Using Critical Consciousness As a Framework to Empower Men with Histories of Incarceration to Improve Their Health in the Health of Their Communities

Background: In the field of SUD, health inequities are manifested as increased negative consequences of SM among minoritized populations (e.g., rates of incarceration). Evidence-based SUD treatments such as pharmacological and behavioral interventions focus exclusively on changing individual factors. These interventions ignore structural factors such as discrimination, poverty, lack of access to treatment, and cultural beliefs. In order to demonstrate the significance and impact of meso and macro level factors in behavioral change, we introduce as an example, Community Wise, a multi-level social work intervention designed to reduce SM among formerly incarcerated men in an urban community.

Methods: Following the innovations described above, our team has followed CBPR to apply CC theory to social work research and practice in the field of SUD in order to promote health equity by addressing racism, classism, and sexism at multiple levels. Therefore, CW included the following components: 1) Critical Dialogue (six weekly two-hours-long group discussions about social determinants of health and inequities); 2) Quality-of-Life-Wheel (six weekly one-hour-long group sessions about individual goal development); and 3) Capacity Building Projects (six weekly one-hour-long group sessions to develop and implement projects to solve community problems). Because we were concerned about inequities and resource distribution, we tested if the impact of facilitator type (peer versus licensed) on SM.

A sample of 602 formerly incarcerated men with a history of SUD and incarceration were enrolled in a 2x2x2x2 randomized-full-factorial-experiment designed to identify intervention components that: 1) significantly reduce substance use frequency and 2) can be delivered for less than $200 per person. Participants were randomized into one of 16 experimental conditions that consisted of all possible combinations of each component delivered separately by a peer and a licensed facilitator. All components were delivered via a closed group format.

The primary outcome was the proportion of SM in the past 30 days collected through the Timeline-Follow-Back and confirmed through saliva tests. Data was collected monthly via tablets using Redcap over five months. Intent-to-treat analysis examined the effect of each experimental component in reducing SM over time.

Results: Participants were predominantly Black (80%), unemployed (84%) and had an average age of 45 (10.5). Drugs of choice included alcohol, cannabis, cocaine, and heroin. All were males with histories of substance use disorder and incarceration. CD and CBP delivered by the peer facilitator were identified for inclusion in the optimized manual because these components produced statistically and clinically significant main and synergistic effects on SM. Specifically, those receiving both components had a reduction in SM over five months that was 73.8% larger than those who did not receive these components (Cohen’s d=-1.2, p=.005).

Conclusions and Implications: CBPR and CC theory have potential to promote health equity and address racism, classism, and sexism at multiple levels. Community Wise, for example, is a promising and optimized intervention to reduce SM among formerly incarcerated men with a history of SUD. We found that CD (micro level) and CBP (macro level) delivered by a trained peer facilitator (meso level) can be delivered for $138 per person.