Black, white, or green? The effects of racial composition and socioeconomic status on neighborhood-level tobacco outlet density.

Objective: To compare predominantly-Black and predominantly-White Maryland areas with similar socioeconomic status to examine the role of both race and socioeconomic status on tobacco outlet availability and tobacco outlet access.Design: Maryland tobacco outlet addresses were geocoded with 2011-2015 American Community Survey sociodemographic data. Two-sample t-tests were conducted comparing the mean values of sociodemographic variables and tobacco outlet density per Census Tract, and spatial lag based regression models were conducted to analyze the direct association between covariables and tobacco outlet density while accounting for spatial dependence between and within jurisdictions.Results: Predominantly-White jurisdictions had lower tobacco outlet availability and access than predominantly-Black jurisdictions, despite similar socioeconomic status. Spatial lag model results showed that median household income and vacant houses had consistent associations with tobacco outlet density across most of the jurisdictions analyzed, and place-based spatial lag models showed direct associations between predominantly-Black jurisdictions and tobacco outlet availability and access.Conclusion: Predominantly-White areas have lower levels of tobacco outlet density than predominantly-Black areas, despite both areas having similar socioeconomic statuses.

Using Zoning as a Public Health Tool to Reduce Alcohol Outlet Oversaturation, Promote Compliance, and Guide Future Enforcement: a Preliminary Analysis of Transform Baltimore.

Alcohol outlet oversaturation often exacerbates negative public health outcomes. Recently, Baltimore City passed an extensive zoning rewrite ("TransForm Baltimore") that sought to give local government and residents a tool to reduce alcohol outlet oversaturation through land use regulation. The present investigation evaluated the outlet and neighborhood characteristics of stores impacted by two components of TransForm Baltimore: (1) a requirement that taverns licensed for on-premise consumption in addition to off-premise, carryout sales generate at least 50% of their business from on-premise sales, and (2) a requirement to close, repurpose, or relocate all package stores (i.e., off-premise alcohol outlets) that have been operating as "non-conforming" in residential zones since 1971. Research assistants visited every off-premise alcohol outlet in the city (n = 685) to complete an observational assessment. Approximately 77% (n = 530) of these off-premise alcohol outlets were open, including 292 taverns and 238 package stores. t tests and chi-square tests were used to compare neighborhood characteristics (neighborhood disadvantage, median household income, and racial segregation) of sham taverns (i.e., taverns with less than 50% space dedicated for on-premise sales that were primarily operating as a package store) and non-conforming package stores. Of the 292 taverns accessible during the study, the remainder were chronically closed (n = 130); 24 (8.2%) were deemed sham taverns. Sham taverns were more likely to be located in communities with more economic disadvantage and lower median household income (t test; p < 0.05). Compared to taverns, a lower proportion of sham taverns had visible dance floor space, patrons drinking, and menus available (chi-square test; p < 0.001). There were 80 residentially zoned, non-conforming alcohol outlets. These non-conforming alcohol outlets were disproportionately distributed in predominately poor and African American communities (t test; p < 0.05). As compared to conforming alcohol outlets, more non-conforming alcohol outlets sold sex paraphernalia and healthy foods (chi-square test; p < 0.05). With active enforcement, TransForm Baltimore offers the opportunity for local government and residents to improve public health and increase health equity in vulnerable and marginalized neighborhoods.

Understanding the relationship between alcohol outlet density and life expectancy in Baltimore City: The role of community violence and community disadvantage.

This research investigated the relationship between alcohol outlet density (AOD) and life expectancy, as mediated by community violence and community disadvantage. We used linear regression models to assess bivariate and multivariate relationships. There was a negative bivariate association between liquor store density and average life expectancy (ß = -7.3370, p < 0.001). This relationship was partially attenuated when controlling for community disadvantage and fully attenuated when controlling for community violence. Bars/taverns (i.e., on-premise) were not associated with average life expectancy (ß = -0.589, p = 0.220). Liquor store density is associated with higher levels of community disadvantage and higher rates of violence, both of which are associated with lower life expectancies. Future research, potential intervention, and current related policies are discussed.

Medicaid Reimbursement of Mental Health Peer-Run Organizations: Results of a National Survey.

This study sought to understand whether knowledge of the Affordable Care Act (ACA) was associated with willingness of mental health peer-run organizations to become Medicaid providers. Through the 2012 National Survey of Peer-Run Organizations, organizational directors reported their organization's willingness to accept Medicaid reimbursement and knowledge about the ACA. Multinomial logistic regression was used to model the association between willingness to accept Medicaid and the primary predictor of knowledge of the ACA, as well as other predictors at the organizational and state levels. Knowledge of the ACA, Medicaid expansion, and discussions about healthcare reform were not significantly associated with willingness to be a Medicaid provider. Having fewer paid staff was associated with not being willing to be a Medicaid provider, suggesting that current staffing capacity is related to attitudes about becoming a Medicaid provider. Organizations had both ideological and practical concerns about Medicaid reimbursement. Concerns about Medicaid reimbursement can potentially be addressed through alternative financing mechanisms that should be able to meet the needs of peer-run organizations.

Changes in Attitudes toward Guns and Shootings following Implementation of the Baltimore Safe Streets Intervention.

Among youth 15 to 24 years of age, homicide and nonfatal shootings are the leading causes of mortality and morbidity. Urban youth's attitudes and perceptions about the use of gun violence to resolve conflict present a major barrier to efforts to reduce gun homicides and nonfatal shootings. The current investigation extends the existing literature on attitudes toward guns and shootings among high-risk youth ages 18 to 24 by measuring perceived norms and viewpoints regarding gun violence in two analogous Baltimore City neighborhoods pre-implementation and 1-year post-implementation of the Safe Streets intervention (adapted from the CeaseFire/Cure Violence intervention). The Safe Streets intervention is designed for communities with high rates of gun violence and utilizes outreach workers to identify and build trusting relationships with youth ages 15 to 24 who are at greatest risk of being involved in gun violence. The outreach workers also position themselves in the community so that they can rapidly intervene in disputes that have the potential to lead to gun violence. Chi-squared tests and exploratory structural equation modeling (ESEM) were used to examine changes in attitudes toward gun violence 1 year after the implementation of the Safe Streets intervention. There was a statistically significantly improvement in 43 % of the attitudes assessed in the intervention community post-intervention compared to 13 % of the attitudes in the control community. There was a statistically significant improvement in the violent attitudes toward personal conflict resolution scale after implementation of the intervention in both the intervention (b = -0.522, p < 0.001) and control community (b = -0.204, p < 0.032). Exposure to the intervention (e.g., seeing stop shooting signs in your neighborhood) was also associated with the nonviolent attitudes toward conflict scale. Overall, the study found greater improvement in attitudes toward violence in the intervention community following the implementation of the Safe Streets program. These findings offer promising insights into future community violence prevention efforts.

Assessing the generalizability of randomized trial results to target populations.

Recent years have seen increasing interest in and attention to evidence-based practices, where the "evidence" generally comes from well-conducted randomized trials. However, while those trials yield accurate estimates of the effect of the intervention for the participants in the trial (known as "internal validity"), they do not always yield relevant information about the effects in a particular target population (known as "external validity"). This may be due to a lack of specification of a target population when designing the trial, difficulties recruiting a sample that is representative of a prespecified target population, or to interest in considering a target population somewhat different from the population directly targeted by the trial. This paper first provides an overview of existing design and analysis methods for assessing and enhancing the ability of a randomized trial to estimate treatment effects in a target population. It then provides a case study using one particular method, which weights the subjects in a randomized trial to match the population on a set of observed characteristics. The case study uses data from a randomized trial of school-wide positive behavioral interventions and supports (PBIS); our interest is in generalizing the results to the state of Maryland. In the case of PBIS, after weighting, estimated effects in the target population were similar to those observed in the randomized trial. The paper illustrates that statistical methods can be used to assess and enhance the external validity of randomized trials, making the results more applicable to policy and clinical questions. However, there are also many open research questions; future research should focus on questions of treatment effect heterogeneity and further developing these methods for enhancing external validity. Researchers should think carefully about the external validity of randomized trials and be cautious about extrapolating results to specific populations unless they are confident of the similarity between the trial sample and that target population.

Neighborhood environment and marijuana use in urban young adults.

Risk factors for marijuana use in older adolescents and young adults have focused primarily on family environment and peer affiliation. A growing body of work has examined the relationship between environmental context and young adult substance use. This study builds on previous research linking neighborhood environment to young adult marijuana use by exploring two distinct features of neighborhoods, namely the physical (e.g., broken windows) and social environment (e.g., adults watching youth). Data were obtained from a longitudinal sample of 398 predominately African American young adults living in an urban environment. The data also included observational measures of physical and social order and disorder collected on the young adult's residential block. Exploratory structural equation modeling (ESEM) was utilized to test hypothesized relationships between these two features of the neighborhood environment and past year young adult marijuana use. A two-factor model of neighborhood environment with good fit indices was selected (CFI = 0.97, RMSEA = 0.037). There was a positive and significant direct effect from neighborhood physical disorder to marijuana use (0.219, p < 0.05) controlling for gender, race, and free and reduced price meal (FARPM) status. The direct effect from neighborhood social environment to marijuana use was not significant. These results converge with previous research linking vacant housing with young adult marijuana use but do not provide empirical support for the neighborhood social environment as a determinant of drug taking. Better explication of the social environment is needed to understand its relationship to drug use.

Brief report: Moving prevention into schools: The impact of a trauma-informed school-based intervention.

Adolescents in disadvantaged communities have high rates of exposure to stress and trauma, which can negatively impact emotion regulation and executive functioning, increasing likelihood of school problems. This pilot study evaluated RAP Club, a 12-session school-based trauma-informed group intervention co-facilitated by a mental health counselor and young adult community member that utilizes evidence-based cognitive-behavioral and mindfulness strategies. Seventh and eighth graders at two urban public schools serving low-income communities were assigned to receive RAP Club (n = 29) or regular school programming (n = 20). RAP Club improved teacher-rated emotion regulation, social and academic competence, classroom behavior, and discipline. Higher program dose predicted improvements in several teacher-rated outcomes. Student self-report outcomes, however, did not vary by study group or dose. Even students with low baseline depression showed improvement in teacher-rated outcomes following program participation, supporting a model of universal program delivery to all students. Findings suggest RAP Club merits further study.

Off-Premise Alcohol Outlets and Substance Use in Young and Emerging Adults.

This investigation examined the association between alcohol outlets and substance use during young adulthood in Baltimore, MD. Geospatial methods were used to determine the number of outlets within walking distance of the participant's home and distance to nearest outlet. Logistic regression models found that distance to the nearest alcohol outlet was associated with past year marijuana use after adjusting for community disadvantage and sociodemographic characteristics (OR = 0.77, p = .03); specifically, as distance to the nearest outlet increased the likelihood of marijuana use decreased. Findings suggest that distance to the nearest alcohol outlet was a better predictor of marijuana use than the density of alcohol outlets.

Maternal relationship security as a moderator of home visiting impacts on maternal psychosocial functioning.

There is variability in home visiting program impacts on the outcomes achieved by high risk families. An understanding of how effects vary among families is important for refining service targeting and content. The current study assessed whether and how maternal attributes, including relationship security, moderate short- and long-term home visiting impacts on maternal psychosocial functioning. In this multisite RCT of home visiting in a population-based, ethnically-diverse sample of families at risk for maltreatment of their newborns (n = 643), families were randomly assigned to home visited (HV) and control groups. HV families were to receive intensive services by trained paraprofessionals from birth-3 years. Outcome data were collected when children were 1, 2, and 3 years old and 7, 8, and 9 years old. Overall, short- and long-term outcomes for HV and control mothers did not differ significantly. Demographic attributes, a general measure of overall maternal risk, and partner violence did not moderate program impact on psychosocial functioning outcomes. Maternal relationship security did moderate program impact. Mothers who scored high on relationship anxiety but not on relationship avoidance showed the greatest benefits, particularly at the long-term follow-up. Mothers scoring high for both relationship anxiety and avoidance experienced some adverse consequences of home visiting. Further research is needed to determine mediating pathways and to inform and test ways to improve the targeting of home visiting and the tailoring of home visit service models to extend positive home visiting impacts to targeted families not benefiting from current models.

Neighborhood disorder and juvenile drug arrests: a preliminary investigation using the NIfETy instrument.

BACKGROUND: Disordered neighborhood environments are associated with crime, drug use, and poor health outcomes. However, research utilizing objective instruments to characterize the neighborhood environment is lacking. OBJECTIVES: This investigation examines the relationship between objective measures of neighborhood disorder and juvenile drug arrests (JDAs) in an urban locale. METHODS: The neighborhood disorder scale was developed using indicators from the Neighborhood Inventory for Environmental Typology (NIfETy) instrument; a valid and reliable tool that assesses physical and social disorder. Data on 3146 JDAs from 2006 were obtained from the police department. RESULTS: Negative binomial regression models revealed a significant association between neighborhood disorder and the count of JDAs in the neighborhood (ß == .34, p < .001). The relationship between neighborhood disorder and JDAs remained significant after adjusting for percent African-Americans in the neighborhood (ß == .24, p < .001). CONCLUSIONS: This preliminary investigation identified a positive and statistically significant relationship between an objective measure of neighborhood disorder and JDAs. Future investigations should examine strategies to reduce drug-related crime by addressing the larger neighborhood and social context in which drug involvement and crime occurs.

A state-wide partnership to promote safe and supportive schools: the PBIS Maryland Initiative.

Schools continue to be an important context for preventive interventions targeting a range of behavioral and mental health problems. Yet competing demands on teachers and shifting priorities in response to federal legislation have posed some unique challenges to prevention researchers working in school settings. This paper summarizes an approach to prevention partnerships developed over a decade and centered on the three-tiered Positive Behavioral Interventions and Supports (PBIS) model. A state-wide initiative was formed and led through a partnership between the Maryland State Department of Education, Sheppard Pratt Health System, and Johns Hopkins University, which focused on implementing evidence-based practices and conducting prevention research in Maryland public schools. Drawing on a community-based participatory research framework for developing research partnerships, we highlight the importance of forming and sustaining authentic relationships to support school-based prevention research and implementation of evidence-based programs. We also discuss how these relationships have been used to disseminate PBIS and rigorously test its effectiveness. We describe some lessons learned from the partnership and identify potential areas for future research on the prevention partnership model. We conclude with a discussion of the implications for both researchers and community partners engaged in translational research in school settings.

X-rated material and perpetration of sexually aggressive behavior among children and adolescents: is there a link?

Longitudinal linkages between intentional exposure to x-rated material and sexually aggressive behavior were examined among youth 10-15 year olds surveyed nationally in the United States. At Wave 1 in 2006, participants (n = 1,588) were queried about these exposures and outcomes in the preceding 12 months. Wave 2 data (n = 1,206) were collected approximately 12 months after Wave 1 and Wave 3 data (n = 1,159) were collected approximately 24 months after Wave 1. Thus, data for this project represent a 36-month time frame. A marginal model with generalized estimating equations was used to represent the population-average odds of sexually aggressive behavior over the 36 months as a function of exposure to x-rated material over the same time and to account for clustering in the data within person over time. An average of 5% of youth reported perpetrating sexually aggressive behavior and 23% of youth reported intentional exposure to x-rated material. After adjusting for other potentially influential proximal (i.e., sexual aggression victimization) and distal characteristics (e.g., substance use), we found that intentional exposure to violent x-rated material over time predicted an almost 6-fold increase in the odds of self-reported sexually aggressive behavior (aOR: 5.8, 95% CI: 3.2, 10.5), whereas exposure to nonviolent x-rated material was not statistically significantly related (aOR: 1.7, 95% CI: 0.94, 2.9). Associations were similar for boys and girls (boys nonviolent x-rated material aOR = 2.0, 95% CI: 0.8, 4.7; violent x-rated material aOR = 6.5, 95% CI: 2.7, 15.3; girls nonviolent x-rated material aOR = 1.2, 95% CI: 0.5, 3.2; violet x-rated material aOR = 6.1, 95% CI: 2.5, 14.8).

Altering school climate through school-wide Positive Behavioral Interventions and Supports: findings from a group-randomized effectiveness trial.

Positive Behavioral Interventions and Supports (PBIS) is a universal, school-wide prevention strategy that is currently implemented in over 7,500 schools to reduce disruptive behavior problems. The present study examines the impact of PBIS on staff reports of school organizational health using data from a group-randomized controlled effectiveness trial of PBIS conducted in 37 elementary schools. Longitudinal multilevel analyses on data from 2,596 staff revealed a significant effect of PBIS on the schools' overall organizational health, resource influence, staff affiliation, and academic emphasis over the 5-year trial; the effects on collegial leadership and institutional integrity were significant when implementation fidelity was included in the model. Trained schools that adopted PBIS the fastest tended to have higher levels of organizational health at baseline, but the later-implementing schools tended to experience the greatest improvements in organizational health after implementing PBIS. This study indicated that changes in school organizational health are important consequences of the PBIS whole-school prevention model, and may in turn be a potential contextual mediator of the effect of PBIS on student performance.

Does Tobacco Outlet Inequality Extend to High-White Mid-Atlantic Jurisdictions? A Study of Socioeconomic Status and Density.

Tobacco outlet density research has evolved to require a more refined examination of socioeconomic status' influence beyond median household income. This study investigates the effects of SES on census-tract-level tobacco outlet density in five predominantly White Maryland jurisdictions. Tobacco license addresses and demographic data were analyzed via t tests and spatial lag modeling. Results showed that higher SES jurisdictions had lower tobacco outlet density than lower SES jurisdictions despite similar White populations and that median household income had consistent associations with tobacco outlet density. This study corroborates findings that differences in SES correlate with differences in tobacco outlet density between racially similar areas.

Factors associated with a six-month return to emergency services among child and adolescent psychiatric patients.

OBJECTIVES: This analysis identified factors associated with emergency department recidivism among pediatric psychiatric patients and factors that may differentiate repeat and one-time visits. METHODS: The researchers examined six-month recidivism among a sample of 509 patients of ages four to 18 years who made mental health visits to an urban pediatric emergency department in 2004. RESULTS: Patients who made repeat visits were more likely to be involved in mental health and social services than patients who did not return to the emergency department. Repeat visitors were also more likely to be African American, have a history of psychiatric hospitalization, and present with suicidal or disruptive behaviors. CONCLUSIONS: These results suggest that the emergency department is being used as part of the continuum of care for patients already in treatment, particularly those displaying disruptive behavior. Additional research is needed to determine whether this recidivism is clinically indicated or reflects a lack of available or appropriate care in community settings.

School Referral Patterns among Adolescents with Serious Emotional Disturbance Enrolled in Systems of Care.

School staff play a critical role in referring adolescents with serious emotional disturbance (SED) to mental health services; however, the mechanisms underlying this referral process are poorly understood. We used data from adolescents (N=4,365) enrolled in SAMHSA's Children's Mental Health Initiative Systems of Care (SOC) and participating in a national evaluation to compare the profiles of youth referred for SOC services by school staff with youth referred for those services by professionals at other agencies. We sought to identify whether school staff referred a unique set of adolescents by examining indicators of global impairment and impairment in school functioning (i.e., absences, suspensions, failures). Using multilevel regression models, we estimated the association of global impairment and school functioning with referral source (i.e., school vs. other) and controlled for SOC community characteristics and individual-level socio-demographics. Findings indicated that adolescents referred from schools had significantly lower levels of global impairment than adolescents referred from mental health settings. However, they had considerable school-related impairment, with rates of absences, suspensions, and failures that were equivalent to youth referred from most other agencies. This study is the first to examine school-related impairment among youth receiving SOC services as a function of referral source. By identifying adolescents with more mild global impairment, who nonetheless experienced significant impairment in school functioning, schools can be key contributors to effectively identifying a unique set of adolescents for SOC services. Further, schools might meaningfully inform the provision of comprehensive services to this population by educating community agencies about school functioning among youth with SED.

Collaborating for violence prevention: training health professionals to work with schools.

The issue of youth violence continues to be a pressing public health problem. Increasingly schools are adopting a public health framework to address this problem and could benefit from the expertise of health professionals. The article explores opportunities for collaboration with schools, recommendations for successful collaboration, and implications for training.

Prevention of youth violence.

Youth violence is widely recognized as a major public health problem. Concern over the number of youth affected by violence in their homes, communities, and in schools has precipitated considerable discussion in the popular press and in professional journals. This article reviews recent activity to reduce youth violence with an emphasis on activity taking place in Maryland. The number of youth murdered or exposed to violence in Maryland remains too high. Although most of our youth are resilient, they are not unaffected by the violence that surrounds them. Exposure to violence places children at high risk for a variety of emotional and behavioral problems, such as poor academic performance, anxiety, post-traumatic stress disorder, and inadequate socialization and development.

Utility of TOCA-R scores during the elementary school years in identifying later violence among adolescent males.

OBJECTIVE: To evaluate the utility of a teacher-rating instrument (TOCA-R) of aggressive behavior during elementary school years in identifying boys at risk for later violence. METHOD: A community epidemiological sample of 415 public school boys was rated at six time points during elementary school regarding their level of aggressive/disruptive behavior. Violence was measured using juvenile police and court records. RESULTS: The risk for later violence varied as a function of the boys' level of aggressive behavior. This relationship peaked in third grade, where more aggressive boys compared to less aggressive boys were twice as likely to commit later violent acts. In respect to identifying at-risk boys, three intervention scenarios were compared. When minimizing false positives, the optimal test was found in the fall of first grade, with 83% of the high-risk compared to 22% of the low-risk boys later having a violent arrest record. When minimizing false negatives, the optimal test was found in the spring of fourth grade (30% of the high-risk boys versus 0% of the low-risk boys). Focusing on both false positives and false negatives, the optimal test was found in the spring of third grade (52% of the high-risk boys versus 14% of the low-risk boys). CONCLUSIONS: Early levels of aggressive behavior are strong and robust predictors of later violence but are of limited utility in the early identification of boys at risk. Consequently, universal interventions followed by selected/indicated interventions based on a multistage assessment promise the highest utility in preventing youth violence. Future research is needed to identify other indicators that can strengthen the screening utility of aggressive behavior.