Partnered implementation of the veteran sponsorship initiative: protocol for a randomized hybrid type 2 effectiveness-implementation trial.

BACKGROUND: The USA is undergoing a suicide epidemic for its youngest Veterans (18-to-34-years-old) as their suicide rate has almost doubled since 2001. Veterans are at the highest risk during their first-year post-discharge, thus creating a "deadly gap." In response, the nation has developed strategies that emphasize a preventive, universal, and public health approach and embrace the value of community interventions. The three-step theory of suicide suggests that community interventions that reduce reintegration difficulties and promote connectedness for Veterans as they transition to civilian life have the greatest likelihood of reducing suicide. Recent research shows that the effectiveness of community interventions can be enhanced when augmented by volunteer and certified sponsors (1-on-1) who actively engage with Veterans, as part of the Veteran Sponsorship Initiative (VSI). METHOD/DESIGN: The purpose of this randomized hybrid type 2 effectiveness-implementation trial is to evaluate the implementation of the VSI in six cities in Texas in collaboration with the US Departments of Defense, Labor and Veterans Affairs, Texas government, and local stakeholders. Texas is an optimal location for this large-scale implementation as it has the second largest population of these young Veterans and is home to the largest US military installation, Fort Hood. The first aim is to determine the effectiveness of the VSI, as evidenced by measures of reintegration difficulties, health/psychological distress, VA healthcare utilization, connectedness, and suicidal risk. The second aim is to determine the feasibility and potential utility of a stakeholder-engaged plan for implementing the VSI in Texas with the intent of future expansion in more states. The evaluators will use a stepped wedge design with a sequential roll-out to participating cities over time. Participants (n=630) will be enrolled on military installations six months prior to discharge. Implementation efforts will draw upon a bundled implementation strategy that includes strategies such as ongoing training, implementation facilitation, and audit and feedback. Formative and summative evaluations will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and will include interviews with participants and periodic reflections with key stakeholders to longitudinally identify barriers and facilitators to implementation. DISCUSSION: This evaluation will have important implications for the national implementation of community interventions that address the epidemic of Veteran suicide. Aligned with the Evidence Act, it is the first large-scale implementation of an evidence-based practice that conducts a thorough assessment of TSMVs during the "deadly gap." TRIAL REGISTRATION: ClinicalTrials.gov ID number: NCT05224440 . Registered on 04 February 2022.

The Effect of EITC Exposure in Childhood on Marriage and Early Childbearing.

Using data from the Panel Study of Income Dynamics, this study analyzes the effect of exposure to the Earned Income Tax Credit (EITC) in childhood on marriage and childbearing in early adulthood. Results suggest that EITC exposure in childhood leads women to delay marriage and first births in early adulthood (ages 16-25), but has no effect on men. A $1,000 increase in EITC exposure in childhood leads to a 2%-3% decline in a woman's likelihood of having a first birth and a comparable decline in her likelihood of marrying by her early 20s. We find similar reductions in fertility among Black and White women, though marriage declines are concentrated among White women. Results are focused on children growing up in the bottom half of the income distribution and those who spent the majority of childhood residing with a single parent-two groups that are the primary beneficiaries of the EITC. These findings have important implications for the well-being of individuals exposed to the EITC in childhood, as well as their future children.

Health Insurance and Human Capital: Evidence from the Affordable Care Act's Dependent Coverage Mandate.

Prior to 2010, young adults between the ages of 18 and 34 had the highest rates of uninsurance in America. The "Dependent Care Provision" of the Affordable Care Act sought to increase insurance rates among young adults by allowing them to stay on their parents' policy until age 26. We examine the human capital decisions young adults make once they have an option for health insurance outside of employer-sponsored health insurance. Using the American Community Survey from 2001 to 2016 and a difference-in-differences research design, we found that the implementation of the mandate was associated with a 3-5 percent increase in college enrollment among women 23-25 years of age. This result is robust to a variety of specifications. We did not find a consistent effect among men. Our results suggest that increased flexibility in health insurance markets has implications for human capital investment.

Household Crowding During Childhood and Long-Term Education Outcomes.

Household crowding, or having more household members than rooms in one's residence, could potentially affect a child's educational attainment directly through a number of mechanisms. We use U.S. longitudinal data from the Panel Study of Income Dynamics to derive new measures of childhood crowding and estimate negative associations between crowding during one's high school years and, respectively, high school graduation by age 19 and maximum education at age 25. These negative relationships persist in multivariate models in which we control for the influence of a variety of factors, including socioeconomic status and housing-cost burden. Given the importance of educational attainment for a range of midlife and later-life outcomes, this study suggests that household crowding during one's high school years is an engine of cumulative inequality over the life course.

Family structure and the economic wellbeing of children in youth and adulthood.

An extensive literature on the relationship between family structure and children's outcomes consistently shows that living with a single parent is associated with negative outcomes. Few US studies, however, examine how a child's family structure affects outcomes for the child once he/she reaches adulthood. We directly examine, using the Panel Study of Income Dynamics, whether family structure during childhood is related to the child's economic wellbeing both during childhood as well as during adulthood. We find that living with a single parent is associated with the level of family resources available during childhood. This finding persists even when we remove time invariant factors within families. We also show that family structure is related to the child's education, marital status, and adult family income. Once we control for the child's demography and economic wellbeing in childhood, however, the associations into adulthood become trivial in size and statistically insignificant, suggesting that the relationship between family structure and children's long-term, economic outcomes is due in large part to the relationship between family structure and economic wellbeing in childhood.

Medicaid expansions and fertility in the United States.

Beginning in the mid-1980s and extending through the early to mid-1990s, a substantial number of women and children in the United States gained eligibility for Medicaid through a series of income-based expansions. Using natality data from the National Center for Health Statistics, we estimate fertility responses to these eligibility expansions. We follow Currie and Gruber (2001) and measure changes in state Medicaid-eligibility policy by simulating the fraction of a standard population that would qualify for benefits in different states and different time periods. From 1985 to 1996, the fraction of women aged 15-44 who were eligible for Medicaid coverage for a pregnancy increased more than 20 percentage points. When we use a state and year fixed-effects model with a limited set of covariates, our estimates indicate that fertility increases in response to Medicaid expansions. However, after we include fixed effects for demographic characteristics, the estimated relationship diminishes substantially in size and is no longer statistically significant. We conclude that there is no robust relationship between Medicaid expansions and fertility.

Labor and delivery complications among teenage mothers.

A broad set of academic literatures shows that childbearing is associated with a variety of negative health outcomes for teenage mothers. Many researchers question whether teenage childbearing is the causal explanation for the negative outcomes (i.e., whether there is a biological effect of teenage childbearing or whether the relationship is due to other factors correlated with health and teenage childbearing). This study investigates the relationship between teenage childbearing and labor and delivery complications using a panel of confidential birth certificate data over the period from 1994 to 2003 from the state of Texas. Findings show that compared to mothers aged 25 to 29 having their first child, teenager mothers appear to have superior health in most--but not all--labor and delivery outcomes.

Maternal employment and the health of low-income young children.

This study examines whether maternal employment affects the health status of low-income, elementary-school-aged children using instrumental variables estimation and experimental data from a welfare-to-work program implemented in the early 1990s. Maternal report of child health status is predicted as a function of exogenous variation in maternal employment associated with random assignment to the experimental group. IV estimates show a modest adverse effect of maternal employment on children's health. Making use of data from another welfare-to-work program we propose that any adverse effect on child health may be tempered by increased family income and access to public health insurance coverage, findings with direct relevance to a number of current policy discussions. In a secondary analysis using fixed effects techniques on longitudinal survey data collected in 1998 and 2001, we find a comparable adverse effect of maternal employment on child health that supports the external validity of our primary result.

Maternal work hours and adolescents' school outcomes among low-income families in four urban counties.

We examine how changes in maternal work hours affect adolescent children's school participation and performance outcomes using data from interviews in 1998 and 2001 with approximately 1700 women who, in May 1995, were welfare-reliant, single mothers of adolescents living in neighborhoods of concentrated poverty in Cuyahoga (Cleveland), Los Angeles, Miami-Dade, and Philadelphia counties. Analyses control for a broad array of mothers' characteristics, including their psychological and physical health, experiences with domestic violence and substance abuse, as well as unobserved time-invariant characteristics. In fixed-effects models, we find unfavorable effects of increased maternal work hours on three of six outcomes: skipping school, performing above average, and parental contact about behavior problems. Adolescent-aged sons seem to be particularly sensitive to changes in mothers' hours of work.

Did welfare reform influence the fertility of young teens?

During the 1990s, states made several reforms to their welfare programs designed to reduce teenage fertility among minors. Among the most prominent of these changes, states started requiring teenage mothers younger than 18 to live with a parent or legal guardian and enroll in high school in order to receive welfare benefits. Using natality data from the National Center for Health Statistics, we compare the trend in fertility rates for young women aged 15 to 17 to the trend for a control group of 18-year-olds. Our estimates imply that the annual percent decline in fertility rates following implementation of these minor parent provisions was 0.7 percentage points larger for young teens than for teens aged 18, a difference of over 22 percent.