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Modelo de Intervencion Psicomedica (MIP) (Psycho-Medical Intervention Model)

Modelo de Intervencion Psicomedica (MIP) (Psycho-Medical Intervention Model) is a comprehensive, individualized, behavior change intervention for persons 18 years and older who inject drugs and are not in a drug treatment program. The goals of MIP are (1) to engage participants in entering and remaining in drug treatment, (2) to reduce participants' drug-related (e.g., sharing of needles) and sex-related (e.g., unprotected sex) behaviors that place them at high risk for the infection and transmission of HIV and viral hepatitis, and (3) to enhance participants' self-efficacy to maintain healthier behaviors and prevent relapse.

MIP, which is based on a motivational interviewing model and case management, addresses participants' goal setting, decision making, reinforcement, self-monitoring, and attitude change in regard to drug use, drug treatment, and HIV risk behaviors through two components:

Outpatient counseling, which is delivered by a counselor through six structured sessions and a booster session. Session topics are selected by the participant in any order, with the exception of the induction session and the booster session, which occur first and last, respectively. Counseling sessions focus on the participant's motivation to change, and the counselor helps the participant to develop a work plan for facilitating behavior change and improving self-efficacy. The participant also is encouraged to enter into drug treatment and receives information on strategies for preventing relapse. HIV risk reduction strategies, such as not sharing needles and safer sex negotiation, are also discussed.
Case management, which is provided by a case manager who meets with the participant after each session to review and reinforce the topic covered and to assist the participant in overcoming barriers to continued participation. The case manager also helps the participant to access drug treatment, additional primary health care, and other services (e.g., housing, social welfare, legal assistance) as needed.

Three trained staff members are needed to implement the program: a counselor with a degree in counseling or nursing, a case manager with experience working with adults who use drugs, and a supervisor with a degree in social sciences or nursing. Before implementing MIP, these staff members must participate in a 3-day, face-to-face training of facilitators, which includes information on motivational interviewing techniques and case management.

In the study reviewed for this summary, MIP was implemented with Puerto Rican adults ages 18-65.

Descriptive Information

Areas of Interest	Substance abuse treatment
Outcomes	Review Date: May 2012 1: Entry into drug treatment 2: Injection drug use 3: Needle sharing 4: Drug treatment dropout
Outcome Categories	Drugs Treatment/recovery
Ages	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	Hispanic or Latino
Settings	Outpatient
Geographic Locations	Rural and/or frontier
Implementation History	MIP was first implemented in Puerto Rico in 1998 and was evaluated from 1998 to 2001 by the Universidad Central del Caribe, Escuela de Medicina (School of Medicine), through funding by the National Institute on Drug Abuse. In 2008, the program was diffused to nine agencies funded by the Centers for Disease Control and Prevention (CDC) in Connecticut, Florida, Kansas, New Jersey, New York, and Pennsylvania.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: No
Adaptations	No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Review Date: May 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Marrero, C. A., Robles, R. R., Colon, H. M., Reyes, J. C., Matos, T. D., Sahai, H., et al. (2005). Factors associated with drug treatment dropout among injection drug users in Puerto Rico. Addictive Behaviors, 30(2), 397-402.

Robles, R. R., Reyes, J. C., Colon, H. M., Sahai, H., Marrero, C. A., Matos, T. D., et al. (2004). Effects of combined counseling and case management to reduce HIV risk behaviors among Hispanic drug injectors in Puerto Rico: A randomized controlled study. Journal of Substance Abuse Treatment, 27(2), 145-152.

Supplementary Materials

McHorney, C. A., Ware, J. E., Jr., & Raczek, A. E. (1993). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care, 31(3), 247-263.

McLellan, A. T., Alterman, A. I., Cacciola, J., Metzger, D., & O'Brien, C. P. (1992). A new measure of substance abuse treatment. Initial studies of the Treatment Services Review. Journal of Nervous and Mental Disease, 180(2), 101-110.

McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., et al. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9(3), 199-213.

Needle, R., Fisher, D. G., Weatherby, N., Chitwood, D., Brown, B., Cesari, H., et al. (1995). The reliability of self-reported HIV risk behaviors of drug users. Psychology of Addictive Behaviors, 9(4), 242-250.

Robles, R. R., Colon, H. M., Sahai, H., Matos, T. D., Marrero, C. A., & Reyes, J. C. (1992). Behavioral risk factors and human immunodeficiency virus (HIV) prevalence among intravenous drug users in Puerto Rico. American Journal of Epidemiology, 135(5), 531-540.

Outcomes

Outcome 1: Entry into drug treatment
Description of Measures	Entry into drug treatment was assessed with revised, culturally adapted versions of the Risk Behavior Assessment (RBA) and Risk Behavior Follow-Up Assessment (RBFA). The RBA and RBFA are 30- to 45-minute structured interviews that measure drug use, drug treatment history, and other factors associated with the risk of HIV transmission. The RBA was administered at baseline, and the RBFA was administered 6 months after baseline.
Key Findings	A 6-month study was conducted with Puerto Rican adults who used injection drugs but were not receiving drug treatment at the time of entry into the study. Each participant received two one-on-one counseling sessions. The first session provided each participant with information on HIV/AIDS, safe needle use and safe sex, and HIV testing; if the participant consented, he or she was tested for HIV. The second counseling session reviewed HIV-related information from the first session and provided referrals for drug treatment and, if needed, health care for those who tested positive for HIV. Participants were then randomly assigned to the control group, which received condoms and needle hygiene materials from outreach workers over the 6-month study period, or the intervention group, which received MIP. At the 6-month assessment, participants in the intervention group were nearly twice as likely as those in the control group to enter drug treatment (odds ratio = 1.95; 95% confidence interval = 1.27-2.99), after controlling for gender, age, frequency of injection, and previous drug treatment history.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.6 (0.0-4.0 scale)

Outcome 2: Injection drug use
Description of Measures	Injection drug use was assessed with revised, culturally adapted versions of the Risk Behavior Assessment (RBA) and the Risk Behavior Follow-Up Assessment (RBFA). The RBA and RBFA are 30- to 45-minute structured interviews that measure drug use, drug treatment history, and other factors associated with the risk of HIV transmission. The RBA was administered at baseline, and the RBFA was administered 6 months after baseline.
Key Findings	A 6-month study was conducted with Puerto Rican adults who used injection drugs but were not receiving drug treatment at the time of entry into the study. Each participant received two one-on-one counseling sessions. The first session provided each participant with information on HIV/AIDS, safe needle use and safe sex, and HIV testing; if the participant consented, he or she was tested for HIV. The second counseling session reviewed HIV-related information from the first session and provided referrals for drug treatment and, if needed, health care for those who tested positive for HIV. Participants were then randomly assigned to the control group, which received condoms and needle hygiene materials from outreach workers over the 6-month study period, or the intervention group, which received MIP. At the 6-month assessment, participants in the intervention group were less likely than those in the control group to continue injection drug use (odds ratio = 0.60; 95% confidence interval = 0.36-0.99), independent of entering drug treatment and after controlling for gender, age, frequency of injection, and previous drug treatment history.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 3: Needle sharing
Description of Measures	Needle sharing was assessed with revised, culturally adapted versions of the Risk Behavior Assessment (RBA) and Risk Behavior Follow-Up Assessment (RBFA). The RBA and RBFA are 30- to 45-minute structured interviews that measure drug use, drug treatment history, and other factors associated with the risk of HIV transmission. The RBA was administered at baseline, and the RBFA was administered 6 months after baseline.
Key Findings	A 6-month study was conducted with Puerto Rican adults who used injection drugs but were not receiving drug treatment at the time of entry into the study. Each participant received two one-on-one counseling sessions. The first session provided each participant with information on HIV/AIDS, safe needle use and safe sex, and HIV testing; if the participant consented, he or she was tested for HIV. The second counseling session reviewed HIV-related information from the first session and provided referrals for drug treatment and, if needed, health care for those who tested positive for HIV. Participants were then randomly assigned to the control group, which received condoms and needle hygiene materials from outreach workers over the 6-month study period, or the intervention group, which received MIP. Of the participants who continued to use injection drugs at the 6-month assessment, those in the intervention group were less than half as likely as those in the control group to share needles (odds ratio = 0.41; 95% confidence interval = 0.16-0.98), after controlling for gender, age, frequency of injection, and previous drug treatment history.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.6 (0.0-4.0 scale)

Outcome 4: Drug treatment dropout
Description of Measures	Drug treatment dropout was assessed with items from the 25-item Treatment Services Review, which was administered to participants to obtain a profile of drug treatment program utilization and services. Participants who indicated that they withdrew from treatment before completing all recommended sessions were categorized as dropping out of drug treatment. Assessments were administered at baseline and 6 months after baseline.
Key Findings	A 6-month study was conducted with Puerto Rican adults who used injection drugs but were not receiving drug treatment at the time of entry into the study. Each participant received two one-on-one counseling sessions. The first session provided each participant with information on HIV/AIDS, safe needle use and safe sex, and HIV testing; if the participant consented, he or she was tested for HIV. The second counseling session reviewed HIV-related information from the first session and provided referrals for drug treatment and, if needed, health care for those who tested positive for HIV. Participants were then randomly assigned to the control group, which received condoms and needle hygiene materials from outreach workers over the 6-month study period, or the intervention group, which received MIP. Findings from the 6-month assessment indicated that of the participants who entered drug treatment, those in the intervention group were less likely than those in the control group to drop out of drug treatment (odds ratio = 0.26; 95% confidence interval = 0.08-0.89; p = .03), after controlling for gender, age, frequency of injection, psychological factors, and receipt of additional care (including medical and psychiatric services).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	89.4% Male 10.6% Female	100% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Entry into drug treatment	2.0	3.9	1.8	2.3	2.5	3.5	2.6
2: Injection drug use	3.4	2.9	1.8	2.3	2.5	3.5	2.7
3: Needle sharing	3.1	2.6	1.8	2.3	2.5	3.5	2.6
4: Drug treatment dropout	2.0	3.8	1.8	3.5	3.0	2.3	2.7

Study Strengths

The study used well-established measures with good psychometric properties for injection drug use risk practices. Attrition was low considering the nature of the sample, and there was a lack of differential attrition between intervention and control groups. Logistic regression models controlled for many sociodemographic and risk behavior confounding variables (e.g., frequency of injection, previous drug treatment history). Data analyses were generally appropriate.

Study Weaknesses

The reliability of data on drug treatment entry and dropout was not clearly established. Intervention fidelity was supported by the use of a curriculum, but only a narrative was provided to describe efforts to ensure fidelity and the protocol for handling therapist drift. Missing data were not addressed statistically, and there was no comparison between participants who completed the 6-month assessment and those who were lost at the 6-month follow-up. Not all confounding variables were addressed, including HIV status and years of drug injection, and greater attention was given to the intervention group, which may have enhanced participants' access to drug treatment.

Readiness for Dissemination

Review Date: May 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Mock file:

Assessment and Staging Form
Behavior Change Self-Assessment Form
Behavioral Risk Assessment
Consent Form
Decisional Balance Form
Form 3A: Drug Treatment History & Experience Guide and Action Plan
Form 4A: Guide for Analysis of Recent Drug Relapse and Action Plan
Form 4B: Guide for Analysis of Recent Sexual Risk and Action Plan
Form 5A: Injection Drug Orientation Guide and Action Plan
Form 6: Sexual Behavior Orientation Guide and Action Plan
Form 7B: Booster Development Guide
Health History Guide and Action Plan
Intake Form
Medical Examination Guide
Progress Notes
Referral

Posters:

Cleaning Works! How To Clean a Used Syringe
Determinants of Risk Addressed by MIP
Goals of MIP
Key Characteristics of MIP
The Core Elements of MIP
The Fundamental Principals of Motivational Interviewing

PROCEED, Inc., Centers for Disease Control and Prevention, & Universidad Central del Caribe. (2011). Modelo de Intervencion Psicomedica (Psycho-Medical Intervention Model, MIP): Implementation manual. Elizabeth, NJ: Author.

Program page on CDC's Diffusion of Effective Behavioral Interventions project Web site, http://www.effectiveinterventions.org/en/HighImpactPrevention/Interventions/MIP.aspx

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.8	3.5	3.5	3.6

Dissemination Strengths

Program materials are well organized and extremely thorough. An implementation manual provides preimplementation guidance, including budgeting information, a timeline for implementation, a readiness assessment, and a discussion of program benefits and potential challenges. Implementation of the intervention is supported by a detailed, step-by-step description of each module. The materials stress the importance of cultural competence, community relations, and participant engagement. The training of facilitators balances didactic instruction with discussion and role-play exercises for participants. In addition, a facilitator workbook reinforces the material covered during training with written guidelines and copies of all client handouts and forms. The program materials place a strong emphasis on the need to maintain fidelity through highly structured sessions. Forms and recommendations are provided for monitoring the implementation process and the participant's change in behavior.

Dissemination Weaknesses

Little guidance is provided on how an agency accesses a complete package of materials and obtains training and ongoing technical assistance if it is not a CDC grantee. Although information regarding process and outcome monitoring is thorough, only limited guidance on conducting a more complete outcome evaluation is available for agencies that are not CDC grantees.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
MIP Intervention Package (includes implementation manual, workbook, PowerPoint slides, mock file, poster, and quality assurance documents)	Included with the MIP Training of Facilitators	Yes
3-day, off-site MIP Training of Facilitators by CDC Capacity Building Assistance (CBA) provider or program developers	Free for up to 20 participants from eligible organizations $5,600 for up to 20 participants from ineligible organizations	Yes
Refresher MIP Training of Facilitators Webinar	Included with the MIP Training of Facilitators	Yes
3-day, on- or off-site MIP Training of Trainers by CDC CBA provider or program developers (includes training manual with posters)	$6,900 for up to 10 participants, plus travel expenses if necessary	No
Refresher MIP Training of Trainers Webinar	Included with the MIP Training of Trainers	No
On-site technical assistance from CDC CBA providers or program developers	Free for eligible organizations, plus travel expenses $500 per half day for ineligible organizations, plus travel expenses	Yes
Phone- or email-based technical assistance from CDC CBA providers or program developers	Free for eligible organizations $150 per hour for ineligible organizations	Yes

Additional Information

Eligible organizations are organizations providing HIV/AIDS prevention or treatment services that are directly funded by CDC, organizations providing HIV/AIDS prevention or treatment services that are indirectly funded by a State or local health department, or stakeholder organizations providing HIV/AIDS prevention or treatment services that are funded through private sources.

Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation, contact:
Jonny F. Andía, M.S., Ph.D.
(404) 639-4956
jonny.andia@cdc.hhs.gov

To learn more about research, contact:
Omar Pérez-Del-Pilar, Ph.D.
(787) 798-3001 ext 2400
omar.perez@uccaribe.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.