Using behavioral theory to adapt advance care planning for homeless-experienced older adults in permanent supportive housing.

BACKGROUND: Older adults experiencing chronic homelessness (i.e., prolonged homelessness and a disabling condition) have low rates of advance care planning (ACP) despite high rates of morbidity and mortality. Rehousing of homeless-experienced individuals into permanent supportive housing (PSH) may present an opportunity to introduce ACP; but this is unknown. Therefore, we explored staff and resident perceptions of conducting ACP in PSH. METHODS: We conducted semi-structured interviews with PSH staff (n = 13) and tenants (PSH residents) (n = 26) in San Francisco. We used the capability (C), opportunity (O), motivation (M), behavior (COM-B) framework within the Behavior Change Wheel model and the Theoretical Domains Framework (TDF) to inform interviews, categorize themes, and guide qualitative thematic analysis. RESULTS: The mean age of PSH residents was 67 (SD = 6.1) years and 52% were women. Of staff, 69% were women. Important COM-B barriers included ACP complexity (C), complicated relationship dynamics (O), resource limitations (O), pessimism (M), variable staff confidence (M), and competing priorities (M). Facilitators included easy-to-use documents/videos, including the PREPARE for Your Care program (C), stability with housing (O), exposure to health crises (O), potential for strong relationships (O), and belief that ACP is impactful (M). Recommendations included adapting materials to the PSH setting, providing staff trainings/scripts, and using optional one-on-one or group sessions. CONCLUSIONS: We identified behavioral determinants related to ACP for formerly chronically homeless older adults in PSH. Future interventions should include using easy-to-use ACP materials and developing resources to educate PSH residents, train staff, and model ACP in groups or one-on-one sessions.

Enhancing grant-writing expertise in BUILD institutions: Building infrastructure leading to diversity.

BACKGROUND: The lack of race/ethnic and gender diversity in grants funded by the National Institutes of Health (NIH) is a persistent challenge related to career advancement and the quality and relevance of health research. We describe pilot programs at nine institutions supported by the NIH-sponsored Building Infrastructure Leading to Diversity (BUILD) program aimed at increasing diversity in biomedical research. METHODS: We collected data from the 2016-2017 Higher Education Research Institute survey of faculty and NIH progress reports for the first four years of the program (2015-2018). We then conducted descriptive analyses of data from the nine BUILD institutions that had collected data and evaluated which activities were associated with research productivity. We used Poisson regression and rate ratios of the numbers of BUILD pilots funded, students included, abstracts, presentations, publications, and submitted and funded grant proposals. RESULTS: Teaching workshops were associated with more abstracts (RR 4.04, 95% CI 2.21-8.09). Workshops on grant writing were associated with more publications (RR 2.64, 95% CI 1.64-4.34) and marginally with marginally more presentations. Incentives to develop courses were associated with more abstracts published (RR 4.33, 95% CI 2.56-7.75). Workshops on research skills and other incentives were not associated with any positive effects. CONCLUSIONS: Pilot interventions show promise in supporting diversity in NIH-level research. Longitudinal modeling that considers time lags in career development in moving from project development to grants submissions can provide more direction for future diversity pilot interventions.

Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study.

BACKGROUND: The homeless population is aging, with early onset of cognitive and functional impairments. It is unclear whether older homeless adults receive caregiving assistance that could prevent long-term disability. OBJECTIVE: We describe characteristics of older homeless-experienced adults with caregiving need and determine factors associated with having unmet need. DESIGN AND PARTICIPANTS: Cross-sectional analysis of a longitudinal study, Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME), examining health, life course events, and functional status among older homeless-experienced (i.e., currently and recently homeless) adults. We recruited 350 homeless adults (July 2013-June 2014) and an additional 100 (August 2017 to July 2018) in Oakland, California; this study includes 303 participants who completed caregiving interviews. MEASUREMENTS: We defined caregiving need as difficulty with activities of daily living (ADLs), instrumental activities of daily living (IADLs), falls, Short Physical Performance Battery (SPPB) score < 10, or Modified Mini-Mental State (3MS) exam impairment. We defined unmet need as having caregiving need and reporting not receiving caregiving assistance in the last 6 months. Using logistic regression, we analyzed associations between respondent characteristics and unmet caregiving need. RESULTS: Among 303 participants, the mean age was 61.3 ± 5.0 years; 73% were men and 82% were Black. Eighty-one percent had caregiving needs, and in 82% of those, their caregiving needs were unmet. Better self-rated health (AOR 2.13, CI [1.02-4.46], p = 0.04) and being a man (AOR 2.30, CI [1.12-4.69], p = 0.02) were associated with higher odds of unmet need. Moderate or high-risk substance use (AOR 0.47, CI [0.23, 0.94], p = 0.03) was associated with lower odds of unmet need. CONCLUSIONS: Older homeless-experienced adults have high prevalence of unmet caregiving need. Interventions that increase caregiving access for homeless-experienced individuals may help avoid poor health outcomes and costly long-term-care needs due to untreated disabilities.

Factors Associated with Incarceration in Older Adults Experiencing Homelessness: Results from the HOPE HOME Study.

BACKGROUND: In the US, the median age of adults experiencing homelessness and incarceration is increasing. Little is known about risk factors for incarceration among older adults experiencing homelessness. To develop targeted interventions, there is a need to understand their risk factors for incarceration. OBJECTIVE: To examine the prevalence and risk factors associated with incarceration in a cohort of older adults experiencing homelessness. DESIGN: Prospective, longitudinal cohort study with interviews every 6 months for a median of 5.8 years. PARTICIPANTS: We recruited adults ≥50 years old and homeless at baseline (n=433) via population-based sampling. MAIN MEASURES: Our dependent variable was incident incarceration, defined as one night in jail or prison per 6-month follow-up period after study enrollment. Independent variables included socioeconomic status, social, health, housing, and prior criminal justice involvement. KEY RESULTS: Participants had a median age of 58 years and were predominantly men (75%) and Black (80%). Seventy percent had at least one chronic medical condition, 12% reported heavy drinking, and 38% endorsed moderate-severe use of cocaine, 8% of amphetamines, and 7% of opioids. At baseline, 84% reported a lifetime history of jail stays; 37% reported prior prison stays. During follow-up, 23% spent time in jail or prison. In multivariable models, factors associated with a higher risk of incarceration included the following: having 6 or more confidants (HR=2.13, 95% CI=1.2-3.7, p=0.007), remaining homeless (HR=1.72, 95% CI=1.1-2.8, p=0.02), heavy drinking (HR=2.05, 95% CI=1.4-3.0, p<0.001), moderate-severe amphetamine use (HR=1.89, 95% CI=1.2-3.0, p=0.006), and being on probation (HR=3.61, 95% CI=2.4-5.4, p<0.001) or parole (HR=3.02, 95% CI=1.5-5.9, p=0.001). CONCLUSIONS: Older adults experiencing homelessness have a high risk of incarceration. There is a need for targeted interventions addressing substance use, homelessness, and reforming parole and probation in order to abate the high ongoing risk of incarceration among older adults experiencing homelessness.

Persistent Homelessness and Violent Victimization Among Older Adults in the HOPE HOME Study.

The homeless population is aging; older homeless adults may be at high risk of experiencing violent victimization. To examine whether homelessness is independently associated with experiencing physical and sexual abuse, we recruited 350 adults, aged 50 and older in Oakland, California, who met criteria for homelessness between July 2013 and June 2014. We interviewed participants at 6-month intervals for 3 years in Oakland about key variables, including housing status. Using generalized estimating equations, we examined whether persistent homelessness in each follow-up period was independently associated with having experienced physical or sexual victimization, after adjusting for known risk factors. The majority of the cohort was men (77.4%) and Black American (79.7%). At baseline, 10.6% had experienced either physical or sexual victimization in the prior 6 months. At 18-month follow-up, 42% of the cohort remained homeless. In adjusted models, persistent homelessness was associated with twice the odds of victimization (adjusted odds ratio [AOR] = 2.01; 95% confidence interval [CI]: [1.41, 2.87]). Older homeless adults experience high rates of victimization. Re-entering housing reduces this risk. Policymakers should recognize exposure to victimization as a negative consequence of homelessness that may be preventable by housing.

Barriers and Solutions to Advance Care Planning among Homeless-Experienced Older Adults.

Background/Objectives: Older homeless-experienced adults have low rates of advance care planning (ACP) engagement despite high rates of morbidity and mortality. To inform intervention development, we examined potential barriers and solutions to ACP engagement. Design: Cross-sectional qualitative study. Setting: We recruited adults who were homeless in the prior three years and ≥50 years of age in the San Francisco Bay Area, and recruited clinical stakeholders from a national meeting of homeless providers. We analyzed qualitative data using thematic analysis. Measurements: We conducted semistructured interviews with homeless-experienced older adults (n = 20) and focus groups with clinical stakeholders (n = 24) about perceived barriers and solutions to ACP engagement. Results: Participants considered ACP important, reflecting on deaths of people in their networks who had died. Participant-identified barriers to ACP included poor ACP knowledge, lack of familial ties and social isolation, competing priorities, avoidance and lack of readiness, fatalism and mistrust, and lack of ACP training for clinical and nonclinical staff. They identified solutions that included framing ACP as a way to provide meaning and assert choice, providing easy-to-read written documents focused on the populations' unique needs, tailoring content and delivery, initiating ACP in nonclinical settings, such as permanent supportive housing, and providing incentives. Conclusions: Both older homeless-experienced adults and clinical stakeholders believe that ACP is important, but acknowledge multiple barriers that impede engagement. By focusing on potential solutions, including capitalizing on opportunities outside of health care settings, focusing on the period after housing, and tailoring content, there are opportunities to improve ACP uptake.

Risk Factors for Falls in Older Adults Experiencing Homelessness: Results from the HOPE HOME Cohort Study.

BACKGROUND: More than half of homeless adults are of age ≥ 50 years. Falls are a common cause of morbidity in older adults in the general population. Risk factors for falls in the general population include poor health, alcohol use, and exposure to unsafe environments. Homeless adults aged ≥ 50 have a high prevalence of known risk factors and face additional potential risks. OBJECTIVES: To examine the prevalence of and risk of falling in a cohort of older homeless adults. DESIGN: Longitudinal cohort study with participant interviews every 6 months for 3 years; data were analyzed using generalized estimating equations (GEEs). PARTICIPANTS: Three hundred fifty adults aged ≥ 50, homeless at study entry, recruited via population-based sampling. MEASURES: The dependent variable is any falls in prior 6 months; independent variables include individual (i.e., illness, behaviors) and social/environmental (i.e., social support, experiencing violence, living unsheltered) factors. RESULTS: Over three quarters of participants were men (77.1%) and Black (79.7%). The median age was 58 (IQR 54, 61). At baseline, one third (33.7%) reported a fall in the prior 6 months. At follow-up visits, 23.1% to 31.2% of participants reported having fallen. In GEE models, individual risk factors (non-Black race, being a women, older age, functional impairment, urinary incontinence, history of stroke, and use of assistive devices, opioid, and marijuana) were associated with increased odds of falls. Environmental and social factors (spending any nights unsheltered (adjusted odds ratio (AOR) = 1.42, CI = 1.10-1.83) and experiencing physical assault (AOR = 1.67, CI = 1.18-2.37) were also associated. CONCLUSIONS: Older homeless adults fall frequently. Likely contributors include having a high prevalence of conditions that increase the risk of falls, compounded by heightened exposure to unsafe environments. Fall prevention in this population should target those at highest risk and address modifiable environmental conditions. Providing shelter or housing and addressing substance use could reduce morbidity from falls in homeless older adults.

Trajectories of functional impairment in homeless older adults: Results from the HOPE HOME study.

Difficulty performing activities of daily living ("functional impairment") is common in homeless adults aged 50 and older. However, little is known about the trajectory of these impairments, nor the extent to which these trajectories are similar to those of older adults in the general population. We identified trajectories of functional impairment in homeless adults aged 50 and older, and risk factors for differing trajectories. We conducted a prospective cohort study of 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, California and interviewed at 6-month intervals for up to 3 years. We assessed functional trajectories based on self-reported difficulty performing 5 activities of daily living. We used multivariable multinomial logistic regression to identify baseline risk factors for each trajectory. At baseline, participants' mean age was 58 years (SD, 5.3), 24.1% were women, 80.9% were African American, and 38.6% had difficulty performing 1 or more activities of daily living. We identified 4 distinct functional trajectories: minimal impairment in 136 participants (41.1%); persistent impairment in 81 (25.4%); partial improvement in 74 (23.5%); and decline in 28 (10.0%). Risk factors for persistent impairment included falls in the 6 months before baseline, depressive symptoms, and low physical performance. Although functional impairment improved in some homeless adults, it persisted or worsened in many others. These findings suggest that, similar to older adults in the general population, functional impairment among older homeless persons is not a transient phenomenon, but instead a chronic issue requiring long-term solutions.

Unmet mental health and substance use treatment needs among older homeless adults: Results from the HOPE HOME Study.

AIMS: To examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults. METHODS: Among 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need. RESULTS: Among those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment. CONCLUSION: Older homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.

Oral health and access to dental care among older homeless adults: results from the HOPE HOME study.

OBJECTIVES: To describe the prevalence of and factors associated with oral health measures in a sample of older homeless adults in Oakland, CA. METHODS: We conducted a cross-sectional analysis of data from a population-based study of 350 homeless adults aged ≥50 in which trained researchers conducted structured interviews using validated questions regarding sociodemographics, health-related behaviors, healthcare utilization, and health status. We assessed self-reported tooth loss, oral pain, and unmet need for dental care. We used multivariable logistic regression to examine factors associated with missing half or more teeth. RESULTS: Over half 201/350 (57.4 percent) of participants were missing at least half of their teeth. Half 191/350 (54.6 percent) reported oral pain in the past 6 months; 101/350 (28.9 percent) reported that oral pain prevented them from eating and 73/350 (20.9 percent) reported that pain prevented sleeping. Almost half, 141/350 (40.3 percent), had not seen a dentist in over 5 years, and over half 190/350 (54.3 percent) reported being unable to obtain needed dental care. In multivariate models, increased age (AOR = 1.09, 95 percent CI 1.04-1.14), moderate-to-high risk alcohol use (AOR = 2.17, CI = 1.23-3.84), moderate-to-high risk cocaine use (AOR = 1.72, CI = 1.03-2.88), and ever smoking (AOR = 2.87, CI = 1.59-5.18) were associated with an increased odds of having lost half or more teeth. CONCLUSIONS: Tooth loss and oral pain are highly prevalent in older homeless adults. Increasing age, alcohol, drug, and tobacco use are associated with tooth loss.

Mobile Phone, Computer, and Internet Use Among Older Homeless Adults: Results from the HOPE HOME Cohort Study.

BACKGROUND: The median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults. OBJECTIVE: This study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years. METHODS: We recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies. RESULTS: Of the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72). CONCLUSIONS: Older homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.

Advance Care Planning for Older Homeless-Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study.

Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.

'The Thing that Really Gets Me Is the Future': Symptomatology in Older Homeless Adults in the HOPE HOME Study.

CONTEXT: The homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults. OBJECTIVES: To characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults. METHODS: We conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis. RESULTS: We found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use. CONCLUSION: Homelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.

Examination of associations between early life victimisation and alcohol's harm from others.

INTRODUCTION AND AIMS: Study aims were to examine: (i) how physical and sexual victimisation in early life are associated with alcohol's harm from others; and (ii) whether respondents' current drinking is a mediator of the association between early life victimisation and alcohol's harm from others among men and women. DESIGN AND METHODS: Data were from national computer-assisted telephone interviews, using the landline sample (3335 men and 3520 women ages ≥18) from the 2010 US National Alcohol Survey. Harms from someone else's drinking included family/marital problems, financial troubles, assault and vandalism in the past 12 months. Victimisation was measured with severe physical abuse or sexual assault before age 18. RESULTS: Severe physical or sexual victimisation before age 18 was reported by 3.4% of men and 8.1% of women. Significantly more men (5.2%) than women (2.4%) reported assault by other drinkers, and significantly more women reported family/marital (5.3%) and financial problems (2.8%) than did men (2.6 and 1% respectively). Severe early life victimisation was robustly associated with a greater likelihood of experiencing past-year harms from other drinkers for both men and women. Men's drinking partially mediated associations between early life victimisation and recent assaults and vandalism by other drinkers. DISCUSSION AND CONCLUSIONS: Early life victimisation may increase risk of harms from someone else's drinking. Health services and interventions that screen for histories of victimisation may help decrease risk of later harms from others' drinking. Reductions in drinking among men with histories of victimisation also could help reduce their exposure to such harms. [Kaplan LM, Greenfield TK, Karriker-Jaffe KJ. Examination of associations between early life victimisation and alcohol's harm from others.

Drinking context and alcohol's harm from others among men and women in the 2010 US National Alcohol Survey.

BACKGROUND: Little is known about how drinking in different contexts is associated with harms from someone else's drinking, including marital problems, financial problems, and assault. We examined how drinking in four different contexts was associated with alcohol's harm from others (AHFO). METHODS: We utilized the landline sample of the 2010 US National Alcohol Survey (n = 5,885) to examine associations between drinking context and AHFO using weighted binary logistic regression. RESULTS: For women, drinking when friends dropped over was positively associated with assault and financial troubles due to someone else's drinking. Drinking when friends dropped over was negatively associated with assault for men. For men, drinking at a bar, party, or during a quiet evening at home were each significantly associated with more assault by someone who had been drinking. Bar drinking among women was significantly associated with more marital problems, whereas drinking at a party at someone else's home was associated with significantly less marital problems. CONCLUSIONS: Context-specific drinking has differential associations with specific types of harms from someone else's drinking for men and women. Additional research on drinking context, relationship to the harmer, and violence experienced by men and women is needed.

Distress and alcohol-related harms from intimates, friends, and strangers.

Alcohol's harms to others (AHTO) has gained increased research and policy attention, yet little information is available on different social relationships involved in such harms or consequences of harms perpetrated by various types of drinkers. Using data from the 2014-15 U.S. National Alcohol Survey (N=5,922), we present analyses comparing frequency and impacts of eight past-year harms from other drinkers. In this sample (53% female; 66% White/Caucasian, 13% Black/African American, and 15% other race; 15% Hispanic/Latino of any race; mean age=47 years), 19% reported at least one harm in the prior 12 months, 8% reported more than one harm, 4.9% reported a family perpetrator, 3.5% a spouse perpetrator, 6.1% a friend perpetrator, and 8.1% a stranger perpetrator. Controlling for basic demographics, the number of harms in the past year and harms perpetrated by known others (but not strangers) were significantly associated with recent distress. When comparing specific harms, financial problems due to a family member's or a spouse/partner's drinking each were associated with significantly greater distress, as were feeling threatened or afraid of family members, spouses/partners or friends who had been drinking. These new data shed light on possible intervention points to reduce negative impacts of AHTO in the U.S.

Alcohol's Harm to Children: Findings from the 2015 United States National Alcohol's Harm to Others Survey.

OBJECTIVES: To examine the prevalence and severity of alcohol's harm to children in the US and the relationship of the harmer to the child, and to examine caregivers' sociodemographic characteristics, alcohol use, and exposure to harm due to a drinking spouse/partner or other family member as risk factors for alcohol's harm to children. STUDY DESIGN: We report data on 764 caregivers (defined as persons with parental responsibility for at least 1 child aged ≤17 years) from the 2015 National Alcohol's Harm to Others Survey, a dual-frame national sample of US adults. RESULTS: Overall 7.4% of caregivers reported alcohol's harm to children in the past year. Risk factors for alcohol's harm to children included the caregiver's own experience of alcohol's harm from a spouse/partner or other family member. Caregivers with a heavy drinker in the household were significantly more likely to report harm to children. A caregiver's own heavy drinking was not a significant risk factor for children in his or her care. CONCLUSIONS: Alcohol places a substantial burden on children in the US. Although a caregiver's own drinking can harm children, other drinkers also increase the risk of alcohol's harm to children. Screening caregivers to determine whether there is a heavy drinker in the household may help reduce alcohol's harm in the family without stigmatizing caregivers, who themselves may not be heavy drinkers.

Reducing child abuse amongst adolescents in low- and middle-income countries: A pre-post trial in South Africa.

BACKGROUND: No known studies have tested the effectiveness of child abuse prevention programmes for adolescents in low- or middle-income countries. 'Parenting for Lifelong Health' ( http://tiny.cc/whoPLH ) is a collaborative project to develop and rigorously test abuse-prevention parenting programmes for free use in low-resource contexts. Research aims of this first pre-post trial in South Africa were: i) to identify indicative effects of the programme on child abuse and related outcomes; ii) to investigate programme safety for testing in a future randomised trial, and iii) to identify potential adaptations. METHODS: Two hundred thirty participants (adolescents and their primary caregivers) were recruited from schools, welfare services and community-sampling in rural, high-poverty South Africa (no exclusion criteria). All participated in a 12-week parenting programme, implemented by local NGO childcare workers to ensure real-world external validity. Standardised pre-post measures with adolescents and caregivers were used, and paired t-tests were conducted for primary outcomes: abuse (physical, emotional abuse and neglect), adolescent behaviour problems and parenting (positive and involved parenting, poor monitoring and inconsistent discipline), and secondary outcomes: mental health, social support and substance use. RESULTS: Participants reported high levels of socio-economic deprivation, e.g. 60 % of adolescents had either an HIV-positive caregiver or were orphaned by AIDS, and 50 % of caregivers experienced intimate partner violence. i) indicative effects: Primary outcomes comparing pre-test and post-test assessments showed reductions reported by adolescents and caregivers in child abuse (adolescent report 63.0 % pre-test to 29.5 % post-test, caregiver report 75.5 % pre-test to 36.5 % post-test, both p < 0.001) poor monitoring/inconsistent discipline (p < .001), adolescent delinquency/aggressive behaviour (both p < .001), and improvements in positive/involved parenting (p < .01 adolescent report, p < .001 caregiver report). Secondary outcomes showed improved social support (p < .001 adolescent and caregiver reports), reduced parental and adolescent depression (both p < .001), parenting stress (p < .001 caregiver report) and caregiver substance use (p < .002 caregiver report). There were no changes in adolescent substance use. No negative effects were detected. ii) Programme acceptability and attendance was high. There was unanticipated programme diffusion within some study villages, with families initiating parenting groups in churches, and diffusion through school assemblies and religious sermons. iii) potential adaptations identified included the need to strengthen components on adolescent substance use and to consider how to support spontaneous programme diffusion with fidelity. CONCLUSIONS: The programme showed no signs of harm and initial evidence of reductions in child abuse and improved caregiver and adolescent outcomes. It showed high acceptability and unexpected community-level diffusion. Findings indicate needs for adaptations, and suitability for the next research step of more rigorous testing in randomised trials, using cluster randomization to allow for diffusion effects.

Understanding Associations Between Neighborhood Socioeconomic Status and Negative Consequences of Drinking: a Moderated Mediation Analysis.

We explored how neighborhood socioeconomic status (SES) is related to negative consequences of drinking to explain why racial/ethnic minority group members are more at risk than Whites for adverse alcohol outcomes. We tested direct and indirect effects of neighborhood SES on alcohol problems and examined differences by gender and race. We used data from the 2000 and 2005 National Alcohol Surveys (N = 7912 drinkers aged 18 and older; 49 % female) linked with data from the 2000 Decennial Census in multivariate path models adjusting for individual demographics. In the full sample, neighborhood disadvantage had a significant direct path to increased negative consequences, with no indirect paths through depression, positive affect or pro-drinking attitudes. Neighborhood affluence had significant indirect paths to increased negative consequences through greater pro-drinking attitudes and increased heavy drinking. Subgroup analyses showed the indirect path from affluence to consequences held for White men, with no effects of neighborhood disadvantage. For racial/ethnic minority men, significant indirect paths emerged from both neighborhood disadvantage and affluence to increased consequences through greater pro-drinking attitudes and more heavy drinking. For minority women, there was an indirect effect of neighborhood affluence through reduced depression to fewer drinking consequences. There were limited neighborhood effects on alcohol outcomes for White women. Interventions targeting pro-drinking attitudes in both affluent and disadvantaged areas may help reduce alcohol-related problems among men. Initiatives to improve neighborhood conditions could enhance mental health of minority women and reduce alcohol-related health disparities.

Those harmed by others' drinking in the US population are more depressed and distressed.

INTRODUCTION AND AIMS: Harms from second-hand smoke were instrumental in enacting tobacco controls. Documenting negative impacts of harms from others' drinking (also called second-hand effects of drinking) is vital to increase political will for optimal alcohol policies. We assessed associations between harms from others' drinking and depression in a national sample of US adults. DESIGN AND METHODS: Using the landline sample from the 2010 National Alcohol Survey (n = 5388), weighted logistic regression models adjusting for alcohol problems in family of origin, respondent drinking pattern (volume and heaviest drinking), poverty and other demographics were used to analyse associations between experiencing harms from others' drinking in the last 12 months with mild to moderate depression (8-item Center for Epidemiologic Studies Depression scale; alpha = 0.92; using cut point ≥8) and current distress. RESULTS: Past 12 month family/marital harms, financial troubles, assaults, and vandalised property attributed to others' drinking were each associated with higher depression scores (all P < 0.001). In a combined model, all harms other than assaults remained highly significant. Similar patterns were found for current distress, but with some specific differences because of measurement and analytic approaches chosen also evident. DISCUSSION: Findings suggest recently experiencing particular harms from others' drinking significantly affects mental health (both depression and distress). This confirms in a US population results recently reported in Australasian samples. CONCLUSIONS: Studies that quantify the extent to which heavy drinkers victimise others are important for alcohol policy. [Greenfield TK, Karriker-Jaffe KJ, Kerr WC, Ye Y, Kaplan LM. Those harmed by others' drinking in the US population are more depressed and distressed. Drug Alcohol Rev 2015;●●:●●-●●].