Challenges in Evaluating a Community-Level Intervention to Address Root Causes of Youth Violence.

Violence disproportionately impacts Black American youth, representing a major health disparity. Addressing the possible root causes of structural inequities to reduce violence may increase the impact of prevention strategies. However, efforts to evaluate the impact of such interventions pose numerous methodological challenges, particularly around selecting an effective evaluation design to detect change at the community level, with adequate power and sampling, and appropriate constructs and measurement strategies. We propose a multiple baseline experimental design to evaluate the impact of a community-level youth violence and suicidality prevention strategy. A multiple baseline experimental design with multiple community units balances the need for scientific rigor with practical and values-based considerations. It includes randomization and plausible counterfactuals without requiring large samples or placing some communities in the position of not receiving the intervention. Considerations related to the conceptualization of the logic model, mechanisms of change, and health disparity outcomes informed the development of the measurement strategy. The strengths and weaknesses of a multiple baseline experimental design are discussed in comparison to versions of randomized clinical trials. Future health disparity intervention evaluation research will benefit from (1) building a shared sense of urgent public need to promote health; (2) respecting the validity of values- and partnership-based decision-making; and (3) promoting community-based and systems-level partnerships in scientific grant funding. The described study has been registered prospectively at clinicaltrials.gov, Protocol Record 21-454.

Relations Between Perceptions of Parental Messages Supporting Fighting and Nonviolence and Adolescents' Physical Aggression: Beliefs as Mediators.

The purpose of this study was to examine adolescents' beliefs about fighting as mediators of longitudinal relations between perceptions of parental support for fighting and nonviolence and changes in adolescents' physical aggression. Participants were 2,575 middle school students (Mage = 12.20, SD = 1.02; 52% female; 83% African American) from the southeastern U.S. attending schools in communities with high rates of violence. Participants completed four waves of assessments every 3 months (i.e., fall, winter, spring, and summer). Each belief subscale mediated relations between perceptions of parental support for fighting and nonviolence and changes in aggression. Parental support for nonviolence was negatively associated with beliefs supporting reactive aggression and positively associated with beliefs against fighting. Parental support for retaliation was positively associated with beliefs supporting reactive and proactive aggression, and negatively associated with beliefs against fighting. Parental support for fighting as sometimes necessary was positively associated with beliefs supporting reactive aggression and beliefs that fighting is sometimes necessary. Beliefs supporting reactive and proactive aggression and beliefs that fighting is sometimes necessary were positively associated with aggression, whereas beliefs against fighting was negatively associated with aggression. Parents' support for fighting and for nonviolence may directly and indirectly reduce adolescents' physical aggression by influencing beliefs about the appropriateness of using aggression for self-defense and to attain a goal. This highlights the importance of jointly investigating multiple types of parental messages and types of beliefs about fighting.

Project GRIP: An Illustration of Participatory Action Research with Communities of People Who Own and Use Firearms.

Firearm-related injury and mortality prevention strategies are often incompatible with and potentially ineffective for the very populations at risk. Such incompatibility is reflective of a cultural disconnect between investigators and prevention specialists and those who own and use firearms. The current paper describes Project GRIP, a research study that was guided by the principles of Participatory Action Research (PAR). We present the project as a case-example and demonstration of how PAR principles can inform an approach to partner with firearm owners in injury prevention research. Though PAR is a general approach and not a set of techniques, we describe the strategies we used in the hopes that they may be useful for investigators using PAR with firearm owners. We discuss the project and our approach across different stages of the process, including entering into PAR with firearm owners, building partnerships, developing a shared vision, mutual understanding, and co-learning, building and maintaining positive relationships, and executing the project tasks. The PAR approach and the intentional emphasis on partnership is, in our opinion, vital to ensuring that the perspectives of firearm owners are incorporated into the research literature so that more ecologically valid and potentially effective injury and mortality prevention strategies can be developed and disseminated.

Mixed methods evaluation of a jail diversion program: Impact on arrests and functioning.

This mixed methods study had two aims: (1) to examine the effectiveness of a jail diversion program in reducing recidivism and promoting educational and employment outcomes; and (2) to qualitatively explore mechanisms through which the program was effective. Participants were 17 individuals arrested for drug offenses who participated in an intensive, law enforcement-based jail diversion program, and 17 individuals in a comparison group. Arrests were extracted from police records, and education and employment were extracted from program data. Four intervention participants completed qualitative interviews. Arrest rates in the intervention group decreased significantly postintervention, and arrest rates in the intervention group were numerically lower than those in the comparison group. Participants experienced significant increases in employment and driver's license status. Participants also identified mechanisms through which the program was effective. This jail diversion program shows promise in reducing recidivism and promoting adaptive functioning. Jail diversion programs that include mentorship, peer support, and removal of barriers to success may be particularly effective.

Association between Rural Residence and Processes of Care in Pancreatic Cancer Treatment.

BACKGROUND: Pancreatic adenocarcinoma (PDAC) is an aggressive malignancy associated with poor outcomes. Surgical resection and receipt of multimodal therapy have been shown to improve outcomes in patients with potentially resectable PDAC; however treatment and outcome disparities persist on many fronts. The aim of this study was to analyze the relationship between rural residence and receipt of quality cancer care in patients diagnosed with non-metastatic PDAC. METHODS: Using the National Cancer Database, patients with non-metastatic pancreatic cancer were identified from 2006-2016. Patients were classified as living in metropolitan, urban, or rural areas. Multivariable logistic regression was used to identify predictors of cancer treatment and survival. RESULTS: A total of 41,786 patients were identified: 81.6% metropolitan, 16.2% urban, and 2.2% rural. Rural residing patients were less likely to receive curative-intent surgery (p = 0.037) and multimodal therapy (p < 0.001) compared to their metropolitan and urban counterparts. On logistic regression analysis, rural residence was independently associated with decreased surgical resection [OR 0.82; CI 95% 0.69-0.99; p = 0.039] and multimodal therapy [OR 0.70; CI 95% 0.38-0.97; p = 0.047]. Rural residence independently predicted decreased overall survival [OR 1.64; CI 95% 1.45-1.93; p < 0.001] for all patients that were analyzed. In the cohort of patients who underwent surgical resection, rural residence did not independently predict overall survival [OR 0.97; CI 95% 0.85-1.11; p = 0.652]. CONCLUSIONS: Rural residence impacts receipt of optimal cancer care in patients with non-metastatic PDAC but does not predict overall survival in patients who receive curative-intent treatment.

Adolescent experiences with online racial discrimination: Implications for prevention and coping.

Online aggression represents a wide range of negative experiences, including online discrimination targeting individuals based on race, but adolescent perspectives are not well-represented. We interviewed 15 adolescents regarding their experiences with online racial discrimination. After a phenomenological analysis, four main themes emerged: types of online racial aggression, processes supporting online racism, personal coping, and strategies to prevent online racial aggression. These themes provided insights into adolescent experiences, including feelings about targeted online racial discrimination, intersectionality with sexual harassment, and comfort through processing with friends. This study highlights adolescents' thoughts regarding advocacy, education, and social media reform to prevent online racial aggression. Future research should ensure that youth voices from minoritized racial backgrounds are integrated into efforts to address these critical social issues.

Cyberbullying and Empathy Among Late-Elementary School Children.

There is currently limited research on the relation between forms of empathy and subsequent cyberbullying in middle childhood, a stage in which cyberbullying behaviors are likely to develop. The purpose of this study was to examine the extent to which affective empathy (experiencing someone else's emotions) and cognitive empathy (perspective-taking) predicted subsequent cyberbullying perpetration in middle childhood. Participants were 105 fourth-and fifth-grade students from two urban elementary schools (M age = 9.66 years, SD = .68). The sample was 66% African American or Black, 15.2% biracial or multiracial, 7.6% Asian or Asian American, and 6.7% Hispanic or Latinx. The sample was evenly divided by gender (51.4% male). Youth completed surveys in the fall (time 1) and spring (time 2) of one school year. Contrary to hypotheses, affective empathy at time 1 did not uniquely predict any form of bullying perpetration (relational, overt, or cyber) at time 2. Cognitive empathy did not predict overt or relational bullying perpetration at time 2. However, higher cognitive empathy at time 1 predicted lower levels of cyberbullying perpetration at time 2. Results suggest promoting cognitive empathy should be a cyberbullying prevention strategy during middle childhood.

Relations between youths' community violence exposure and their physical aggression: The protective role of adults.

The purpose of this study was to examine whether adults moderated the relations between youths' community violence exposure and subsequent physical aggression. Participants were 2575 middle school students (Mage = 12.3, SD = 1.00; 52% female) in the southeastern U.S. who completed surveys collected in the fall, winter, spring, and summer. The sample was predominantly African American (72%). High adult support was associated with weaker relations between exposure to violence in the fall and aggression in the winter among male adolescents. High adult support was related to weaker relations between victimization in the fall and aggression in the winter among female adolescents. Strategies promoting supportive adult relationships may benefit male adolescents by buffering the adverse impact of community violence exposure.

Palliative Therapies in Metastatic Pancreatic Cancer: Does Medicaid Expansion Make a Difference?

BACKGROUND: The aim of this study was to evaluate the impact of medicaid expansion (ME) on receipt of palliative therapies in metastatic pancreatic cancer patients. PATIENTS AND METHODS: A difference-in-differences (DID) approach was used to analyze patients with metastatic pancreatic cancer identified from the National Cancer Database diagnosed during two time periods: pre-expansion (2010-2012) and post-expansion (2014-2016). Patients diagnosed while residing in ME states were compared with those in non-ME states. Multivariable logistic regression was used to identify predictors of receipt of palliative therapies. RESULTS: Of 87,738 patients overall, 7483(18.1%) received palliative therapies in the pre-expansion, while 10,211(21.5%) received palliative therapies in the post-expansion period. In the pre-expansion period, treatment at a high-volume facility (HVF) (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.02-1.18) and non-west geographic location were predictive of increased palliative therapies. In the post-expansion period, treatment at an HVF (OR 1.09, 95% CI 1.02-1.16), geographic location, and living in an ME state at the time of diagnosis (OR 1.14, 95% CI 1.06-1.22) were predictive of increased palliative therapies. Older age, highest quartile median income (zip-code based), and treatment at a nonacademic facility were independently associated with decreased palliative therapies in both periods. DID analysis demonstrated that patients with metastatic pancreatic cancer living in ME states had increased receipt of palliative therapies relative to those in non-ME states (DID = 2.68, p < 0.001). CONCLUSIONS: The overall utilization of palliative therapies in metastatic pancreatic cancer is low. Multiple sociodemographic disparities exist in the receipt of palliative therapies. ME is associated with increased receipt of palliative therapies in patients with metastatic pancreatic cancer.

Fragmentation of Care in Pancreatic Cancer: Effects on Receipt of Care and Survival.

BACKGROUND: The impact of fragmentation of care (FC), i.e., receipt of care at > 1 institution, on treatment of pancreatic cancer is unknown. The purpose of this study was to determine factors associated with FC in curative-intent treatment of pancreatic cancer (PDAC) patients and evaluate how FC affects survival outcomes. METHODS: Using the National Cancer Database (NCDB), data on stage I-III PDAC patients diagnosed 2006-2016 were extracted. Multiple logistic regression analyses were performed to identify factors predictive of FC and survival. RESULTS: Of the 20,013 patients identified, 24.1% had FC. Factors predictive of FC were stage-III tumors (odds ratio [OR] 1.36; p = 0.014), higher median-income [third quartile (OR 1.38; p = 0.006) and highest-quartile (OR 1.50; p = 0.003)], care at high-volume facility (OR 1.47; p < 0.001), and receipt of multi-modal therapy (OR 1.69; p < 0.001). In contrast, age > 80 years (OR 0.82; p = 0.018), Black (OR 0.85; p = 0.013) or Asian race (OR 0.76; p = 0.033), Charlson comorbidity-index 2 (OR 0.85; p = 0.033), treatment at non-academic facility (OR 0.87; p = 0.041), and non-private insurance were negatively predictive of FC. FC independently predicted decreased 30-day [OR 0.57; p < 0.001] and 90-day mortality [OR 0.61; p < 0.001] and improved overall survival [hazard ratio 0.91; p < 0.001]. DISCUSSION: Sociodemographic factors are significantly associated with FC in curative-intent treatment of PDAC patients. FC was found to predict improved 30-day, 90-day, and overall survival outcomes.

Association Between Adverse Childhood Experiences and Posttraumatic Stress Disorder Symptoms in Adults With Injury.

This case-control study examines the risk factors associated with acute stress disorder in patients with severe injury.

Disparities in Access to Oncologic Care in Pancreatic Cancer: A Systematic Review.

BACKGROUND: Pancreatic cancer care is complex, and multiple disparities in receipt of therapies have been documented. The authors aimed to conduct a systematic review of the literature to critically assess and summarize disparities in access to oncologic therapies for pancreatic cancer. METHODS: A search of PubMed, Scopus, Web of Science, and Cochrane databases were performed for studies reporting disparities in access to oncologic care for pancreatic cancer. Primary research articles published in the United States from 2000 to 2020 were included. Data were independently extracted, and risk of bias was assessed using the modified Newcastle-Ottawa scale. RESULTS: The inclusion criteria were met by 47 studies. All the studies used retrospective data, with 70 % involving national database studies, 41 assessing the impact of race/ethnicity, 22 assessing the impact of socioeconomic status, 18 assessing the impact of insurance status, 23 assessing the impact of gender, 26 assessing the impact of age, and 3 assessing the impact of location on the delivery of cancer-directed therapies. Race, socioeconomic status, insurance status, gender, and age- based disparities in receipt of surgical resection, treatment at high-volume facilities and multimodal therapy for resectable pancreatic cancer, receipt of systemic chemotherapy for metastatic cancer, and receipt of expected standard-of-care treatment are reported. CONCLUSION: Significant sociodemographic disparities in access to equitable oncologic care exist along the continuum of pancreatic cancer care. Multiple patient, provider, and systemic factors contribute to these disparities. The ongoing study of these disparities is important to elucidate processes that may be targeted to improve access to equitable oncologic care for patients with pancreatic cancer.

Association of Medicaid Expansion with Pancreatic Cancer Treatment and Outcomes: Evidence from the National Cancer Database.

BACKGROUND: Socioeconomic- and demographic-based disparities exist in the treatment of pancreatic adenocarcinoma (PDAC). Medicaid expansion (ME) may have an impact on these disparities. Analyses of patients with PDAC from the National Cancer Database (NCDB) were performed to examine the impact of ME on access to treatment and outcomes. METHODS: Patients with non-metastatic PDAC diagnosed between 2006 and 2016 were identified. Multiple logistic regression analyses were performed to evaluate factors associated with curative-intent surgical resection, multimodal therapy, treatment at a high-volume facility (HVF), and survival. RESULTS: The study identified 41,876 patients who met the criteria. Medicaid expansion was independently associated with curative-intent resection (odds ratio [OR] 1.54; 95 % confidence interval [CI] 1.43-1.67; p < 0.001). In a multivariable analysis, ME was independently associated with multimodal therapy (OR 1.60; 95 % CI 1.44-1.76; p < 0.001) and treatment at an HVF (OR 1.57; 95 % CI 1.42-1.74; p < 0.001). Medicaid expansion was independently associated with improved 30-day mortality (OR 0.49; 95 % CI 0.34-0.79) and 90-day mortality (OR 0.48 95 % CI 0.35-0.59). Cox regression analysis demonstrated that after adjustment for other variables, ME status was associated with improved overall survival (hazard ratio [HR], 0.82; 95 % CI 0.73-0.90; p < 0.001). CONCLUSIONS: Medicaid expansion is associated with increased use of care processes that improve outcomes in PDAC, operative outcomes, and overall survival. The study data suggest that ME has helped to improve disparities in PDAC in ME states.

Beliefs as Mediators of Relations Between Exposure to Violence and Physical Aggression During Early Adolescence.

This study examined beliefs about aggression and self-efficacy for nonviolent responses as mediators of longitudinal relations between exposure to violence and physical aggression. Participants were a predominantly African American (79%) sample of 2,705 early adolescents from three middle schools within urban neighborhoods with high rates of violence. Participants completed measures across four waves (fall, winter, spring, and summer) within a school year. Beliefs supporting proactive aggression, beliefs against fighting, and self-efficacy for nonviolence partially mediated relations between witnessing violence and physical aggression. Indirect effects for beliefs supporting proactive aggression and self-efficacy were maintained after controlling for victimization and negative life events. Beliefs supporting proactive aggression mediated the effects of violent victimization on physical aggression, but these effects were not significant after controlling for witnessing violence and negative life events. The findings underscore the importance of examining the unique pathways from witnessing community violence versus violent victimization to physical aggression.

Early Adolescents' Social Goals in Peer Conflict Situations: A Mixed Methods Study.

Identification of goals is a key social-cognitive process that guides whether adolescents engage in aggressive or nonviolent behavior during social conflicts. This study investigated early adolescents' goals in response to hypothetical social conflict situations involving close friends and peers. Participants (n = 160; Mage = 12.7, 53% female) were 7th graders from two urban and one rural middle school. On average, participants identified 2.5 goals for each situation. Qualitative analysis using a grounded theory approach identified nine themes representing the goals generated by participants: instrumental-control, relationship maintenance, maintain image and reputation/self-defense, conflict avoidance, seek more information, revenge, tension reduction, moral, and stay out of trouble. Quantitative analysis indicated that female participants identified more goals than male participants, but there were few differences in their types of goals. There were few differences across school sites. The findings highlight the variety of social goals specific to the developmental period of early adolescence.

The Dosage, Context, and Modality of Interventions to Prevent Cyberbullying Perpetration and Victimization: a Systematic Review.

Past reviews of cyberbullying preventative interventions have critiqued the field regarding scientific rigor, and a meta-analysis found that randomized controlled trials (RCTs) of such interventions were more effective than non-RCTs. However, no review has examined the risk of bias, dosage, modality, and delivery context of such programs to date. The current study addresses this gap through a systematic review of the literature. Potential articles (N = 4,737) from 4 databases were identified and screened (Academic Search Premier including ERIC, PsychINFO, and the Psychology and Behavioral Collection; PubMed; Web of Science; Compendex); 72 articles were reviewed for eligibility. Final articles included (N = 30) were based on a rigorous search process guided by inclusion and exclusion criteria. The majority of studies were conducted in Europe; two were conducted in the USA, three in Australia, and two in the Middle East. Efforts to reduce risk of bias were evaluated using the Cochrane's Risk of Bias tool. Harvest plots were constructed to qualitatively illustrate the rigor, dosage, modality, and context of the interventions, and meta-analytic random effects models were conducted to examine effect sizes of the interventions on cyberbullying perpetration and victimization. Results suggest that cyberbullying interventions delivered through schools are effective, though expanded follow-up time is suggested, and additional evidence is needed for home settings and digital delivery.

In-person victimization, cyber victimization, and polyvictimization in relation to internalizing symptoms and self-esteem in adolescents with attention-deficit/hyperactivity disorder.

BACKGROUND: There is mixed evidence for whether in-person victimization and cyber victimization are differentially linked to internalizing symptoms and self-esteem among adolescents with attention-deficit/hyperactivity disorder (ADHD). The goals of the present study were to (1) evaluate in-person victimization and cyber victimization in relation to internalizing symptoms (i.e., anxiety and depression) and self-esteem and (2) examine differences in internalizing symptoms and self-esteem between in-person victimization, cyber victimization, and polyvictimization (i.e., both in-person victimization and cyber victimization). METHODS: Participants were 78 adolescents (ages 13-17 years) diagnosed with ADHD who completed ratings of in-person victimization, cyber victimization, anxiety, depression, and self-esteem. Parents completed ratings of their adolescent's anxiety and depression. RESULTS: Adolescents with ADHD reported experiencing higher rates of in-person victimization (64%) than cyber victimization (23%) in the last 30 days. In addition, 22% reported that they experienced polyvictimization. In-person victimization was associated with higher adolescent-reported anxiety symptoms, whereas cyber victimization was associated with higher parent-reported depressive symptoms; both were associated with lower adolescent-reported self-esteem. Adolescents who reported polyvictimization reported the highest anxiety and depressive symptoms and the lowest self-esteem. CONCLUSIONS: Approximately one quarter of adolescents with ADHD report experiencing polyvictimization in the past month. Findings indicate that in-person victimization and cyber victimization are each uniquely associated with lower self-esteem and differentially associated with co-occurring internalizing symptoms among adolescents with ADHD. Polyvictimization is especially linked to higher internalizing symptoms and lower self-esteem. Longitudinal studies are needed to better understand the directionality of these associations.

Adverse Childhood Experiences Among Children with Neurodevelopmental Delays: Relations to Diagnoses, Behavioral Health, and Clinical Severity.

Limited research has examined adverse childhood experiences (ACEs) among children at risk for neurodevelopmental delays. The purpose of this study was to (1) identify the prevalence of ACEs among children at risk for neurodevelopmental delays; (2) explore differences in rates of ACEs across neurodevelopmental diagnoses; and (3) examine relations between ACEs and indicators of behavioral health functioning (e.g., enuresis, feeding problems, sleeping problems, and functional impairment). Participants were 193 children ages 2 to 11 who received a developmental and behavioral pediatrics evaluation at a subspecialty clinic. Caregivers completed a survey about their child's ACEs, and researchers conducted an electronic health record review. Overall, 47% experienced at least one ACE. ACEs were not related to neurodevelopmental diagnosis or to externalizing symptoms. ACEs were related to difficulty sleeping, lower hyperactivity, and greater functional impairment at home. The relations between early adversity and poor behavioral health functioning may develop over time, creating an excellent window of opportunity for prevention work.