practices were barriers. Compliance was high, aided by self-selected eating times, reminders, and weekly calls. Recommendations included the incorporation of dietary education sessions and text messages to provide additional support and reminders.ConclusionsThis study indicates that TRE is a feasible weight management strategy in women living with overweight/obesity and HIV, receiving DTG-based treatment in a resource-limited community. These findings will ensure that the forthcoming TRE randomised controlled trial is adapted and optimised to the local South African context.

Change in care needs of people with severe mental illness with and without a non-Western migration background: are their needs equally served throughout treatment?

People with a non-Western migration background living in Western countries are more likely to experience psychiatric problems and have more severe symptoms when they do. Patients of non-Western origin also have more unmet needs for care. This study focuses on differences between Western and non-Western patients in care needs being met during the course of mental health treatment. The care needs of 1099 patients, 39% with and 61% without a non-Western migration background, recorded between 2017 and 2020 in Flexible Assertive Community Treatment, were compared. Non-Western migrants more often received psychotic disorder diagnoses, had more socio-economic problems, met, unmet and total needs for care and experienced less reduction in unmet needs during treatment. This was specifically the case for the rehabilitation areas: daily activities, treatment information, basic education, paid work and meaningful life and recovery. After controlling for socio-economic factors and diagnosis, group differences in change in number of unmet needs were no longer significant. However, the reduction in unmet needs in the areas of basic education, paid work and meaningful life and recovery remained significantly smaller for non-Western patients. Except for the rehabilitation domains of basic education, paidwork and meaningful life, the disadvantages in resolving the care needs of patients with a non-Western migration background do not remain significant after taking into account socioeconomic factors and diagnosis. Collaboration of mental health care and the social domain is warranted to improve socio-economic factors for patients with a non-Western migration background, to better address their unmet needs for care.

Early Health Impacts of a Primary Care Consultation Model for People Served by Assertive Community Treatment teams.

The cardiometabolic health outcomes and life expectancy of people living with serious mental illness (SMI) continue to significantly flag behind that of the general population. This study explores the possibility of using the evidence-based Assertive Community Treatment (ACT) model and infrastructure to increase access to primary care and improve cardiometabolic outcomes of people with SMI. Four ACT teams in a large urban area received the services of a primary care consultant who was co-located at a Federally Qualified Health Center (FQHC), met regularly with ACT team clinicians to review a cardiometabolic registry of participants, and engaged participants in primary care services. Health screening rates, primary care utilization, and cardiometabolic outcomes-body mass index, blood pressure, hemoglobin A1c, cholesterol, and tobacco smoking status-were monitored over the course of a year. The efficacy of this integrated care model was also explored through focus groups with ACT team staff and participants. Significant improvements in screening rates were found for the ACT teams that received this integrated care intervention; however, only modest improvements in cardiometabolic outcomes were found. Future longitudinal, multi-site studies are needed to fully determine the impact of integrated care models on the physical health outcomes of this vulnerable population.

Training community members to deliver an intervention for substance use disorder: Overcoming implementation barriers in American Indian communities

IntroductionAlthough American Indian and Alaska Native (AI/AN) people have high rates of abstinence from alcohol and other drugs, there also is evidence of greater rates of substance use disorders (SUDs) in Native communities. Health disparities associated with substance use are compounded by inadequate access to evidence-based treatments (EBTs). Lack of mental health providers is one notable barrier to EBT implementation in rural AI reservation communities. Our Indigenous Recovery Planning (IRP) intervention merges cultural lessons and culturally adapted relapse prevention strategies to facilitate SUD recovery in the reservation environment. One key implementation strategy is training non-specialist community-based facilitators to deliver IRP, thereby increasing its acceptability and sustainability. This manuscript reports the facilitator training, supervision, and fidelity monitoring procedures used in our ongoing clinical trial of IRP. MethodThe study recruited four AI non-specialist providers from the community to serve as IRP facilitators. Initial training involved an introductory motivational interviewing workshop followed by a 2-day workshop in the IRP curriculum. Then we conducted an open trial of the 6-week intervention with weekly supervision meetings as part of the facilitator training process. During the open trial we also assessed participant and facilitator receptivity to the IRP intervention and pilot tested our fidelity monitoring protocol. ResultsThe initial training workshops provided facilitators with information they needed to understand the rationale behind IRP and determine whether the facilitator role was a good fit; however, additional training and supervision during the open trial was needed to ensure proper treatment delivery. Although participant and facilitator feedback ratings were positive, the open trial helped us identify revisions needed to improve our approach to facilitator training, supervision, and fidelity monitoring. We revised these procedures, and also developed a protocol to train new facilitators who join the study midstream. ConclusionThe open trial was an important aspect of the facilitator training process and helped our team identify several areas of improvement. Our approach to training, supervising, and monitoring community member facilitators may serve as an example of how to overcome one barrier to implementing evidence-based SUD treatments in rural reservation communities with few mental health professionals.

Simultaneous removal of groundwater manganese and ammonia nitrogen based on high-flux gravity driven ceramic membrane (HF-GDCM) coupled with aerated fluidized birnessite

High concentrations of manganese ion (Mn2+) and ammonia nitrogen (NH3-N) in groundwater are indicative of a critical environmental issue that necessitates immediate attention. The gravity-driven ceramic membrane (GDCM) technology has shown great potential for groundwater treatment in rural communities, owing to its low energy demand and user-friendly operation. Active manganese oxide (MnOx) is extensively used for the concurrent removal of Mn2+ and NH3-N, leveraging its large specific surface area and abundant adsorption sites. Our research group has developed a GDCM-MnOx coupled system to address this challenge. However, membrane fouling, manifested as a reduction in flux or an increase in transmembrane pressure, has been a significant barrier to its widespread adoption. To address this challenge, we have implemented a continuous aeration system in conjunction with GDCM to fluidize birnessite to achieve the higher membrane flux, which has also proven effective in mitigating fouling while maintaining high water purification performance. Over a period of 100 days or more, the high membrane flux in the high-flux GDCM system (HF-GDCM) enhanced with aerated fluidized birnessite has been consistently maintained at approximately 34 L/(m2·h) at a water head of 1 m. Moreover, the HF-GDCM system efficiently removed manganese and NH3-N from groundwater under a hydraulic retention time (HRT) of less than 2.5 h, while also improving membrane permeability. The involvement of manganese oxidizing bacteria (MnOB) and ammonium-oxidizing bacteria (AOB) of Hypomicrobium and Nocardioides in the removal processes within the HF-GDCM system was confirmed. Additionally, XPS analysis confirmed the predominant oxidation state of MnOx to be Mn(III). The MnOx, deposited on powdered activated carbon (PAC) particles in a flower-like configuration, progressively formed a birnessite-like functional layer as the manganese ion content increased over time. Consequently, the HF-GDCM coupled with aerated fluidized birnessite is deemed suitable for water purification in small-scale rural or reservoir settings.