DETERMINING THE FEASIBILITY AND ACCEPTABILITY OF A NOVEL STIGMA RESISTANCE TEXT MESSAGE INTERVENTION FOR PEOPLE WHO USE DRUGS

Stigma in people who use drugs (PWUD) is a risk factor for treatment engagement, psychosocial health, and overdose, yet there are few evidence-based interventions to support PWUD in managing and coping with substance-related stigma. The specific aims of this mixed-methods dissertation were to: 1) identify self-stigma patterns and risk factors in an eight-state cohort of rural-dwelling PWUD, 2) identify stigma-related attitudes and beliefs that are salient in rural contexts, 3) develop an automated text message stigma resistance intervention, 4) establish the intervention’s feasibility, acceptability, and preliminary effectiveness in rural-dwelling PWUD. In Aim 1, we used latent class analysis to establish rural self-stigma typologies (N=3048). We selected a five-class model, with four classes defined by stigma severity (“Low,” “Medium-Low,” “Medium-High,” “High”) and a fifth (“High Fearers/Low Perceivers”) exhibiting high shame and fear of enacted stigma but low perceived stigma. Members of progressively severe stigma classes were more likely to be justice-involved, inject drugs, and avoid healthcare and treatment. “High Fearers/Low Perceivers” were more likely to be younger women and less likely to inject drugs, experience homelessness, or encounter the justice system. In Aim 2, using reflexive thematic analysis of in-depth interviews with PWUD (N=22), we developed a conceptual framework of salient stigma-related attitudes, beliefs, and behaviors in the rural context. We identified manifestations (stereotypes, prejudice, discrimination), outcomes (immediate reactions, personal consequences), and responses (adaptive and maladaptive coping styles) that can be targeted in culturally responsive stigma interventions. In Aim 3, we used an iterative convergent design to develop an intervention prototype. Messages (N=56) were reviewed by content experts, piloted tested with PWUD (N=22), and mapped to stigma resistance domains, relevant health communication and/or psychotherapeutic theories, and salient stigma-related beliefs. In Aim 4, we piloted the four-week intervention (Project RESTART) with 30 PWUD. Key outcomes included strong retention (90%), acceptability (mean item score: 3.55, SD: 0.34), message engagement (median responses: 4, IQR: 1-17), and effectiveness (Cohen’s d: stigma resistance (0.56), self-stigma (0.50), self-esteem (0.49)). Results were corroborated in sub-sample follow-up interviews (n=13). Findings indicate Project RESTART is a feasible and acceptable intervention whose effectiveness should be established in a scale-up trial.