Share of Adult Suicides After Recent Jail Release.

Importance: Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown. Objective: To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts. Design, Setting, and Participants: This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024. Main Outcomes and Measures: The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated. Results: Included in the analysis were 2019 estimates for 7 091 897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays. Conclusions and Relevance: This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.

Analysis of implementation processes in a hybrid effectiveness-implementation trial of interpersonal psychotherapy (IPT) for major depressive disorder in prisons: Training, supervision, and recommendations.

BACKGROUND: There are 10 million admissions to U.S. prisons and jails each year. More than half of those admitted have mental health problems. The goal of this article is to inform: (1) implementation of evidence-based mental health treatments in prisons and jails, an important effort that needs more evidence to guide it; (2) psychotherapy and interpersonal psychotherapy (IPT) training efforts, especially in low-resource settings. METHODS: A randomized hybrid effectiveness-implementation trial of group IPT for major depressive disorder (MDD) in state prisons found that IPT increased rates of MDD remission and lowered posttraumatic stress disorder symptoms relative to prison treatment as usual. The trial used prison counselors, only some of whom had prior psychotherapy training/experience, to deliver IPT. IPT treatment adherence was high (96%), but trial training and supervision were too costly to be scalable outside the trial. The current article reports results from a planned qualitative analysis of 460 structured implementation and supervision documents in that trial to describe training and supervision processes and lessons learned, inform training recommendations, and facilitate future work to optimize training and supervision for under-resourced settings. RESULTS: Themes identified in implementation and supervision process notes reflected: work on psychotherapy basics (reflective listening, focusing on emotions, open-ended questions, specific experiences), IPT case conceptualization (forming a conceptualization, what is and is not therapeutic work, structure and limit setting, structure vs. flexibility), IPT techniques (enhancing social support, role plays, communication analysis), psychotherapy processes (alliance repair, managing group processes), and managing difficult situations (avoidance, specific clients, challenging work settings). Counselors were receptive to feedback; some relied on study supervisors for support in managing stressful prison working conditions. CONCLUSIONS: Findings can be used to make future training and supervision more efficient. Based on our results, we recommend that initial and refresher training focus on IPT case conceptualization, steps for addressing each IPT problem area, and reflective listening. We also recommend supervision through at least counselors' first two rounds of groups. More low-cost, scalable training methods are needed to get mental health treatment to individuals who need it most, who are often served in challenging, low-resource settings such as prisons. This is a mental health access and equity issue. TRIAL REGISTRATION: The trial was registered at clinicaltrials.gov (NCT01685294).

Severe Maternal Morbidity Disparities Before and During the COVID Pandemic in a Medicaid Population.

This study assessed racial and ethnic disparities in severe maternal mortality during delivery through 6 weeks postpartum, before and during the COVID pandemic, in a statewide Medicaid population. This retrospective, population-based, cohort study used Medicaid claims data linked to birth certificates from the Michigan Department of Health and Human Services Health Services Data Warehouse that included all individuals giving birth between January 1, 2017, and October 31, 2021, in Michigan who had Medicaid insurance during the month of childbirth. The SMM rate increased more during the COVID pandemic for Black (1.36 [1.26-1.46]) compared to White individuals (1.17 [1.09-1.26], p-value<0.01 Black vs White). The Black-White and Hispanic-White disparities in severe maternal morbidity, already high in the Medicaid population, widened during the COVID pandemic. Multilevel interventions are needed to reduce disparities in maternal morbidity and mortality. Conflict of interest disclosure: No conflicts to disclose.

Study protocol: Exploring the use of Family Health Histories in the African American community to reduce health disparities in Flint, Michigan.

Background: Health disparities are costly and preventable differences in disease progression that disproportionately affect minority communities such as African Americans. Practices to reduce health disparities can be rooted in prevention, particularly through screening tools. Family Health History tools are preventative screening mechanisms meant to explore family history to better understand how an individual's health can potentially be predicted or impacted. These tools are underutilized in the African American community. Contributions to this underutilization include a lack of cultural tailoring in the tools, a lack of health literacy in community members, and a lack of effective health communication. The Family Health History Study will create a culturally appropriate Family Health History toolkit to increase family health history utilization and ultimately decrease health disparities. Methods: The proposed sample will be composed of 195 African American adults ages 18 + who live in Genesee County, Michigan. The study consists of two phases: the development phase and the randomized pilot study phase. The goal of the development phase (n = 95) is to explore how Family Health History toolkits can be modified to better serve the African American community using a community based participatory research approach and to create a culturally tailored family health history toolkit. In the pilot study phase, 100 participants will be randomized to the culturally tailored toolkit or the current standard Family Health History toolkit. Outcomes will include feasibility and acceptability of the intervention. Discussion: This study will result in a culturally appropriate Family Health History tool that is co-developed with community members that can be utilized by African American adults to better understand their family health histories. Trial registration: Clinicaltrials.gov: NCT05358964 Date: May 5, 2022.

Mental health interventions for individuals with serious mental illness in the criminal legal system: a systematic review.

BACKGROUND: Globally, individuals with mental illness get in contact with the law at a greater rate than the general population. The goal of this review was to identify and describe: (1) effectiveness of mental health interventions for individuals with serious mental illness (SMI) who have criminal legal involvement; (2) additional outcomes targeted by these interventions; (3) settings/contexts where interventions were delivered; and (4) barriers and facilitating factors for implementing these interventions. METHODS: A systematic review was conducted to summarize the mental health treatment literature for individuals with serious mental illness with criminal legal involvement (i.e., bipolar disorder, schizophrenia, major depressive disorder). Searches were conducted using PsychINFO, Embase, ProQuest, PubMed, and Web of Science. Articles were eligible if they were intervention studies among criminal legal involved populations with a mental health primary outcome and provided description of the intervention. RESULTS: A total of 13 eligible studies were identified. Tested interventions were categorized as cognitive/behavioral, community-based, interpersonal (IPT), psychoeducational, or court-based. Studies that used IPT-based interventions reported clinically significant improvements in mental health symptoms and were also feasible and acceptable. Other interventions demonstrated positive trends favoring the mental health outcomes but did not show statistically and clinically significant changes. All studies reported treatment outcomes, with only 8 studies reporting both treatment and implementation outcomes. CONCLUSION: Our findings highlight a need for more mental health research in this population. Studies with randomized design, larger sample size and studies that utilize non-clinicians are needed.

Recommended Mental Health Practices for Individuals Interacting With U.S. Police, Court, Jail, Probation, and Parole Systems.

OBJECTIVE: Tens of millions of individuals with mental health problems interact with the U.S. criminal legal system (including 911, police, jail detention and sentences, courts, and probation and parole) each year. The authors sought to identify recommended mental health practices for criminal legal system-involved individuals and report the percentages of U.S. counties and of the U.S. population living in counties in which each recommended practice is present. METHODS: Recommended practices for criminal legal-involved individuals with mental health problems were identified from meta-analyses, reviews, and best practice recommendations. Up to four respondents per county (i.e., jail, probation, community mental health, and community substance use treatment administrators) from 950 counties were asked whether each recommended practice was present for criminal legal-involved individuals. Weighted percentages of U.S. counties using recommended practices and of the U.S. population living in counties with each recommended practice are reported. RESULTS: Fifty-nine recommended practices, including general mental health approaches (e.g., permanent supportive housing, Medicaid continuity) and diagnosis-specific mental health treatments (including medications and psychotherapies), were identified. Weighted data from respondents (N=791 from 519 counties) indicated that each recommended practice was present for criminal legal-involved individuals in only 21.9%-43.0% of U.S. counties. CONCLUSIONS: These results inform implementation efforts by indicating the presence of recommended care practices for criminal legal-involved individuals with mental health problems in counties nationwide. Because supportive housing, access to Medicaid reactivation in jails, and psychosocial interventions for physical pain have low presence but high importance for recovery, implementation efforts might first target these approaches.

Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol.

BACKGROUND: Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail. METHODS: This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data. CONCLUSIONS: This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

Neighborhood Deprivation and Severe Maternal Morbidity in a Medicaid Population.

INTRODUCTION: Few studies have examined whether neighborhood deprivation is associated with severe maternal morbidity (SMM) in already socioeconomically disadvantaged populations. Little is known about to what extent neighborhood deprivation accounts for Black-White disparities in SMM. This study investigated these questions among a statewide Medicaid-insured population, a low-income population with heightened risk of SMM. METHODS: Data were from Michigan statewide linked birth records and Medicaid claims between 01/01/2016 and 12/31/2019, and were analyzed between 2022 and 2023. Neighborhood deprivation was measured with the Area Deprivation Index at census block group and categorized as low, medium, or high deprivation. Multilevel logistic models were used to examine the association between neighborhood deprivation and SMM. Fairlie nonlinear decomposition was conducted to quantify the contribution of neighborhood deprivation to SMM racial disparity. RESULTS: People in the most deprived neighborhoods had higher odds of SMM than those in the least deprived neighborhoods (aOR [95% CI]: 1.27 [1.15, 1.40]). Such association was observed in Black (aOR [95% CI]: 1.34 [1.07, 1.67]) and White (aOR [95% CI]: 1.26 [1.12, 1.42]) racial subgroups. Decomposition showed that of 57.5 (cases per 10,000) explained disparity in SMM, neighborhood deprivation accounted for 23.1 (cases per 10,000; 95% CI: 16.3, 30.0) or two-fifths (40.2%) of the Black-White disparity. Analysis on SMM excluding blood transfusion showed consistent but weaker results. CONCLUSIONS: Neighborhood deprivation may be used as an effective tool to identify at-risk individuals within a low-income population. Community-engaged interventions aiming at improving neighborhood conditions may be helpful to reduce both SMM prevalence and racial inequity in SMM.

Managed Care Updates of Subscriber Jail Release to Prompt Community Suicide Prevention: Clinical Trial Protocol.

Background: Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail. Methods: This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data. Conclusions: This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk. Trial Registration: The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023, https://beta.clinicaltrials.gov/study/NCT05579600?cond=Suicide&term=Managed%20Care&rank=1.

Effectiveness of acceptance and commitment therapy for inpatients with psychosis: Implementation feasibility and acceptability from a pilot randomized controlled trial.

OBJECTIVE: Acceptance and Commitment Therapy for Inpatients (ACT-IN) with psychosis has been found to be efficacious in previous trials, but its effectiveness has not been studied when implemented by frontline clinicians in routine settings. METHOD: In this pilot randomized controlled effectiveness trial, inpatients with schizophrenia-spectrum disorders were randomized to ACT-IN plus treatment as usual (TAU) (n = 23) or a time/attention matched (TAM) supportive condition plus TAU (n = 23) delivered by routine hospital staff. Both conditions received individual and group therapy during inpatient care and completed follow-up phone sessions during the first month post-discharge. Patients were assessed through 4 months post-discharge (blinded to condition) to determine feasibility, acceptability, and preliminary effectiveness of ACT-IN. RESULTS: ACT-IN was feasible to deliver with fidelity by frontline staff when integrated into an acute care setting. At post-treatment, patients reported significantly greater treatment satisfaction in ACT-IN relative to TAM. Overall, results showed significant but similar improvements for both conditions through 4-month follow-up in psychiatric symptoms, functioning, and mindfulness. Only ACT-IN improved over time in distress. Furthermore, patients receiving TAM had a 3.76 times greater risk of rehospitalization over 4 months compared with ACT-IN. CONCLUSIONS: ACT-IN is feasible and acceptable for patients with psychosis, can be implemented by hospital staff when integrated into acute treatment, and may result in decreased rehospitalization compared to alternative therapies. A future full-scale randomized-controlled implementation trial is warranted. CLINICALTRIALS: gov Identifer: NCT02336581.

Impact of County-level health infrastructure on participation in a reform effort to reduce the use of jail for individuals with mental health disorders.

BACKGROUND: The national Stepping Up Initiative has attracted over 500 counties interested in reducing the use of jail for individuals with mental health disorders. This paper identifies socioeconomic, criminal legal, and health care factors that predict the likelihood of counties joining Stepping Up. RESULTS: After performing variable selection, logistic regression models were performed on 3,141 U.S. counties. Counties designated as medically underserved and/or mental health staffing shortage areas were less likely to participate in this initiative. Logistic regression models showed that larger counties (populations over 250,000) with better health care infrastructure, more mental health providers per capita, higher percent of Medicaid funded drug treatment services, and at least one medical school, were more likely to join Stepping Up. These counties had lower per capita jail populations, higher concentration of police resources, and higher pretrial incarceration rate. CONCLUSIONS: County-level health care delivery factors are major contributors to a county's likelihood, or willingness, of engaging in Stepping Up reform efforts to reduce jail population with mental health disorders issues. Therefore, improving availability and accessibility of medical and behavioral health care in different communities, may facilitate efforts to address the unnecessary incarceration of individuals with mental health disorders.

Study protocol for the ROSE Scale-Up Study: Informing a decision about ROSE as universal postpartum depression prevention.

PURPOSE: To examine the effectiveness, cost-outcome, equity, scalability, and mechanisms of the Reach Out, Stay strong, Essentials for mothers of newborns (ROSE) postpartum depression prevention (PPD) program as universal versus selective or indicated prevention. BACKGROUND: The United States Preventive Services Task Force (USPSTF) currently recommends PPD prevention for pregnant people at risk of PPD (i.e., selective/indicated prevention). However, universal prevention may be more scalable, equitable, and cost-beneficial. DESIGN: Effectiveness of ROSE for preventing PPD among people at risk is known. To assess ROSE as universal prevention, we need to determine the effectiveness of ROSE among all pregnant people, including those screening negative for PPD risk. We will enroll 2320 pregnant people, assess them with commonly available PPD risk prediction tools, randomize everyone to ROSE or enhanced care as usual, and assess ROSE as universal, selective, and indicated prevention in terms of: (1) effectiveness (PPD prevention and functioning), (2) cost-benefit, (3) equity (PPD cases prevented by universal prevention that would not be prevented under selective/indicated for minority vs. non-Hispanic white people), (4) quantitative and qualitative measures of scalability (from 98 agencies previously implementing ROSE), (5) ROSE mechanisms across risk levels. We will integrate results to outline pros and cons of the three prevention approaches (i.e., universal, selective, indicated). CONCLUSION: This will be the first trial to assess universal vs. selective/indicated PPD prevention. Trial design illustrates a novel, efficient way to make these comparisons. This trial, the largest PPD prevention trial to date, will examine scalability, an understudied area of implementation science.

Computer-based intervention for residents of domestic violence shelters with substance use: A randomized pilot study.

BACKGROUND: Intimate Partner Violence (IPV) is a significant public health problem often associated with serious mental health and physical health implications. Substance use disorders (SUDs) are one of the most common comorbidities among women with IPV, increasing risk of subsequent IPV. METHODS: The current study examined the feasibility, acceptability, and preliminary effectiveness of a brief computerized intervention to reduce alcohol and drug use among women with IPV. Fifty women with recent IPV and alcohol and drug use risk were recruited from domestic violence shelters and randomized to the experimental computerized intervention or to an attention and time control condition. The primary outcome was percent heavy drinking or drug using days in 3 month increments over the 6 months after leaving the shelter. Receipt of substance use services and IPV severity were evaluated as secondary outcomes. RESULTS: The computerized intervention was feasible and acceptable, with high (n = 20, 80%) completion rates, engagement with the intervention, and satisfaction scores. As expected in this pilot trial, there were no significant differences between conditions in percent heavy drinking/drug using days or receipt of substance use services and large individual differences in outcomes. For example, receipt of substance use services decreased by a mean of 0.05 times/day from the baseline to the 6-month time period in the control condition (range -1.00 to +0.55) and increased by a mean of 0.06 times/day in the intervention condition (range -0.13 to +0.89). There were large decreases in IPV severity over time in both conditions, but directions of differences favored the control condition for IPV severity. CONCLUSION: A computerized intervention to reduce the risk of alcohol/drug use and subsequent IPV is feasible and acceptable among residents of a domestic violence shelter. A fully powered trial is needed to conclusively evaluate outcomes.

A multi-level intervention to reduce the stigma of substance use and criminal involvement: a pilot feasibility trial protocol.

BACKGROUND: Stigma associated with substance use and criminal involvement is pervasive and creates a barrier to evidence-based addiction care within the criminal legal system. Research has yet to examine a multi-level stigma intervention which targets the intersection of these stigmas among both criminal legal staff and legally-involved clients. METHODS: This paper presents the protocol for a non-randomized trial of a multi-level stigma intervention called Combatting Stigma to Aid Reentry and Recovery (CSTARR) that involves two interventions: (1) training for criminal legal staff to address public stigma and (2) group-based acceptance and commitment therapy to address self-stigma among legally-involved adults enrolled in substance use treatment. Staff and client participants are engaged with a program called the Tennessee Recovery Oriented Compliance Strategy in 6 East Tennessee counties. This study examines the feasibility, acceptability, and preliminary effectiveness of CSTARR using a type 1 hybrid implementation/effectiveness trial with pre to post follow-up. DISCUSSION: Stigma must be addressed in the criminal legal system to facilitate the uptake of evidence-based addiction care. This study is the first to evaluate a stigma intervention designed for the criminal legal setting and results will be used to inform a larger, randomized controlled trial. The rationale for this study, research design and measures, as well as potential implications for the field are described. TRIAL REGISTRATION: This clinical trial is registered at clinicaltrials.gov with the identifier NCT05152342. Registered 11/5/2021 at https://register. CLINICALTRIALS: gov/prs/app/action/SelectProtocol?sid=S000BIN8&selectaction=Edit&uid=U0005X4C&ts=2&cx=-u3wsbx .

Implementation Preparation Costs of Virtual Reality Job Interview Training in Prisons: A Budget Impact Analysis.

Virtual Reality Job Interview Training (VR-JIT) has increased employment rates for returning citizens when added to a successful prison-based employment readiness program. However, implementation preparation cost-expenses prior to offering VR-JIT to intended recipients-is unknown. We estimated the cost of implementation preparation activities (e.g., organizing workflow) for two prisons to deliver VR-JIT. We conducted a budget impact analysis and enumerated the labor costs incurred during this important stage of implementation. Labor costs were approximately $8,847 per prison. Our sensitivity analysis estimated the labor costs to replicate this effort in a new prison to range from $2,877 to $4,306 per prison. Thus, VR-JIT may be an affordable tool for prison-based employment readiness programs to improve gainful employment.

Study protocol: The Maternal Health Multilevel Intervention for Racial Equity (Maternal Health MIRACLE) Project.

PURPOSE: To test the effectiveness and cost-effectiveness of a multilevel intervention for population-level African American (AA) severe maternal morbidity and mortality. BACKGROUND: Severe maternal morbidity and mortality in the U.S. disproportionately affect AA women. Inequities occur at many levels, including community, provider, and health system levels. DESIGN: Intervention. Throughout the two intervention counties, we will expand access to enhanced prenatal care services using telehealth and flexible scheduling (community level), provide actionable maternal health-focused anti-racism training (provider level), and implement equity-focused community care maternal safety bundles (health system level). Partnership. Interventions were developed/co-developed by intervention county partners, including AA women, enhanced prenatal care staff, and health providers. For equity, 46% of project direct cost dollars go to our partners. Most study investigators are female (75%) and/or AA (38%). Partners are overwhelmingly AA women. Sample, measures, analyses. We use a quasi-experimental difference-in-differences with propensity scores approach to compare pre (2016-2019) to post (2022-2025) changes in outcomes for Medicaid-insured women in intervention counties to similar women in the other Michigan, USA, counties. The sample includes all Medicaid-insured deliveries in Michigan during these years (n ~ 540,000), with women observed during pregnancy, at birth, and up to 1 year postpartum. Measures are taken from a linked dataset that includes Medicaid claims and vital records. CONCLUSION: This study is among the first to examine effects of any multilevel intervention on AA severe maternal morbidity and mortality. It features a rigorous quasi-experimental design, multilevel multi-partner county-wide interventions developed by community partners, and assessment of intervention effects using population-level data.

The relationship between community public health, behavioral health service accessibility, and mass incarceration.

BACKGROUND: The relationship between healthcare service accessibility in the community and incarceration is an important, yet not widely understood, phenomenon. Community behavioral health and the criminal legal systems are treated separately, which creates a competing demand to confront mass incarceration and expand available services. As a result, the relationship between behavioral health services, demographics and community factors, and incarceration rate has not been well addressed. Understanding potential drivers of incarceration, including access to community-based services, is necessary to reduce entry into the legal system and decrease recidivism. This study identifies county-level demographic, socioeconomic, healthcare services availability/accessibility, and criminal legal characteristics that predict per capita jail population across the U.S. More than 10 million individuals pass through U.S. jails each year, increasing the urgency of addressing this challenge. METHODS: The selection of variables for our model proceeded in stages. The study commenced by identifying potential descriptors and then using machine learning techniques to select non-collinear variables to predict county jail population per capita. Beta regression was then applied to nationally available data from all 3,141 U.S. counties to identify factors predicting county jail population size. Data sources include the Vera Institute's incarceration database, Robert Wood Johnson Foundation's County Health Rankings and Roadmaps, Uniform Crime Report, and the U.S. Census. RESULTS: Fewer per capita psychiatrists (z-score = -2.16; p = .031), lower percent of drug treatment paid by Medicaid (-3.66; p < .001), higher per capita healthcare costs (5.71; p < .001), higher number of physically unhealthy days in a month (8.6; p < .001), lower high school graduation rate (-4.05; p < .001), smaller county size (-2.66, p = .008; -2.71, p = .007; medium and large versus small counties, respectively), and more police officers per capita (8.74; p < .001) were associated with higher per capita jail population. Controlling for other factors, violent crime rate did not predict incarceration rate. CONCLUSIONS: Counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita. Increasing access to services, including mental health providers, and improving the affordability of drug treatment and healthcare may help reduce incarceration rates.

Social vulnerability, COVID-19 impact, and decision making among adults in a low-resource community.

Socially vulnerable individuals, including those with greater exposure to adversity and social instability, are at greater risk for a variety of negative outcomes following exposure to public health crises. One hypothesized mechanism linking social vulnerability to poor health outcomes is delay discounting, the behavioral tendency to select smaller immediately available rewards relative to larger delayed rewards. However, little research has examined the impact of real-world disease outbreaks, such as the COVID-19 pandemic, on the relation between social vulnerability and delay discounting. This study examined whether the severity of COVID-19 impact moderated the association between social vulnerability and delay discounting in a diverse sample of 72 human adults (Mage = 42.4; 69% Black; 87% female) drawn from two low-resource urban areas. Contrary to hypotheses, results indicated that exposure to more severe COVID-19 impacts did not affect decision making among individuals with higher levels of social vulnerability. Conversely, findings suggest that individuals with lower levels of social vulnerability who reported more significant impacts of COVID-19 evidenced a greater tendency to select larger, delayed rewards relative to individuals with greater social vulnerability. Findings suggest the recent pandemic may influence the relation between social vulnerability and behavioral processes underlying health decision-making.

Belonging to Something Greater Than Self: Flint Women Giving Back to the Community.

BACKGROUND: Having meaning in life promotes happiness and well-being across the lifespan. METHODS: A community-based participatory qualitative study was conducted to understand meaning in life, having a voice and the different ways women give back to their community by serving others. Interviews were held with participants (n = 100) who were community residents, people serving women, or both. RESULTS: Participants defined meaning in life as having a sense of significance, a deep connection to their community, and a sense of acknowledgement for their overall contributions. They emphasized the importance of opportunities for women to contribute to something greater than themselves. Participants suggested organizations would be responsive to the needs of women when women have a stronger voice. CONCLUSIONS: Women served their community in many roles. However, despite some societal progress, women continue to be underpaid and their contributions undervalued. Rectifying these inequities might contribute to better addressing the needs of women.

MOSAIC (MOthers' AdvocateS In the Community) for pregnant women and mothers of children under 5 with experience of intimate partner violence: A pilot randomized trial study protocol.

BACKGROUND: Pregnancy and motherhood increase the risk for long-term exposure to physical, psychological and sexual intimate partner violence (IPV; sexual or physical violence by current or former partners). Pregnant women and mothers with children under 5 who have experienced IPV exhibit poor physical and mental health and obstetric outcomes. Depression and posttraumatic stress disorder (PTSD) are the two most common mental health consequences of IPV. There is good evidence that women with good social support have better mental health and IPV outcomes. METHODS: This study will develop MOthers' AdvocateS In the Community (MOSAIC) Plus intervention for pregnant women and mothers with children under the age of 5. MOSAIC uses trained mentor mothers and has been found to reduce subsequent IPV. This study will blend the original MOSAIC intervention with principles of interpersonal psychotherapy (IPT) to address symptoms of depression, PTSD, and prevent subsequent risk of IPV. We will conduct a pilot randomized trial of the MOSAIC Plus intervention compared to the traditional MOSAIC intervention to determine its feasibility and acceptability. Study samples include focus groups (n = 36), open trial (n = 15), and a randomized pilot trial including 40 pregnant women and mothers with children under 5 who report current/recent of IPV and elevated symptoms of maternal depression and/or PTSD. The study's primary outcome will be changes in maternal depressive and PTSD symptoms. Secondary outcomes will include reduction in subsequent IPV, improvement in functioning, changes in social support and effectiveness in obtaining resources. DISCUSSION: This is a formative study evaluating the feasibility and acceptability of a mentor mother intervention for pregnant women and mothers with children under 5. Promising results of this study will be used for a larger, fully-powered randomized trial evaluating the effectiveness of a mentor mother intervention in preventing subsequent IPV and reducing depressive and PTSD symptoms in this population.