The Effects of Coexposure to Extremes of Heat and Particulate Air Pollution on Mortality in California: Implications for Climate Change.

Rationale: Extremes of heat and particulate air pollution threaten human health and are becoming more frequent because of climate change. Understanding the health impacts of coexposure to extreme heat and air pollution is urgent. Objectives: To estimate the association of acute coexposure to extreme heat and ambient fine particulate matter (PM2.5) with all-cause, cardiovascular, and respiratory mortality in California from 2014 to 2019. Methods: We used a case-crossover study design with time-stratified matching using conditional logistic regression to estimate mortality associations with acute coexposures to extreme heat and PM2.5. For each case day (date of death) and its control days, daily average PM2.5 and maximum and minimum temperatures were assigned (0- to 3-day lag) on the basis of the decedent's residence census tract. Measurements and Main Results: All-cause mortality risk increased 6.1% (95% confidence interval [CI], 4.1-8.1) on extreme maximum temperature-only days and 5.0% (95% CI, 3.0-8.0) on extreme PM2.5-only days, compared with nonextreme days. Risk increased by 21.0% (95% CI, 6.6-37.3) on days with exposure to both extreme maximum temperature and PM2.5. Increased risk of cardiovascular and respiratory mortality on extreme coexposure days was 29.9% (95% CI, 3.3-63.3) and 38.0% (95% CI, -12.5 to 117.7), respectively, and were more than the sum of individual effects of extreme temperature and PM2.5 only. A similar pattern was observed for coexposure to extreme PM2.5 and minimum temperature. Effect estimates were larger over age 75 years. Conclusions: Short-term exposure to extreme heat and air pollution alone were individually associated with increased risk of mortality, but their coexposure had larger effects beyond the sum of their individual effects.

Maternal and adolescent depressive symptoms and family conflict: An autoregressive cross-lagged examination of competing models in multi-stressed mothers and adolescents.

Maternal and adolescent depression are challenges that often co-occur. Many studies have drawn bivariate associations between maternal depressive symptoms, adolescent depressive symptoms, and family conflict, but few have examined reciprocal effects. Even among extant studies, there is a lack of clarity related to directionality of influence. Three competing theoretical models may explain the relationship between maternal depressive symptoms, adolescent depressive symptoms, and family conflict, and these processes may differ by adolescents' sex. Using three time points of data from 187 diverse mother-adolescent dyads, we fit a taxonomy of autoregressive cross-lagged structural equation models to simultaneously evaluate the competing theoretical models and also examine differences by sex using multiple-group analyses. Results indicate a symptom-driven model whereby adolescent depressive symptoms predicted increases in family conflict. Sex differences were also found. For males, but not females, greater adolescent depressive symptoms predicted subsequent increases in maternal depressive symptoms, which then predicted lower family conflict-possibly indicating maternal disengagement/withdrawal. Our findings suggest addressing adolescent depressive symptoms in order to prevent family conflict and that distinctive targets for the prevention/intervention of family conflict should account for differences by adolescents' sex.

Minority and low-SES families' experiences during the early phases of the COVID-19 pandemic crisis: A qualitative study.

Objectives: To explore minority and low-SES families' general experiences with the stay-at-home mandate initiated by the COVID-19 pandemic crisis. Methods: Semi-structured qualitative interviews (n = 31) were conducted in May 2020 - six to nine weeks after the stay-at-home mandate was initiated in Chicago Heights, Illinois. Participants were randomly selected from the parent Chicago Heights Early Childhood Center (CHECC) study (N = 2,185). Thematic content analysis of transcribed semi-structured interviews were employed. Results: During the early phases of the COVID-19 pandemic crisis, ethnic minority and low-SES families were generally comfortable in their homes, but both children and their parents experienced poor wellbeing, such as elevated stress. Families reportedly avoided social resources, despite low-SES. Upon reflection, parents expressed that the pandemic had changed them and, in some ways, the changes were positive. Conclusion: Readily available crisis-oriented resources, for both children and parents, are needed to help families maintain or rebuild their sense of control over their lives during the early phases of a collective crisis (e.g., pandemic). Although early observations help to contextual families' initial experiences, examining long-term trends can inform meaningful policies and practices that both support how low-SES families buffer against COVID-19-related negative impacts and mitigate ethnic and SES inequities and disparities.

Acquisition of Information About Innovative Practices in Outpatient Mental Health Clinics.

This study uses qualitative interviews with leaders of 34 mental health clinics in the context of a statewide rollout of clinical and business innovations to explore how clinics first learn about innovations and which external sources of information they access. Clinic leaders reported accessing information about innovations mainly from government agencies, professional associations, peer organizations, and research literature. Leaders mentioned an average of two external sources of information. There was evidence of variation in how leaders accessed information and how information about innovations was communicated within clinics. Findings have implications for improving dissemination of information about innovations in mental health systems.

Maternal Depressive Symptoms, Adolescent Daughters' Substance Use, and Father Residence in Minority Families.

Background: Maternal depression has been linked to substance use in adolescents, but the mechanisms of the relationship between maternal depression and adolescent substance use are less clear. Specifically, previous literature has overlooked the role of fathers as a potential protective or exacerbating factor in buffering this relationship. Objectives: The goal of this study was to investigate the association between maternal depressive symptoms and adolescent substance use, exploring father's residential status as a moderator for adolescents living with a mother with depressive symptoms. Method: Paper-and-pencil surveys were administered to a sample of 176 mothers and their adolescent daughters aged 14-18, predominantly identifying as African American/Black. Participants included a subset of mothers with HIV. Results: The results revealed that maternal depressive symptoms were not directly associated with adolescent substance use. However, father's residential status was found to be a significant moderator in the relationship between maternal depressive symptoms and adolescent substance use. Specifically, when fathers were involved in the daughter's life (residential or non-resident), substance use was higher in adolescents of mothers with high depressive symptoms than in those of mothers with low depressive symptoms. Conclusion: The results suggest that varied family dynamics are critical to understanding engagement in substance use among adolescent girls, including the influence of both mothers and fathers.

Research-Supported Intervention and Discretion Among Frontline Workers Implementing Home Visitation Services.

OBJECTIVE: We examine how frontline workers and supervisors delivering a research supported intervention (RSI) to reduce child neglect negotiated system-related challenges, the pragmatics of RSI implementation, and their professional identities and relationships with clients. METHODS: We conducted semi-structured interviews, small group discussions, and focus groups with frontline workers and supervisors in one large county over two time periods. We used iterative coding to analyze qualitative data. RESULTS: Frontline workers navigated several aspects of RSI implementation and sustainment: (1) contract requirements and information dissemination, (2) fidelity, (3) competing demands and crises, (4) structure versus creativity, and (5) relationships with clients. CONCLUSIONS: Workers dynamically negotiated multiple system- and provider-level (or outer- and inner-contextual) demands influencing RSI provision for clients with complex service needs. Results affirm the need to attend to the unintended consequences of implementing new contract, reimbursement, and other system organizational processes and to address the "committed work" supporting RSI delivery.

Sexual intercourse among adolescent daughters of mothers with depressive symptoms from minority families.

This study investigated the association between maternal depressive symptoms and adolescent engagement in sexual intercourse in a non-clinical sample of mothers and their adolescent daughters from minority families. The current study explores ways in which maternal depression, family factors, and adolescent sex interact. Data were from a cross-sectional study of 176 mother-daughter dyads, including a subset of mothers with HIV. Logistic regression analyses revealed that among mothers who were not current marijuana users, more maternal depressive symptoms was associated with daughters' engagement in sexual intercourse. Neither parent-child conflict nor parental involvement significantly mediated the relationship between maternal depressive symptoms and adolescent sex. This study provides the first empirical evidence that non-clinical depressive symptoms in mothers are associated with adolescent engagement in sexual intercourse.

EBT Fidelity Trajectories Across Training Cohorts Using the Interagency Collaborative Team Strategy.

The Interdisciplinary Collaborative Team (ICT) strategy uses front-line providers as adaptation, training and quality control agents for multi-agency EBT implementation. This study tests whether an ICT transmits fidelity to subsequent provider cohorts. SafeCare was implemented by home visitors from multiple community-based agencies contracting with child welfare. Client-reported fidelity trajectories for 5,769 visits, 957 clients and 45 providers were compared using three-level growth models. Provider cohorts trained and live-coached by the ICT attained benchmark fidelity after 12 weeks, and this was sustained. Hispanic clients reported high cultural competency, supporting a cultural adaptation crafted by the ICT.

Leadership, Organizational Climate, and Perceived Burden of Evidence-Based Practice in Mental Health Services.

The use of evidence-based practices (EBPs) is associated with favorable client outcomes, yet perceived burden of using EBPs may affect the adoption and implementation of such practices. Multilevel path analysis was used to examine the associations of transformational leadership with organizational climate, and their associations with perceived burden of using EBPs. Results indicated significant relationships between transformational leadership and empowering and demoralizing climates, and between demoralizing climate and perceived burden of EBPs. We found significant indirect associations of leadership and perceived burden through organizational climate. Findings suggest that further research is needed to examine the extent to which improving leadership and organizational climate may reduce perceived burden and use of EBPs with the ultimate goal of enhancing quality of care.

Collaboration, negotiation, and coalescence for interagency-collaborative teams to scale-up evidence-based practice.

Implementation and scale-up of evidence-based practices (EBPs) is often portrayed as involving multiple stakeholders collaborating harmoniously in the service of a shared vision. In practice, however, collaboration is a more complex process that may involve shared and competing interests and agendas, and negotiation. The present study examined the scale-up of an EBP across an entire service system using the Interagency Collaborative Team approach. Participants were key stakeholders in a large-scale county-wide implementation of an EBP to reduce child neglect, SafeCare. Semistructured interviews and/or focus groups were conducted with 54 individuals representing diverse constituents in the service system, followed by an iterative approach to coding and analysis of transcripts. The study was conceptualized using the Exploration, Preparation, Implementation, and Sustainment framework. Although community stakeholders eventually coalesced around implementation of SafeCare, several challenges affected the implementation process. These challenges included differing organizational cultures, strategies, and approaches to collaboration; competing priorities across levels of leadership; power struggles; and role ambiguity. Each of the factors identified influenced how stakeholders approached the EBP implementation process. System-wide scale-up of EBPs involves multiple stakeholders operating in a nexus of differing agendas, priorities, leadership styles, and negotiation strategies. The term collaboration may oversimplify the multifaceted nature of the scale-up process. Implementation efforts should openly acknowledge and consider this nexus when individual stakeholders and organizations enter into EBP implementation through collaborative processes.

Parentification, substance use, and sex among adolescent daughters from ethnic minority families: the moderating role of monitoring.

Guided by structural family systems theory, this study explored the relationship between parentification and adolescent daughters' sexual risk engagement and substance use. We also explored how adolescent reports of parental monitoring moderated the relationship between parentification and adolescent risk. Data were from a cross-sectional, cross-generational study of 176 mother-daughter dyads from low-income, inner-city, ethnic minority families. In this sample, which included a subset of mothers with HIV, parental physical symptoms were associated with slightly higher levels of parentification. Parentification was associated with adolescent daughters' intention to have sex (but not substance use) in a direction opposite to prediction. Higher parentification was associated with lower intention to have sex. Parental monitoring did not moderate relationships between parentification and adolescent risk. These findings highlight that despite the negative influence hypothesized in structural family systems theory, parentification was not associated with risk engagement of high-risk adolescent daughters in ethnic minority families with low income.

Interagency Collaborative Team Model for Capacity Building to Scale-Up Evidence-Based Practice.

BACKGROUND: System-wide scale up of evidence-based practice (EBP) is a complex process. Yet, few strategic approaches exist to support EBP implementation and sustainment across a service system. Building on the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework, we developed and are testing the Interagency Collaborative Team (ICT) process model to implement an evidence-based child neglect intervention (i.e., SafeCare®) within a large children's service system. The ICT model emphasizes the role of local agency collaborations in creating structural supports for successful implementation. METHODS: We describe the ICT model and present preliminary qualitative results from use of the implementation model in one large scale EBP implementation. Qualitative interviews were conducted to assess challenges in building system, organization, and home visitor collaboration and capacity to implement the EBP. Data collection and analysis centered on EBP implementation issues, as well as the experiences of home visitors under the ICT model. RESULTS: Six notable issues relating to implementation process emerged from participant interviews, including: (a) initial commitment and collaboration among stakeholders, (b) leadership, (c) communication, (d) practice fit with local context, (e) ongoing negotiation and problem solving, and (f) early successes. These issues highlight strengths and areas for development in the ICT model. CONCLUSIONS: Use of the ICT model led to sustained and widespread use of SafeCare in one large county. Although some aspects of the implementation model may benefit from enhancement, qualitative findings suggest that the ICT process generates strong structural supports for implementation and creates conditions in which tensions between EBP structure and local contextual variations can be resolved in ways that support the expansion and maintenance of an EBP while preserving potential for public health benefit.

Exploration and Adoption of Evidence-based Practice by US Child Welfare Agencies.

OBJECTIVE: To examine the extent to which child welfare agencies adopt new practices and to determine the barriers to and facilitators of adoption of new practices. METHODS: Data came from telephone interviews with the directors of the 92 public child welfare agencies that constituted the probability sample for the first National Survey of Child and Adolescent Well-being (NSCAWI). In a semi-structured 40 minute interview administered by a trained Research Associate, agency directors were asked about agency demographics, knowledge of evidence-based practices, use of technical assistance and actual use of evidence-based practices.. Of the 92 agencies, 83 or 90% agreed to be interviewed. RESULTS: Agencies reported that the majority of staff had a BA degree (53.45%) and that they either paid for (52.6%) or provided (80.7%) continuing education. Although agencies routinely collect standardized child outcomes (90%) they much less frequently collect measures of child functioning (30.9%). Almost all agencies (94%) had started a new program or practice but only 24.8% were evidence-based and strategies used to explore new programs or practices usually involved local or state contracts. Factors that were associated with program success included internal support for the innovation (27.3%), and an existing evidence base (23.5%). CONCLUSIONS: Directors of child welfare agencies frequently institute new programs or practices but they are not often evidence-based. Because virtually all agencies provide some continuing education adding discussions of evidence-based programs/practices may spur adaption. Reliance on local and state colleagues to explore new programs and practices suggests that developing well informed social networks may be a way to increase the spread of evidence0based practices.

Does socioeconomic and environmental burden affect vulnerability to extreme air pollution and heat? A case-crossover study of mortality in California.

BACKGROUND: Extreme heat and air pollution is associated with increased mortality. Recent evidence suggests the combined effects of both is greater than the effects of each individual exposure. Low neighborhood socioeconomic status ("socioeconomic burden") has also been associated with increased exposure and vulnerability to both heat and air pollution. We investigated if neighborhood socioeconomic burden or the combination of socioeconomic and environmental exposures ("socioenvironmental burden") modified the effect of combined exposure to extreme heat and particulate air pollution on mortality in California. METHODS: We used a time-stratified case-crossover design to assess the impact of daily exposure to extreme particulate matter <2.5 µm (PM2.5) and heat on cardiovascular, respiratory, and all-cause mortality in California 2014-2019. Daily average PM2.5 and maximum temperatures based on decedent's residential census tract were dichotomized as extreme or not. Census tract-level socioenvironmental and socioeconomic burden was assessed with the CalEnviroScreen (CES) score and a social deprivation index (SDI), and individual educational attainment was derived from death certificates. Conditional logistic regression was used to estimate associations of heat and PM2.5 with mortality with a product term used to evaluate effect measure modification. RESULTS: During the study period 1,514,292 all-cause deaths could be assigned residential exposures. Extreme heat and air pollution alone and combined were associated with increased mortality, matching prior reports. Decedents in census tracts with higher socioenvironmental and socioeconomic burden experienced more days with extreme PM2.5 exposure. However, we found no consistent effect measure modification by CES or SDI on combined or separate extreme heat and PM2.5 exposure on odds of total, cardiovascular or respiratory mortality. No effect measure modification was observed for individual education attainment. CONCLUSION: We did not find evidence that neighborhood socioenvironmental- or socioeconomic burden significantly influenced the individual or combined impact of extreme exposures to heat and PM2.5 on mortality in California. IMPACT: We investigated the effect measure modification by socioeconomic and socioenvironmental of the co-occurrence of heat and PM2.5, which adds support to the limited previous literature on effect measure modification by socioeconomic and socioenvironmental burden of heat alone and PM2.5 alone. We found no consistent effect measure modification by neighborhood socioenvironmental and socioeconomic burden or individual level SES of the mortality association with extreme heat and PM2.5 co-exposure. However, we did find increased number of days with extreme PM2.5 exposure in neighborhoods with high socioenvironmental and socioeconomic burden. We evaluated multiple area-level and an individual-level SES and socioenvironmental burden metrics, each estimating socioenvironmental factors differently, making our conclusion more robust.

Adaptation Resources and Responses to Wildfire Smoke and Other Forms of Air Pollution in Low-Income Urban Settings: A Mixed-Methods Study.

Little is known about how low-income residents of urban communities engage their knowledge, attitudes, behaviors, and resources to mitigate the health impacts of wildfire smoke and other forms of air pollution. We interviewed 40 adults in Los Angeles, California, to explore their threat assessments of days of poor air quality, adaptation resources and behaviors, and the impacts of air pollution and wildfire smoke on physical and mental health. Participants resided in census tracts that were disproportionately burdened by air pollution and socioeconomic vulnerability. All participants reported experiencing days of poor air quality due primarily to wildfire smoke. Sixty percent received advanced warnings of days of poor air quality or routinely monitored air quality via cell phone apps or news broadcasts. Adaptation behaviors included remaining indoors, circulating indoor air, and wearing face masks when outdoors. Most (82.5%) of the participants reported some physical or mental health problem or symptom during days of poor air quality, but several indicated that symptom severity was mitigated by their adaptive behaviors. Although low-income residents perceive themselves to be at risk for the physical and mental health impacts of air pollution, they have also adapted to that risk with limited resources.

Ambient temperature and air pollution associations with suicide and homicide mortality in California: A statewide case-crossover study.

BACKGROUND: Higher ambient temperature and air pollution may contribute to increased risk of behaviors harmful to oneself or to others; however, quantitative evidence is limited. We examined the relationship of deaths due to suicide and homicide with temperature and air pollution in California-a state prone to high levels of both exposures. METHOD: California death certificates from 2014 to 2019 were used to identify deaths due to suicide and homicide. Residential data for decedents were used to assign exposure to daily temperature (maximum[Tmax], minimum[Tmin]) and daily average air pollution concentrations (particulate matter <10 µm[PM10] and < 2.5 µm[PM2.5], nitrogen dioxide[NO2], ozone[O3]). Tmin served as a surrogate for nighttime temperature. A time-stratified case-crossover study design using conditional logistic regression was used to assess the effects of daily exposure to temperature and air pollutants on suicide and homicide mortality, adjusting for relative humidity. Effect modification by sex and age was assessed. RESULTS: We observed 24,387 deaths due to suicide and 10,767 deaths due to homicide. We found a monotonic temperature association for both outcomes. A 5 °C increase in Tmax at lag-2 and Tmin at lag-0 was associated with 3.1 % (95 % confidence interval [CI]: 1.1 %-5.2 %) and 3.8 % (95%CI: 0.9 %-6.8 %) increased odds of death due to suicide, respectively. The increased odds of homicide mortality per 5 °C increase in Tmax at lag-0 and Tmin at lag-1 were 4.9 % (95%CI: 1.6 %-8.1 %) and 6.2 % (95%CI: 1.6 %-11.0 %), respectively. No air pollutant associations were statistically significant. Temperature associations were robust after adjustment for PM2.5. Some temperature effects were larger among women for suicide and men for homicide mortality, and among those over age 65 years for both outcomes. CONCLUSION: Risk of suicide and homicide mortality increases with increasing daily ambient temperatures. Findings have public health relevance given anticipated increases in temperatures due to global climate change.

Caregiver reports of serious injuries in children who remain at home after a child protective services investigation.

The study objectives were to examine serious injuries requiring medical attention among children who remain at home after a child welfare/child protective services (CPS) maltreatment investigation in the US and to determine whether child/caregiver characteristics and ongoing CPS involvement are related to injuries requiring medical attention. Using the National Survey of Child and Adolescent Well-being, we analyzed data on the subsample of children who remained at home (N = 3,440). A multivariate logistic regression model included child characteristics, chronic illness and disability in the child, level of CPS involvement, subsequent foster care placement, caregiver characteristics, and caregiver/family psychological variables. Injuries requiring medical attention were identified in 10.6% of the in-home population over a 15-month period, with no differences in rates by age. Children with a chronic medical condition (OR = 2.07; 95% CI, 1.20-3.58) and children with depressed caregivers (OR = 2.28; 95% CI, 1.45-3.58) were more likely to have an injury that required medical care. Older caregivers (>54 years) were less likely (OR = 0.15; 95% CI, 0.03-0.69) to have a child with an injury requiring care. Injuries were not related to further involvement with CPS after the initial maltreatment investigation. Children with chronic medical conditions who remained in their biological homes or whose caregivers were depressed were likely to experience an injury requiring medical attention. Older caregivers were less likely to report a child injury. Extending existing health policies for foster children to children who remain at home following referral to CPS may encourage more comprehensive injury prevention for this population.

Evaluating child welfare policies with decision-analytic simulation models.

The objective was to demonstrate decision-analytic modeling in support of Child Welfare policymakers considering implementing evidence-based interventions. Outcomes included permanency (e.g., adoptions) and stability (e.g., foster placement changes). Analyses of a randomized trial of KEEP-a foster parenting intervention-and NSCAW-1 estimated placement change rates and KEEP's effects. A microsimulation model generalized these findings to other Child Welfare systems. The model projected that KEEP could increase permanency and stability, identifying strategies targeting higher-risk children and geographical regions that achieve benefits efficiently. Decision-analytic models enable planners to gauge the value of potential implementations.

Vulnerable, Resilient, or Both? A Qualitative Study of Adaptation Resources and Behaviors to Heat Waves and Health Outcomes of Low-Income Residents of Urban Heat Islands.

Little is known of how low-income residents of urban heat islands engage their knowledge, attitudes, behaviors, and resources to mitigate the health impacts of heat waves. In this qualitative study, we conducted semi-structured interviews with 40 adults in two such neighborhoods in Los Angeles California to explore their adaptation resources and behaviors, the impacts of heat waves on physical and mental health, and threat assessments of future heat waves. Eighty percent of participants received advanced warning of heat waves from television news and social media. The most common resource was air conditioning (AC) units or fans. However, one-third of participants lacked AC, and many of those with AC engaged in limited use due primarily to the high cost of electricity. Adaptation behaviors include staying hydrated, remaining indoors or going to cooler locations, reducing energy usage, and consuming certain foods and drinks. Most of the participants reported some physical or mental health problem or symptom during heat waves, suggesting vulnerability to heat waves. Almost all participants asserted that heat waves were likely to increase in frequency and intensity with adverse health effects for vulnerable populations. Despite limited resources, low-income residents of urban heat islands utilize a wide range of behaviors to minimize the severity of health impacts, suggesting they are both vulnerable and resilient to heat waves.

Advancing a conceptual model of evidence-based practice implementation in public service sectors.

Implementation science is a quickly growing discipline. Lessons learned from business and medical settings are being applied but it is unclear how well they translate to settings with different historical origins and customs (e.g., public mental health, social service, alcohol/drug sectors). The purpose of this paper is to propose a multi-level, four phase model of the implementation process (i.e., Exploration, Adoption/Preparation, Implementation, Sustainment), derived from extant literature, and apply it to public sector services. We highlight features of the model likely to be particularly important in each phase, while considering the outer and inner contexts (i.e., levels) of public sector service systems.