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.

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.

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.

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.

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.

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.

Maternal Relationship Insecurity and Depressive Symptoms as Moderators of Home Visiting Impacts on Child Outcomes.

The purpose of this study was to determine the extent to which maternal relationship insecurity and severe depressive symptoms moderate home visiting impacts on developmental and behavioral outcomes in 2-year old children. In an experimental trial of the Healthy Families Alaska home visiting program, families (N = 249) were randomly assigned to home visiting (n = 126) or community services as usual (n = 123). Maternal severe depressive symptoms (CES-D ≥ 24) and relationship insecurity were measured using the Center for Epidemiologic Studies Depression Scale and the Attachment Style Questionnaire at baseline. Child cognitive and psychomotor development and behavior problems were measured with the Bayley Scales of Infant Development and the Child Behavior Checklist at follow-up. The results revealed that home visiting significantly impacted three outcomes- child cognitive development, internalizing behavior, and externalizing behavior. Home visiting impacts were limited to subgroups defined by maternal depressive symptoms and relationship insecurity. Home visiting improved cognitive development (B = 6.02, p < .03), and decreased internalizing behavior (B = -3.83, p = .02) and externalizing behavior problems (B = -3.74, p = .03) in children of mothers with either severe depressive symptoms or high levels of discomfort with trust at baseline, but not both. Family engagement in home visiting seems to play a role in mediating these moderating effects. These findings reflect the importance of screening for maternal relationship insecurity and depressive symptoms to distinguish family subgroups likely to benefit from home visiting from those for whom an enhanced service model might be needed.

Improving capacity to monitor and support sustainability of mental health peer-run organizations.

Peer-run mental health organizations are managed and staffed by people with lived experience of the mental health system. These understudied organizations are increasingly recognized as an important component of the behavioral health care and social support systems. This Open Forum describes the National Survey of Peer-Run Organizations, which was conducted in 2012 to gather information about peer-run organizations and programs, organizational operations, policy perspectives, and service systems. A total of 895 entities were identified and contacted as potential peer-run organizations. Information was obtained for 715 (80%) entities, and 380 of the 715 responding entities met the criteria for a peer-run organization. Implementation of the Affordable Care Act may entail benefits and unintended consequences for peer-run organizations. It is essential that we understand this population of organizations and continue to monitor changes associated with policies intended to provide better access to care that promotes wellness and recovery.

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.

School mental health resources and adolescent mental health service use.

OBJECTIVE: Although schools are identified as critical for detecting youth mental disorders, little is known about whether the number of mental health providers and types of resources that they offer influence student mental health service use. Such information could inform the development and allocation of appropriate school-based resources to increase service use. This article examines associations of school resources with past-year mental health service use among students with 12-month DSM-IV mental disorders. METHOD: Data come from the U.S. National Comorbidity Survey Adolescent Supplement (NCS-A), a national survey of adolescent mental health that included 4,445 adolescent-parent pairs in 227 schools in which principals and mental health coordinators completed surveys about school resources and policies for addressing student emotional problems. Adolescents and parents completed the Composite International Diagnostic Interview and reported mental health service use across multiple sectors. Multilevel multivariate regression was used to examine associations of school mental health resources and individual-level service use. RESULTS: Nearly half (45.3%) of adolescents with a 12-month DSM-IV disorder received past-year mental health services. Substantial variation existed in school resources. Increased school engagement in early identification was significantly associated with mental health service use for adolescents with mild/moderate mental and behavior disorders. The ratio of students to mental health providers was not associated with overall service use, but was associated with sector of service use. CONCLUSIONS: School mental health resources, particularly those related to early identification, may facilitate mental health service use and may influence sector of service use for youths with DSM disorders.

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.

Effects of school-wide positive behavioral interventions and supports on child behavior problems.

OBJECTIVE: School-Wide Positive Behavioral Interventions and Supports (SWPBIS) is a universal prevention strategy currently implemented in >16,000 schools across the United States. SWPBIS intends to reduce students' behavior problems by altering staff behaviors and developing systems and supports to meet children's behavioral needs. The current study reports intervention effects on child behaviors and adjustment from an effectiveness trial of SWPBIS. METHODS: The sample of 12,344 elementary school children was 52.9% male, 45.1% African American, and 46.1% Caucasian. Approximately 49% received free or reduced-priced meals, and 12.9% received special education services at baseline. The trial used a group randomized controlled effectiveness design implemented in 37 elementary schools. Multilevel analyses were conducted on teachers' ratings of children's behavior problems, concentration problems, social-emotional functioning, prosocial behavior, office discipline referrals, and suspensions at 5 time points over the course of 4 school years. RESULTS: The multilevel results indicated significant effects of SWPBIS on children's behavior problems, concentration problems, social-emotional functioning, and prosocial behavior. Children in SWPBIS schools also were 33% less likely to receive an office discipline referral than those in the comparison schools. The effects tended to be strongest among children who were first exposed to SWPBIS in kindergarten. CONCLUSIONS: These findings provide support for the hypothesized reduction in behavior problems and improvements in prosocial behavior and effective emotion regulation after training in SWPBIS. The SWPBIS framework appears to be a promising approach for reducing problems and promoting adjustment among elementary school children.

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.

The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial.

OBJECTIVE: To build on prior research documenting the impact of School-wide Positive Behavioral Interventions and Supports (SWPBIS) on school climate and discipline problems to examine the extent to which it affects bullying and peer rejection during the transition into early adolescence. DESIGN: Three-level models were fit using hierarchical linear modeling to determine the effect of SWPBIS on children's involvement in bullying. SETTING: Thirty-seven Maryland public elementary schools. PARTICIPANTS: Data involved 12 344 children (52.9% male, 45.1% African American, 46.1% white) followed up longitudinally across 4 school years. INTERVENTION: A randomized controlled effectiveness trial of SWPBIS. OUTCOME MEASURES: Reports from teachers on bully-related behaviors were assessed through the Teacher Observation of Classroom Adaptation-Checklist. RESULTS: Analyses indicated that children in schools that implemented SWPBIS displayed lower rates of teacher-reported bullying and peer rejection than those in schools without SWPBIS. A significant interaction also emerged between grade level of first exposure to SWPBIS and intervention status, suggesting that the effects of SWPBIS on rejection were strongest among children who were first exposed to SWPBIS at a younger age. CONCLUSIONS: The results indicated that SWPBIS has a significant effect on teachers' reports of children's involvement in bullying as victims and perpetrators. The findings were considered in light of other outcomes for students, staff, and the school environment, and they suggest that SWPBIS may help address the increasing national concerns related to school bullying by improving school climate.

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.

Multiple imputation by chained equations: what is it and how does it work?

Multivariate imputation by chained equations (MICE) has emerged as a principled method of dealing with missing data. Despite properties that make MICE particularly useful for large imputation procedures and advances in software development that now make it accessible to many researchers, many psychiatric researchers have not been trained in these methods and few practical resources exist to guide researchers in the implementation of this technique. This paper provides an introduction to the MICE method with a focus on practical aspects and challenges in using this method. A brief review of software programs available to implement MICE and then analyze multiply imputed data is also provided.