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Opioid-related mortality increased by nearly 400% between 2000 and 2018. In response, federal, state, and local governments have enacted a heterogeneous collection of opioid-related policies in an effort to reverse the opioid crisis, producing a policy landscape that is both complex and dynamic. Correspondingly, there has been a rise in opioid-policy related evaluation studies, as policymakers and other stakeholders seek to understand which policies are most effective. In this paper, we provide an overview of methodological challenges facing opioid policy researchers when evaluating the effects of opioid policies using observational data, as well as some potential solutions to those challenges. In particular, we discuss the following key challenges: (1) Obtaining high-quality opioid policy data; (2) Appropriately operationalizing and specifying opioid policies; (3) Obtaining high-quality opioid outcome data; (4) Addressing confounding due to systematic differences between policy and non-policy states; (5) Identifying heterogeneous policy effects across states, population subgroups, and time; (6) Disentangling effects of concurrent policies; and (7) Overcoming limited statistical power to detect policy effects afforded by commonly-used methods. We discuss each of these challenges and propose some ways forward to address them. Increasing the methodological rigor of opioid evaluation studies is imperative to identifying and implementing opioid policies that are most effective at reducing opioid-related harms.

It is often of interest to use observational data to estimate the causal effect of a target exposure or treatment on an outcome. When estimating the treatment effect, it is essential to appropriately adjust for selection bias due to observed confounders using, for example, propensity score weighting. Selection bias due to confounders occurs when individuals who are treated are substantially different from those who are untreated with respect to covariates that are also associated with the outcome. A comparison of the unadjusted, naive treatment effect estimate with the propensity score adjusted treatment effect estimate provides an estimate of the selection bias due to these observed confounders. In this paper, we propose methods to identify the observed covariate that explains the largest proportion of the estimated selection bias. Identification of the most influential observed covariate or covariates is important in resource-sensitive settings where the number of covariates obtained from individuals needs to be minimized due to cost and/or patient burden and in settings where this covariate can provide actionable information to healthcare agencies, providers, and stakeholders. We propose straightforward parametric and nonparametric procedures to examine the role of observed covariates and quantify the proportion of the observed selection bias explained by each covariate. We demonstrate good finite sample performance of our proposed estimates using a simulation study and use our procedures to identify the most influential covariates that explain the observed selection bias in estimating the causal effect of alcohol use on progression of Huntington’s disease (HD), a rare neurological disease.

IntroductionAssessing the impact of COVID-19 policy is critical for informing future policies. However, there are concerns about the overall strength of COVID-19 impact evaluation studies given the circumstances for evaluation and concerns about the publication environment. This study systematically reviewed the strength of evidence in the published COVID-19 policy impact evaluation literature.MethodsWe included studies that were primarily designed to estimate the quantitative impact of one or more implemented COVID-19 policies on direct SARS-CoV-2 and COVID-19 outcomes. After searching PubMed for peer-reviewed articles published on November 26, 2020 or earlier and screening, all studies were reviewed by three reviewers first independently and then to consensus. The review tool was based on previously developed and released review guidance for COVID-19 policy impact evaluation, assessing what impact evaluation method was used, graphical display of outcomes data, functional form for the outcomes, timing between policy and impact, concurrent changes to the outcomes, and an overall rating.ResultsAfter 102 articles were identified as potentially meeting inclusion criteria, we identified 36 published articles that evaluated the quantitative impact of COVID-19 policies on direct COVID-19 outcomes. The majority (n=23/36) of studies in our sample examined the impact of stay-at-home requirements. Nine studies were set aside because the study design was considered inappropriate for COVID-19 policy impact evaluation (n=8 pre/post; n=1 cross-section), and 27 articles were given a full consensus assessment. 20/27 met criteria for graphical display of data, 5/27 for functional form, 19/27 for timing between policy implementation and impact, and only 3/27 for concurrent changes to the outcomes. Only 1/27 studies passed all of the above checks, and 4/27 were rated as overall appropriate. Including the 9 studies set aside, reviewers found that only four of the 36 identified published and peer-reviewed health policy impact evaluation studies passed a set of key design checks for identifying the causal impact of policies on COVID-19 outcomes.DiscussionThe reviewed literature directly evaluating the impact of COVID-19 policies largely failed to meet key design criteria for inference of sufficient rigor to be actionable by policy-makers. This was largely driven by the circumstances under which policies were passed making it difficult to attribute changes in COVID-19 outcomes to particular policies. More reliable evidence review is needed to both identify and produce policy-actionable evidence, alongside the recognition that actionable evidence is often unlikely to be feasible.

Objectives: Key stakeholders can have differing views about which information is essential to inform placement decisions for all patients. This study examined consensus across stakeholder groups on the most important individual needs and treatment outcomes for informing decisions specifically about the level of care for an adolescent in substance use treatment. Methods: We conducted an online modified-Delphi process with treatment providers, policymakers, researchers, and parents of adolescents who have received substance use treatment. Participants rated 48 individual needs from the Global Appraisal of Individual Needs–Initial that were mapped onto the 6 dimensions of the American Society of Addiction Medicine Criteria. In addition, participants rated 10 treatment outcomes from the Substance Abuse and Mental Health Services Administration's National Outcome Measures. We assessed consensus within stakeholder groups using the RAND/UCLA Appropriateness Method. We considered the items reaching consensus with the highest ratings across stakeholder groups as the most important individual needs and treatment outcomes. Results: We recruited 194 participants (81 providers, 54 policymakers, 32 researchers, 27 parents). Participants identified suicidality and severity of substance use disorder symptoms as the most important individual needs, and reduction in substance use as the most important treatment outcome. Conclusions: Standardized procedures for matching adolescents to levels of care for substance use treatment should at a minimum be based on assessments of suicidality and severity of substance use disorder symptoms, and consider reduction in substance use as a primary treatment outcome. These findings can progress the development of “level-of-care” decision rules specifically for adolescents.

Many universities have pre departure programs that aim to prevent alcohol misuse and sexual assault among college students abroad, yet little is known about students’ uptake of this preventative information. In this study, 2,245 study abroad students from 63 different institutions were asked about receiving pre departure alcohol/drug and sexual assa ult prevention information. Only 38% of students reported receiving pre departure information specific to alcohol/drug misuse abroad and only 22% reported receiving sexual assault prevention information prior to departure. Notably, students who were heavie r drinkers prior to departure and those who intended to drink the most while abroad reported lower rates of information receipt. Overall, these findings suggest that either students are not receiving the preventative information that universities intend them to receive or the programming is not impactful enough to be recalled. Thus, there may be missed opportunities to better prepare students for risks specific to study abroad programs.

Huntington’s Disease (HD) is a rare inherited neurodegenerative disorder with a typical onset between the ages of 30 - 50. Juvenile onset Huntington’s Disease (JoHD), defined by onset of symptoms before the age of 21, manifests differently from adult-onset HD. JoHD, is thought to be present in approximately 5% of HD cases, although the exact prevalence is unknown. It has not been studied extensively. JOIN-HD is a prospective, observational, multi-national patient registry of individuals (both patients and caregivers) affected by JoHD. The primary objective of the registry is to identify individuals affected by JoHD and to map their locations globally. Secondary objectives include supporting focused research for this population and identifying unmet needs of JoHD families to improve advocacy, care and support. It is anticipated that JOIN-HD will serve as a tool to facilitate recruitment to future research and clinical trials through the identification of potentially eligible participants. Pre-registration for JOIN-HD opened in Q1 2021, and Stage I is due to launch in Q3 2021. Participants will be invited to self-enrol and participate remotely via an electronic data capture portal. Stage I will capture participant demographics and information about the links participants have with the HD community. Two further stages of the registry are planned, with Stage II collecting data on medical history/experience of JoHD and Stage III incorporating a Clinician led interview.

Background The course of Huntington’s disease (HD) is believed to be modulated by lifestyle and genetic factors. However, we do not understand how the interplay of these affects disease progression. An efficient method of measuring lifestyle factors involves the use of digital monitoring devices, but their long-term use in clinical HD populations has not yet been explored. Aim Investigate the use of digital technologies in a longitudinal observational study to inform our understanding of the contribution of multi-domain lifestyle and genetic factors in the progression of HD. Methods We plan to recruit 300-450 people with early to mid-stage HD to a 12-month observational study measuring aspects of physical activity, nutrition and sleep. Participants with existing genome wide association study (GWAS) data will be preferentially recruited. Assessment of dietary, sleep and physical activity habits will be performed at baseline and 12-month follow-up Clinical measures will be obtained from the corresponding annual Enroll-HD assessment (within 8 weeks of the DOMINO-HD assessment). Each participant will wear a Fitbit for the duration of the study. Lifestyle, genetic and clinical data will be linked and propensity score weighting methodology will be applied to examine the causal effect of the multi-domain lifestyle and genetic measures on HD progression. Results The start of recruitment was delayed by 10 months due to Covid-19. As of 1st July 2021, we have recruited 36 participants across 5 clinical sites, with recruitment planned to continue until March 2022. Conclusion Successful collection of longitudinal lifestyle data, combined with functional clinical measures and genetic factors will allow, for the first time, the investigation of causal relationships between environmental and genetic modifiers with HD progression. We can then use the information generated to design lifestyle interventions aimed at improving quality of life and prognosis in HD.

Background Evidence of best practice for long term physical activity Huntington’s disease (HD) is lacking, due in part, to inherent challenges in the delivery and evaluation of such life-style interventions. Aim To investigate the feasibility of a nested randomized controlled trial (RCT) of physical activity into Enroll-HD, an established HD cohort study. Methods We conducted a ‘Trial within a Cohort’ (TWiC) evaluation of an exercise intervention compared to usual activity in individuals with early-mid stage HD. All participants completed their usual Enroll-HD assessments and PACE-HD assessments, which included measures of fitness (predicted maximal oxygen uptake) and self-reported and quantitative measures of physical activity. We explored the use of propensity score weighting to compare the individuals in the intervention arm of the RCT to those in the cohort. Results Of the 274 participants screened, 204 met the inclusion criteria and of those, 54 (26.5%) declined to participate and 34 (16.7%) were not contactable. Recruitment targets were only narrowly missed; 59/60 (98.3%) for the cohort and 57/60 (93.5%) for the RCT. Retention rates at 12 months were ~ 85 in both groups. Percentage (%) data completeness for outcomes measures at baseline ranged from 42.3-100% and at 12 month follow up from 19.2–85.2 %. Imbalances in pretreatment confounders for the cohort and the RCT could not to be addressed via propensity score weighting likely due to small sample sizes. Conclusion A targeted recruitment strategy was instrumental in achieving target recruitment; retention at 12 months was excellent. Pre-specified criteria for minimum dataset data completion (both PACE-HD and linked Enroll-HD datasets) were met. The TWiC design, with linkage to Enroll-HD, is feasible for long-term physical activity evaluation in HD provided sample size requirements can be achieved. *PACE-HD & Enroll-HD site principal investigators Teresa Montojo. Neurology Department, Fundacion Jimenez Diaz, Madrid, Spain. Jesus Miguel Ruiz Idiago. Neuropsychiatry Unit, Hospital Mare de Deu de la Merce, Barcelona, Spain. Department of Psychiatry and Forensic Medicine, Universitat Autonoma de Barcelona, Spain. Julie Hershberg. University of Southern California, Division of Biokinesiology and Physical Therapy. Re+active physical therapy & wellness, Los Angeles, CA, USA. Yvette Bordelon. Department of Neurology, University of California, Los Angeles, CA, USA. Karen Marder, Columbia University Irving Medical Center, New York, NY, USA. Lori Quinn, Teachers College, Columbia University, New York, NY, USA. Ralf Reilmann. George-Huntington-Institute and Institute for Clinical Radiology, University of Munster, Munster, Germany. Kathrin Reetz. University Hospital Aachen, Germany. Bernhard Landwehrmeyer. University Hospital Ulm, Germany.

OBJECTIVE: To estimate the impact of implementing prescription drug monitoring program (PDMP) best practices on prescription opioid use. DATA SOURCES: 2007–2012 Medicare claims for noncancer pain patients, and PDMP attributes from the Prescription Drug Abuse Policy System. STUDY DESIGN: We derived PDMP composite scores using the number of best practices adopted by states (range: 0‐14), classifying states as either no PDMP, low strength (0

Purpose: To implement a multilevel, church-based intervention with diverse disparity populations using community-based participatory research and evaluate feasibility, acceptability, and preliminary effectiveness in improving obesity-related outcomes. Design: Cluster randomized controlled trial (pilot). Setting: Two midsized (∼200 adults) African American baptist and 2 very large (∼2000) Latino Catholic churches in South Los Angeles, California. Participants: Adult (18+ years) congregants (n = 268 enrolled at baseline, ranging from 45 to 99 per church). Intervention: Various components were implemented over 5 months and included 2 sermons by pastor, educational handouts, church vegetable and fruit gardens, cooking and nutrition classes, daily mobile messaging, community mapping of food and physical activity environments, and identification of congregational policy changes to increase healthy meals. Measures: Outcomes included objectively measured body weight, body mass index (BMI), and systolic and diastolic blood pressure (BP), plus self-reported overall healthiness of diet and usual minutes spent in physical activity each week; control variables include sex, age, race–ethnicity, English proficiency, education, household income, and (for physical activity outcome) self-reported health status. Analysis: Multivariate linear regression models estimated the average effect size of the intervention, controlling for pair fixed effects, a main effect of the intervention, and baseline values of the outcomes. Results: Among those completing follow-up (68%), the intervention resulted in statistically significantly less weight gain and greater weight loss (−0.05 effect sizes; 95% confidence interval [CI] = −0.06 to −0.04), lower BMI (−0.08; 95% CI = −0.11 to −0.05), and healthier diet (−0.09; 95% CI = −0.17 to −0.00). There was no evidence of an intervention impact on BP or physical activity minutes per week. Conclusion: Implementing a multilevel intervention across diverse congregations resulted in small improvements in obesity outcomes. A longer time line is needed to fully implement and assess effects of community and congregation environmental strategies and to allow for potential larger impacts of the intervention.

Introduction\ud Despite being genetically inherited, it is unclear how non-genetic factors (e.g., substance use, employment) might contribute to the progression and severity of Huntington's disease (HD).\ud \ud Methods\ud We used propensity score (PS) weighting in a large (n = 2914) longitudinal dataset (Enroll-HD) to examine the impact of education, employment status, and use of tobacco, alcohol, and recreational and therapeutic drugs on HD progression. Each factor was investigated in isolation while controlling for 19 other factors to ensure that groups were balanced at baseline on potential confounders using PS weights. Outcomes were compared several years later using doubly robust models.\ud \ud Results\ud Our results highlighted cases where modifiable (non-genetic) factors - namely light and moderate alcohol use and employment - would have been associated with HD progression in models that did not use PS weights to control for baseline imbalances. These associations did not hold once we applied PS weights to balance baseline groups. We also found potential evidence of a protective effect of substance use (primarily marijuana use), and that those who needed antidepressant treatment were likely to progress faster than non-users.\ud \ud Conclusions\ud Our study is the first to examine the effect of non-genetic factors on HD using a novel application of PS weighting. We show that previously-reported associated factors – including light and moderate alcohol use – are reduced and no longer significantly linked to HD progression after PS weighting. This indicates the potential value of PS weighting in examining non-genetic factors contributing to HD as well as in addressing the known biases that occur with observational data.

Recent studies show that during study abroad experiences, college students greatly increase their drinking behavior, experience multiple alcohol-related consequences, engage in sexual risk behaviors, and are at-risk for sexual violence victimization. These studies, however, have been limited by small sample sizes of students from single institutions who are often studying in a particular country or region. To better understand the extent of the risks experienced by college students studying abroad, we conducted a longitudinal survey study of 2,630 students from 65 different U.S. colleges and universities studying in 12 diverse locations abroad. Total drinks per week and heavy drinking days more than doubled while students were abroad, with heavier predeparture drinkers, men, and students under age 21 experiencing the greatest increases. There were few observed overall changes in alcohol-related consequences and risky sexual behaviors; however, specific groups, such as those with heavier predeparture consequences and sexual risk behaviors, men, and those on longer abroad programs reported greater consequences and risky sex abroad. One in five students (21%) experienced sexual violence abroad, with non-consensual physical contact the most prevalent form. Women, those under age 21, and those with a history of sexual violence were most likely to experience sexual violence abroad. Findings indicate that study abroad students may warrant targeted predeparture programming to help prevent heavy drinking and sexual violence experiences abroad.

Objective Characterize the state of the science in opioid policy research based on a literature review of opioid policy studies. Methods We conducted a scoping review of studies evaluating the impact of U.S. state-level and federal-level policies on opioid-related outcomes published in 2005−2018. We characterized: 1) state and federal policies evaluated, 2) opioid-related outcomes examined, and 3) study design and analytic methods (summarized overall and by policy category). Results In total, 145 studies were reviewed (79 % state-level policies, 21 % federal-level policies) and classified with respect to 8 distinct policy categories and 7 outcome categories. The majority of studies evaluated policies related to prescription opioids (prescription drug monitoring programs (PDMPs), opioid prescribing policies, federal regulation of prescription opioids, pain clinic laws) and considered policy impacts with respect to proximal outcomes (e.g., opioid prescribing behaviors). In total, only 29 (20 % of studies) met each of three key criteria for rigorous design: analysis of longitudinal data with a comparison group design, adjustment for difference between policy-enacting and comparison states, and adjustment for potentially confounding co-occurring policies. These more rigorous studies were predominately published in 2017–2018 and primarily evaluated PDMPs, marijuana laws, treatment-related policies, and overdose prevention policies. Conclusions Our results indicated that study design rigor varied notably across policy categories, highlighting the need for broader adoption of rigorous methods in the opioid policy field. More evaluation studies are needed regarding overdose prevention policies and policies related to treatment access. Greater examination of distal outcomes and potential unintended consequences are also warranted.

Over the last two decades, there has been a surge of opioid-related overdose deaths resulting in a myriad of state policy responses. Researchers have evaluated the effectiveness of such policies using a wide-range of statistical models, each of which requires multiple design choices that can influence the accuracy and precision of the estimated policy effects. This simulation study used real-world data to compare model performance across a range of important statistical constructs to better understand which methods are appropriate for measuring the impacts of state-level opioid policies on opioid-related mortality. Our findings show that many commonly-used methods have very low statistical power to detect a significant policy effect (

Background In a recently published randomized controlled trial (RCT) of Volunteer Recovery Support for Adolescents (VRSA), a secondary finding indicated that better adherence to planned VRSA telephone session frequency resulted in significantly higher remission rates relative to lower session adherence. However, interpretation of this dose-response relationship may have been confounded by participant characteristics such as baseline levels of substance use and mental health problems. Methods The present study used statistical methods designed to approximate RCTs when comparing more than two nonequivalent groups that include an assessment of the potential impact of omitted variables. Classification and Regression Tree (CRT) analysis was used to establish the cut-point between high (H) and low (L) VRSA dosage groups. Because we were interested in generalizing to youth with poor attendance, the L-VRSA group served as the reference group. Balancing weights for H-VRSA and a services as usual (SAU) control group were calculated to ensure similarity of baseline pretreatment characteristics to the reference group, and sensitivity of findings to unobserved confounding variables was assessed. Results Findings suggested that superior remission rates at the end of the intervention phase were the result of high adherence to planned VRSA session frequency. Recommendations to achieve high VRSA participation among a larger segment of youth and to test whether longer VRSA duration improves the stability of recovery outcomes are provided. Conclusion Few published dose-response studies have adequately controlled for selection confounds from both observed and unobserved confounding. As such, the present study aims to both assess the impact of different dosage levels of VRSA and provide a template for how to apply state-of-the-art statistical methods designed to approximate randomized controlled trials to such studies.

Religious congregations play an important role in HIV prevention and care. However, most research on congregation-based HIV activities has focused on prevention. Using data from a nationally repres...

Background Many active buprenorphine prescribers treat few patients monthly, but little information is available regarding how prescribers’ buprenorphine caseload fluctuates over time or how long it takes new prescribers to reach higher patient caseloads. We examine buprenorphine-prescribing clinicians’ patient caseloads over time and explore prescriber characteristics associated with different caseload trajectories. Methods Using 2006–2018 national buprenorphine pharmacy claims, we calculate monthly patient caseloads for buprenorphine prescribers for 6 years following a clinician’s first filled buprenorphine prescription. We use K-means clustering to identify clusters of clinician caseload trajectories and bivariate analyses to examine prescriber and county characteristics associated with different trajectory classes. Results We identified 42,067 buprenorphine prescribers with 3 trajectory classes. High-volume (1.4%;n = 571) whose mean monthly patient caseload increased to approximately 40 patients through the initial 20 months and stabilized at 40 or more patients; moderate-volume (9.2%;n = 3891) whose mean patient caseload increased during the initial 20 months, stabilizing at 15–20 patients; and low-volume (89.4%;n = 37,605), who typically had fewer than 5 patients monthly. Most low-volume prescribers (n = 31,470; 83.7% of all prescribers) initially treated 1–2 patients for several months, followed by no subsequent prescribing. Conclusion Almost three-quarters of buprenorphine prescribers treated no more than a few patients for several months before ceasing buprenorphine prescribing; only 10% of prescribers averaged more than 10 patients per month over the next 6 years. Efforts are needed to identify factors contributing to prescribers being willing to continue prescribing buprenorphine over time and to prescribe to more patients in order to increase access to buprenorphine treatment.

Background Over 1.6 million adolescents in the United States meet criteria for substance use disorders (SUDs). While there are promising treatments for SUDs, adolescents respond to these treatments differentially in part based on the setting in which treatments are delivered. One way to address such individualized response to treatment is through the development of adaptive interventions (AIs): sequences of decision rules for altering treatment based on an individual’s needs. This protocol describes a project with the overarching goal of beginning the development of AIs that provide recommendations for altering the setting of an adolescent’s substance use treatment. This project has three discrete aims: (1) explore the views of various stakeholders (parents, providers, policymakers, and researchers) on deciding the setting of substance use treatment for an adolescent based on individualized need, (2) generate hypotheses concerning candidate AIs, and (3) compare the relative effectiveness among candidate AIs and non-adaptive interventions commonly used in everyday practice. Methods This project uses a mixed-methods approach. First, we will conduct an iterative stakeholder engagement process, using RAND’s ExpertLens online system, to assess the importance of considering specific individual needs and clinical outcomes when deciding the setting for an adolescent’s substance use treatment. Second, we will use results from the stakeholder engagement process to analyze an observational longitudinal data set of 15,656 adolescents in substance use treatment, supported by the Substance Abuse and Mental Health Services Administration, using the Global Appraisal of Individual Needs questionnaire. We will utilize methods based on Q-learning regression to generate hypotheses about candidate AIs. Third, we will use robust statistical methods that aim to appropriately handle casemix adjustment on a large number of covariates (marginal structural modeling and inverse probability of treatment weights) to compare the relative effectiveness among candidate AIs and non-adaptive decision rules that are commonly used in everyday practice. Discussion This project begins filling a major gap in clinical and research efforts for adolescents in substance use treatment. Findings could be used to inform the further development and revision of influential multi-dimensional assessment and treatment planning tools, or lay the foundation for subsequent experiments to further develop or test AIs for treatment planning. Electronic supplementary material The online version of this article (10.1186/s13722-017-0099-4) contains supplementary material, which is available to authorized users.

There is a widely held belief that children’s general and psychological health benefits from owning and/or interacting with pets. In our study, we aimed to determine whether children who live with ...

Background and aims Prescription Drug Monitoring Programs (PDMPs) are a principal strategy used in the United States to address prescription drug abuse. We (1) compared opioid use pre- and post-PDMP implementation and (2) estimated differences of PDMP impact by reason for Medicare eligibility and plan type. Design Analysis of opioid prescription claims in US states that implemented PDMPs relative to non-PDMP states during 2007-12. Setting Florida, Louisiana, Nebraska, New Jersey, Vermont, Georgia, Wisconsin, Maryland, New Hampshire and Arkansas, USA. Participants A total of 310 105 disabled and older adult Medicare enrolees. Measurements Primary outcomes were monthly total opioid volume, mean daily morphine milligram equivalent (MME) dose per prescription and number of opioid prescriptions dispensed. The key predictors were PDMP status and time. Tests for moderation examined PDMP impact by Medicare eligibility (disability versus age) and drug plan [privately provided Medicare Advantage (MAPD) versus fee-for-service (PDP)]. Findings Overall, PDMP implementation was associated with reduced opioid volume [-2.36 kg/month, 95% confidence interval (CI) = -3.44, -1.28] and no changes in mean MMEs or opioid prescriptions 12 months after implementation compared with non-PDMP states. We found evidence of strong moderation effects. In PDMP states, estimated monthly opioid volumes decreased 1.67 kg (95% CI = -2.38, -0.96) and 0.75 kg (95% CI = -1.32, -0.18) among disabled and older adults, respectively, and 1.2 kg, regardless of plan type. MME reductions were 3.73 mg/prescription (95% CI = -6.22, -1.24) in disabled and 3.02 mg/prescription (95% CI = -3.86, -2.18) in MAPD beneficiaries, but there were no changes in older adults and PDP beneficiaries. Dispensed prescriptions increased 259/month (95% CI = 39, 479) among the disabled and decreased 610/month (95% CI = -953, -257) among MAPD beneficiaries. Conclusions Prescription drug monitoring programs (PDMPs) are associated with reductions in opioid use, measured by volume, among disabled and older adult Medicare beneficiaries in the United States compared with states that do not have PDMPs. PDMP impact on daily doses and daily prescriptions varied by reason for eligibility and plan type. These findings cannot be generalized beyond the 10 US states studied.

Background There is increasing international interest in alternatives to the use of arrest for minor drug offences. While Australia has been at the forefront in the provision of diversionary programs for minor drug offences there remain key gaps in knowledge about the cost-effectiveness of different approaches. Here we set out to assess the cost-effectiveness of cannabis cautioning schemes whereby police refer minor cannabis use and possession offenders to education and/or treatment instead of arresting and charging them. Methods This study used a purpose built nation-wide online survey to evaluate cost-effectiveness of cannabis cautioning versus a traditional response for minor cannabis offences (arrest). The survey was completed by a self-selected group of detected cannabis offenders. The outcome measure was self-reported cannabis use days in the previous month post-intervention. Cost data included costs of policing, court, penalties, assessment, treatment and educational sessions. Propensity score weighting and doubly robust regression analyses were utilised to address differences between the groups. Results There were 195 respondents who reported being arrested for a cannabis possession/use offence and 355 who reported receiving a formal cannabis caution. After matching on a range of characteristics (age, prior criminal conviction, cannabis consumption, employment status, self-reported criminal activity prior to detection, severity of dependence) there was no statistically significant difference in cannabis use pre- and post-police intervention between the two groups(N=544). After matching and bootstrapping the costs there was a significant difference in costs; the mean cost for the charge group (net of fines) was $733 (SD 151) and $388 (SD 111) for the caution group. Conclusion These results indicate that after matching on a range of relevant characteristics there were no differences across groups in the change in self-reported cannabis use days, but cannabis cautioning was less costly than charge/arrest. These results add to the evidence about the efficacy and desirability of alternatives to arrest both within Australia and abroad.

Background Adolescents respond differentially to substance use treatment based on their individual needs and goals. Providers may benefit from guidance (via decision rules) for personalizing aspects of treatment, such as level-of-care (LOC) placements, like choosing between outpatient or inpatient care. The field lacks an empirically-supported foundation to inform the development of an adaptive LOC-placement protocol. This work begins to build the evidence base for adaptive protocols by estimating them from a large observational dataset. Methods We estimated two-stage LOC-placement protocols adapted to individual adolescent characteristics collected from the Global Appraisal of Individual Needs assessment tool (n = 10,131 adolescents). We used a modified version of Q-learning, a regression-based method for estimating personalized treatment rules over time, to estimate four protocols, each targeting a potentially distinct treatment goal: one primary outcome (a composite of ten positive treatment outcomes) and three secondary (substance frequency, substance problems, and emotional problems). We compared the adaptive protocols to non-adaptive protocols using an independent dataset. Results Intensive outpatient was recommended for all adolescents at intake for the primary outcome, while low-risk adolescents were recommended for no further treatment at followup while higher-risk patients were recommended to inpatient. Our adaptive protocols outperformed static protocols by an average of 0.4 standard deviations (95 % confidence interval 0.2−0.6) of the primary outcome. Conclusions Adaptive protocols provide a simple one-to-one guide between adolescents’ needs and recommended treatment which can be used as decision support for clinicians making LOC-placement decisions.

Background Exercise is emerging as an important aspect in the management of disease-related symptoms and functional decline in people with Huntington disease (HD). Long-term evaluation of physical activity and exercise participation in HD has yet to be undertaken. Objective The objective is to investigate the feasibility of a nested randomized controlled trial (RCT) alongside a longitudinal observational study of physical activity and exercise outcomes in people with HD. Design This will be a 12-month longitudinal observational study (n = 120) with a nested evaluation of a physical activity intervention (n = 30) compared with usual activity (n = 30) using a “trial within a cohort” design. Setting The study will take place in HD specialist clinics in Germany, Spain, and the United States, with intervention delivery in community settings. Participants The participants will have early-mid–stage HD and be participating in the Enroll-HD study. Intervention This will be a 12-month physical activity behavioral change intervention, delivered by physical therapists in 18 sessions, targeting uptake of aerobic exercise and increased physical activity. Measurements All participants (n = 120) will complete Enroll-HD assessments (motor, cognitive, behavioral, and quality of life) at baseline and at 12 months. Additional Physical ACtivity and Exercise Outcomes in Huntington Disease (PACE-HD) assessments include fitness (predicted maximal oxygen uptake [V o2max]), self-reported and quantitative measures of physical activity, disease-specific symptoms, and walking endurance. RCT participants (n = 60) will complete an additional battery of quantitative motor assessments and a 6-month interim assessment. Enroll-HD data will be linked to PACE-HD physical activity and fitness data. Limitations The limitations include that the embedded RCT is open, and assessors at RCT sites are not blinded to participant allocation. Conclusion PACE-HD will enable determination of the feasibility of long-term physical activity interventions in people with HD. The novel “trial within a cohort” design and incorporation of data linkage have potential to reduce participant burden. This design could be applied to other neurological diseases and movement disorders where recruitment and retention are challenging.

Practical factors can significantly influence the setting, or level of care, in which an adolescent receives substance use treatment. This study aimed to identify the practical factors that stakeholders find most critical to consider when planning substance use treatment for adolescents. We conducted online panels with four stakeholder groups: providers, policymakers, researchers, and parents. Participants nominated, rated, and commented on the importance of 10 practical factors that could influence treatment setting decisions. We assessed consensus on the rated importance of practical factors using the RAND/UCLA Appropriateness Method, and we thematically analyzed comments made by stakeholders to explain how they differentiated relative importance. Overall, 153 stakeholders (66 providers, 38 policymakers, 27 researchers, and 22 parents) identified continuity of care, coordination of care across service sectors, and quality of care as the practical factors of highest importance. Participants considered practical factors to be of higher importance when they perceived a practical factor to: trump clinical appropriateness as the reason for placing an adolescent in a given setting, steer an adolescent toward a specific setting, or steer an adolescent away from specific settings. Conversely, participants rated lower the practical factors they perceived applicable to clinical intervention rather than treatment setting, unrelated to initial recommendations, relevant to any setting, or applicable only to certain contexts and sub-populations. These findings help elucidate why stakeholders view certain practical factors as critical to consider in real-world decisions about substance use treatment settings for adolescents. Future research should investigate how to incorporate these practical factors alongside clinical needs and treatment goals in placement criteria and treatment matching.

The current study seeks to advance understanding about how to address substance use and co-occurring mental health problems in adolescents. Specifically, we compared the effectiveness of two evidence-based treatment programs (Motivational Enhancement Treatment/Cognitive Behavior Therapy, 5 Sessions [MET/CBT5] and Adolescent Community Reinforcement Approach [A-CRA]) for both substance use and mental health outcomes (i.e., crossover effects). We used statistical methods designed to approximate randomized controlled trials when comparing nonequivalent groups using observational study data. Our methods also included an assessment of the potential impact of omitted variables. We found that after applying balancing weighting to ensure similarity of the baseline samples (given the nonrandomized study design), both groups significantly improved on the two substance use outcomes (days abstinent and percent of youth in recovery) and on the two mental health outcomes (post-traumatic stress disorder (PTSD) symptoms and general emotional problems). Youth in A-CRA were significantly more likely to be in recovery at the 3-month follow-up compared to youth in MET/CBT5, but the size of this effect was very small. Youth receiving MET/CBT5 appeared to show significantly more improvement in the two mental health measures compared to youth in A-CRA, though these effect sizes were also very small. The findings indicate that adolescents with co-occurring substance use and mental health problems improve on both substance use and mental health outcomes with both treatments even though they are not specifically targeting mental health problems.

Background: Long-term fine particulate matter (PM2.5) exposure is linked with cardiovascular disease, and disadvantaged status may increase susceptibility to air pollution-related health effects. In addition, there are concerns that this association may be partially explained by confounding by socioeconomic status (SES). Objectives: We examined the roles that individual- and neighborhood-level SES (NSES) play in the association between PM2.5 exposure and cardiovascular disease. Methods: The study population comprised 51,754 postmenopausal women from the Women’s Health Initiative Observational Study. PM2.5 concentrations were predicted at participant residences using fine-scale regionalized universal kriging models. We assessed individual-level SES and NSES (Census-tract level) across several SES domains including education, occupation, and income/wealth, as well as through an NSES score, which captures several important dimensions of SES. Cox proportional-hazards regression adjusted for SES factors and other covariates to determine the risk of a first cardiovascular event. Results: A 5 μg/m3 higher exposure to PM2.5 was associated with a 13% increased risk of cardiovascular event [hazard ratio (HR) 1.13; 95% confidence interval (CI): 1.02, 1.26]. Adjustment for SES factors did not meaningfully affect the risk estimate. Higher risk estimates were observed among participants living in low-SES neighborhoods. The most and least disadvantaged quartiles of the NSES score had HRs of 1.39 (95% CI: 1.21, 1.61) and 0.90 (95% CI: 0.72, 1.07), respectively. Conclusions: Women with lower NSES may be more susceptible to air pollution-related health effects. The association between air pollution and cardiovascular disease was not explained by confounding from individual-level SES or NSES. Citation: Chi GC, Hajat A, Bird CE, Cullen MR, Griffin BA, Miller KA, Shih RA, Stefanick ML, Vedal S, Whitsel EA, Kaufman JD. 2016. Individual and neighborhood socioeconomic status and the association between air pollution and cardiovascular disease. Environ Health Perspect 124:1840–1847; http://dx.doi.org/10.1289/EHP199

HIV-related stigma and mistrust contribute to HIV disparities. Addressing stigma with faith partners may be effective, but few church-based stigma reduction interventions have been tested. We implemented a pilot intervention with 3 Latino and 2 African American churches (4 in matched pairs) in high HIV prevalence areas of Los Angeles County to reduce HIV stigma and mistrust and increase HIV testing. The intervention included HIV education and peer leader workshops, pastor-delivered sermons on HIV with imagined contact scenarios, and HIV testing events. We surveyed congregants at baseline and 6 month follow-up (n = 1235) and found statistically significant (p

More than 30 years into the HIV epidemic, HIV-related stigma remains a barrier to prevention and treatment efforts (Earnshaw, Bogart, Dovidio, & Williams, 2013). The U.S. National HIV/AIDS Strategy holds that stigma reduction is essential to reducing HIV-related disparities (White House Office of National AIDS Policy, 2010). African Americans and Latinos continue to be disproportionately affected by HIV, accounting for 65% of new infections in 2010 while representing only 28% of the population (Prevention, 2012). Faith-based organizations (FBOs) have been suggested as key community partners in addressing HIV disparities (Nunn, et al., 2013; Sachs, 2008; Sutton & Parks, 2013; UNAIDS, 2009; Woldehanna, Ringheim, & Murphy, 2005), but their roles in addressing HIV stigma are unclear. Prior literature on congregation-based HIV prevention interventions has focused almost exclusively on African American churches (Agate, et al., 2005; Baldwin, et al., 2008; Berkley-Patton, et al., 2010; Berkley-Patton, Moore, Hawes, Thompson, & Bohn, 2012; Griffith, Pichon, Campbell, & Allen, 2010; MacMaster, et al., 2007; Marcus, et al., 2004; Tyrell, et al., 2008; Wingood, Simpson-Robinson, Braxton, & Raiford, 2011). Although these and many community initiatives such as The Balm in Gilead (http://www.balmingilead.org/index.php/hiv.html) aim to work with congregations to reduce stigma as part of HIV education and testing programs, there have been few published evaluations of the extent to which such efforts actually reduce stigma. Further, few studies have measured HIV stigma in church-affiliated populations (Berkley-Patton, et al., 2013; Berkley-Patton, Thompson, et al., 2012; Bluthenthal, et al., 2012; Lindley, Coleman, Gaddist, & White, 2010; Muturi & An, 2010), despite being noted consistently as a barrier to congregation-based HIV programming (Williams, Palar, & Derose, 2011). HIV stigma in congregational settings is often attributed to religious taboos on homosexual contact between men, multiple sex partners, and drug use, which are likely to be viewed through a moral lens, facilitating stigmatization and the casting of blame (and shame). However, no previous church-based studies to our knowledge have measured these related stigmatizing attitudes (regarding homosexuality and drug addiction) and how they might contribute to HIV stigma. To develop effective HIV stigma reduction interventions in collaboration with FBOs, it is important to explore dimensions and predictors of HIV stigma among church-affiliated populations. We therefore explored HIV stigma and associated stigmas regarding same-sex sexual relations and drug addiction, using baseline data from an intervention study that aimed to reduce HIV stigma among congregants from three Latino and two African American churches in high HIV-prevalence communities. Background on HIV Stigma Previous research has identified two types of stigma relevant to HIV: instrumental stigma refers to concern about the potential consequences of interacting with a stigmatized person, such as becoming infected with HIV, while symbolic stigma refers to concern about what the stigmatized condition, such as HIV, symbolizes (Bos, Schaalma, & Pryor, 2008; Herek & Capitanio, 1998). Instrumental stigma can play out in feelings of discomfort about interacting with HIV-positive individuals, while symbolic stigma encompasses both an HIV-positive individual’s feelings of shame for having HIV as well as non-infected individuals’ rejection and blame towards those with HIV. To understand the predictors of stigma in our study, we draw on the seminal work of Goffman (1963), who described stigmatization as a social process involving the discrediting of members of an entire group based on one or more attributes. We also use the work of Herek (1999), who identified four characteristics of HIV that are likely to evoke stigma: 1) the cause is perceived to be the bearer’s responsibility; 2) the condition is unalterable or degenerative; 3) the condition is perceived to be contagious or to place others in harm’s way; and 4) the condition is readily apparent to others. We also draw upon previous work on the predictors of HIV stigma in general (i.e., not specifically HIV-positive) U.S. populations, as well as the few studies of HIV stigma among religious congregants. The most consistent individual-level, independent factors associated with lower instrumental and symbolic HIV stigma among general U.S. populations have been younger age, higher education, personal contact with people with HIV or AIDS, greater knowledge about HIV transmission, and more favorable attitudes towards gays (Herek, 1999). The two previous U.S. church-based studies of which we are aware that quantitatively measured HIV stigma focused on African Americans and were somewhat limited in terms of how much they explored the predictors of stigma. Berkley-Patton et al. (2013) found that an HIV education and testing intervention did not reduce HIV stigma among congregants and community members served by outreach programs at four African American churches, and found that only greater HIV knowledge and income (but not age, gender, or religiosity) were predictive of lower HIV stigma score at baseline. Lindley et al. (2010), in a study of congregants, pastors, and pastoral care lay leaders from 20 African American churches, found that male gender, older age, and lower HIV knowledge were associated with higher HIV stigma. Focus of this Study In order to inform African American and Latino church-based interventions to reduce HIV stigma, we focused this study on factors that might be associated with stigma. First, we examined whether personally knowing someone with HIV was associated with lower HIV stigma (Herek & Capitanio, 1997; Mall, Middelkoop, Mark, Wood, & Bekker, 2013; Nambiar & Rimal, 2012). Such an association would support the contact hypothesis (Pettigrew & Tropp, 2006), which suggests that intergroup contact can reduce prejudice. We also examined whether stigmas related to drug addiction and homosexuality were associated with higher HIV stigma (Capitanio & Herek, 1999; Herek & Capitanio, 1999; Price & Hsu, 1992; St. Lawrence, Husfeldt, Kelly, Hood, & Smith, 1990). Finally, since research has found that individuals who have never discussed HIV with anyone have more negative attitudes toward people with HIV (Genberg, et al., 2009), we also explore whether specific types of communication about HIV within and outside church are associated with HIV stigma. In this paper, we: 1) describe HIV stigma scales that we adapted from previous work to characterize four HIV stigma dimensions (discomfort, shame, rejection, and blame); 2) assess the extent to which these HIV stigma scales tap into different components of HIV stigma and examine their relationships to stigmas regarding drug addiction and homosexuality; and 3) test the following hypotheses: a) African American and Latino religious congregants who know someone with HIV will express lower HIV stigma, controlling for other factors; and b) Congregants with higher drug addiction and homosexuality stigmas will have higher HIV stigma after controlling for other factors. No previous studies have examined HIV-related attitudes among Latino congregants, the ways in which multiple dimensions of HIV stigma compare across congregants of different races and ethnicities, the extent to which attitudes regarding homosexuality and drug addiction are associated with HIV-related attitudes in congregational settings, or whether knowing someone with HIV influences HIV-related attitudes in congregational settings.

This study sought to examine whether: (1) the health composition of the social networks of children living in subsidized housing within market rate developments (among higher-income neighbors) differs from the social network composition of children living in public housing developments (among lower-income neighbors); and (2) children’s social network composition is associated with children’s own health. We found no significant differences in the health characteristics of the social networks of children living in these different types of public housing. However, social network composition was significantly associated with several aspects of children’s own health, suggesting the potential importance of social networks for the health of vulnerable populations.

Objectives. In a survey of families living in public housing, we investigated whether caretakers’ social networks are linked with children’s health status. Methods. In 2011, 209 children and their caretakers living in public housing in suburban Montgomery County, Maryland, were surveyed regarding their health and social networks. We used logistic regression models to examine the associations between the perceived health composition of caretaker social networks and corresponding child health characteristics (e.g., exercise, diet). Results. With each 10% increase in the proportion of the caretaker’s social network that exercised regularly, the child’s odds of exercising increased by 34% (adjusted odds ratio = 1.34; 95% confidence interval = 1.07, 1.69) after the caretaker’s own exercise behavior and the composition of the child’s peer network had been taken into account. Although children’s overweight or obese status was associated with caretakers’ social networks, the results were no longer significant after adjustment for caretakers’ own weight status. Conclusions. We found that caretaker social networks are independently associated with certain aspects of child health, suggesting the importance of the broader social environment for low-income children’s health.

Background Although Huntington’s disease (HD) is a genetically inherited disorder, it is not clear how non-genetic factors such as environment and behavior may contribute to progression. Aims We used a causal inference approach to run simulated pseudo-randomized trials in a large (n=2,914) longitudinal dataset, to study the effects of exposure to non-genetic factors on progression of HD: education, employment status, tobacco use, alcohol use, and use of recreational and therapeutic drugs. Methods Each factor was investigated in isolation while controlling for nineteen others factors (including baseline severity of HD), to guarantee that groups were well balanced at baseline on all potential confounders using propensity score (PS) weights. Outcomes were compared several years later using doubly robust (DR) outcome models. The primary outcome was a composite HD severity measure that included assessments of motor, cognitive and functional abilities. Results We only found significant evidence that antidepressant use was detrimental to HD progression over time, compared with similarly matched individuals who were not taking antidepressants (effect size difference=0.13; 95% confidence interval=0.05,0.21). Conclusions This study is the first to examine the impact of non-genetic factors on HD using causal inference methods. We show that previously reported significant factors – including alcohol and recreational drug use – were no longer causally linked to HD progression after PS weighting. This highlights the important role PS weighting can play in examining non-genetic factors contributing to HD progression, and the caution needed when interpreting findings from studies that do not attempt to use such methods.

Background and aims Across the Huntington’s Disease (HD) communities, there has been some success in delivering exercise interventions in HD over the short term. In order to move the field forward we now need studies with longer term follow-up to elucidate the potential effect of exercise and physical activity on disease progression. The efficient use of existing data and consideration of patient preferences is critical for evaluation of non-drug interventions where recruitment and retention are challenging. Methods In PACE-HD we utilise a Trial-within-a-Cohort design involving six Enroll-HD sites across Europe and USA. This design involves longitudinal evaluation of physical fitness and activity in a cohort of people with manifest HD (n=120) and a nested randomized trial (RCT) at 3 sites (n=60) of 12-months exercise compared to usual care. The intervention incorporates a physical activity coaching program with goal setting, an associated workbook, and provision of exercise equipment and FitBit devices for self-monitoring of exercise. Assessments include fitness testing and the use of wearable technologies to capture and quantify dose (frequency, duration, intensity) of physical activity in a large HD cohort. Participants in the RCT allocated to usual activity and those from the observational cohort will provide reference data (n=90) from their annual Enroll-HD assessments that we will utilise to evaluate exercise effects in those randomized to supported exercise (n=30). Outcomes Should the design prove to be feasible, it will pave the way for robust evaluation of exercise in HD supported by the existing Enroll cohort.

Drawing upon data from the Deployment Life Study, this article examines whether female military spouses (SPs) are disadvantaged relative to matched civilian peers in terms of hours worked and earnings, paying particular attention to gaps among the highest educated women. Female SPs do earn less than comparable civilian peers in terms of raw dollars and percentage earnings. Moreover, military wives who are part of the labor force work as many hours as their civilian counterparts, but still earn significantly less for that work. Contrary to predictions, the most educated SPs are not disproportionately affected compared to spouses with less education. These results suggest that SPs at all education levels could benefit from employment assistance; in particular, women already participating in the labor force may benefit from support in finding higher paying jobs.

Substance use patterns among Latinos likely reflect changes in attitudes resulting from acculturation, but little is known about Latinos’ attitudes regarding drug addiction. We surveyed a church-based sample of Latinos and African Americans (N = 1,235) about attitudes toward drug addiction and socio-demographics. Linear regression models compared Latino subgroups with African-Americans. In adjusted models, Latinos had significantly higher drug addiction stigma scores compared to African Americans across all subgroups (US-born Latinos, β = 0.22, p

Providers who treat adolescents with co-occurring substance use and mental health issues may prioritize treatment of one set of symptoms believing that improvements in one domain will result in improvements of the other. However, limited empirical data for adolescents provide evidence of such “spillover effects.” Using data from 2900 youth in an outpatient treatment, we examined whether during-treatment changes in substance use or mental health symptoms predicted 12-month outcomes in the analogous and opposite domains. There was very little evidence of spillover effects, only that youth with no internal distress at 0 and 3 months reported lower levels of substance use problems at 12-months relative to youth with internal distress that stayed the same from 0 to 3 months. These findings suggest that providers treat both sets of substance use and mental health symptoms in an integrated manner given that these symptoms commonly co-occur among youth with either set.

Community-based human immunodeficiency virus (HIV) testing at religious congregations has been proposed as a potentially effective way to increase screening among disproportionately affected populations, such as those self-identifying as African American and Latino. Although congregations may provide reach into these communities, the extent to which church-based HIV testing alleviates access barriers, identifies new cases, and reaches people at increased risk for HIV is not well documented. We examined the results of an HIV testing program that was conducted as part of a larger intervention aimed at reducing HIV stigma at five churches in Los Angeles County, California, in 2011-2012. HIV screening identified one positive result in 323 tests but reached a substantial proportion of people who had not been tested before, including many who lacked health insurance. Although this approach may not be an efficient way to identify cases of previously unknown HIV infection, it could help achieve universal testing goals.

With their extensive social reach and influence across diverse communities, faith-based organizations have an opportunity to help address HIV worldwide. In a series of studies conducted over eight years with community partners, RAND researchers sought to better understand the capacity of urban congregations for HIV prevention and care, specifically in the areas of stigma reduction and HIV testing. This research brief outlines their findings.

Long-term fine particulate matter (PM2.5) exposure is linked with cardiovascular disease, and disadvantaged status may increase susceptibility to air pollution-related health effects. In addition, there are concerns that this association may be partially explained by confounding by socioeconomic status (SES).We examined the roles that individual- and neighborhood-level SES (NSES) play in the association between PM2.5 exposure and cardiovascular disease.The study population comprised 51,754 postmenopausal women from the Women's Health Initiative Observational Study. PM2.5 concentrations were predicted at participant residences using fine-scale regionalized universal kriging models. We assessed individual-level SES and NSES (Census-tract level) across several SES domains including education, occupation, and income/wealth, as well as through an NSES score, which captures several important dimensions of SES. Cox proportional-hazards regression adjusted for SES factors and other covariates to determine the risk of a first cardiovascular event.A 5 μg/m3 higher exposure to PM2.5 was associated with a 13% increased risk of cardiovascular event [hazard ratio (HR) 1.13; 95% confidence interval (CI): 1.02, 1.26]. Adjustment for SES factors did not meaningfully affect the risk estimate. Higher risk estimates were observed among participants living in low-SES neighborhoods. The most and least disadvantaged quartiles of the NSES score had HRs of 1.39 (95% CI: 1.21, 1.61) and 0.90 (95% CI: 0.72, 1.07), respectively.Women with lower NSES may be more susceptible to air pollution-related health effects. The association between air pollution and cardiovascular disease was not explained by confounding from individual-level SES or NSES. Citation: Chi GC, Hajat A, Bird CE, Cullen MR, Griffin BA, Miller KA, Shih RA, Stefanick ML, Vedal S, Whitsel EA, Kaufman JD. 2016. Individual and neighborhood socioeconomic status and the association between air pollution and cardiovascular disease. Environ Health Perspect 124:1840-1847; http://dx.doi.org/10.1289/EHP199.

Objectives. We assessed whether 2 types of public housing—scattered among market-rate housing developments or clustered in small public housing projects—were associated with the perceived health and health behaviors of residents’ social networks. Methods. Leveraging a natural experiment in Montgomery County, Maryland, in which residents were randomly assigned to different types of public housing, we surveyed 453 heads of household in 2011. We asked residents about their own health as well as the perceived health of their network members, including their neighbors. Results. Residents in scattered-site public housing perceived that their neighbors were more likely to exercise than residents of clustered public housing (24.7% of network members vs 14.0%; P Conclusions. Different types of public housing have a modest impact on the health composition of one’s social network, suggesting the importance of housing policy for health.

Substance use treatment is rarely a one-time event for individuals with substance use disorders. Sustained reductions in substance use and its related symptoms may result from multiple treatment episodes.We use a marginal structural model with inverse-probability-of-treatment weighting to estimate the causal effects of cumulative treatment experiences over a period of 9 months on drug use at the end of 1-year among 2870 adolescents receiving care in community-based treatment settings. During the 9 months, adolescents move in and out of outpatient and residential treatment with periods where they only receive biological drug screening (BDS) or no treatment at all. The use of inverse-probability-of-treatment weighting reduces confounding bias due to observed baseline and time-varying measures over the course of follow-up; weights were estimated using generalized boosted models.Each additional period of treatment (representing at least one day, 1 session, or 1 BDS during the 90 day period between follow-up visits) yielded reductions in average substance use frequency at 1-year relative to no treatment during the 90-day period. For residential treatment it was a 16% decrease (95% CI=-27%, -7%), for outpatient treatment it was a 9% decrease (95% CI=-18%, -0%), and for BDS (with no additional outpatient or residential treatment) it was an 11% decrease (95% CI=-20%, -3%).Using robust statistical methods, we find promising (albeit preliminary) evidence that additional periods of outpatient and residential treatment, as well as biological drug screening, lead to reductions in substance use outcomes at one year.

The purpose of this study was to compare the relative effectiveness of three treatment modalities for adolescent substance use: biological drug screening (BDS), Motivational Enhancement Therapy-Cognitive Behavioral Therapy (MET/CBT5), and BDS combined with MET/CBT5, relative to no treatment.This study comprised 5,186 adolescents (70% male) enrolled in substance use treatment and tracked through the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment's database (BDS = 1,110; MET/CBT5 = 784; BDS combined with MET/CBT5 = 2,539; no treatment = 753). Outcomes of interest were substance use frequency and severity of substance use problems at 3, 6, and 12 months, as measured by the Global Appraisal of Individual Needs survey. Propensity score weighting was used to adjust for pretreatment covariate imbalances between groups. Weighted generalized linear models were used to estimate the impact of treatment on outcomes at 3, 6, and 12 months.BDS, alone or in combination with MET/CBT5, was associated with improved substance use and substance problems outcomes. Relative to youth reporting no treatment services, the BDS group reported significantly lower substance use at all visits, with the observed difference increasing over time. BDS alone was associated with significantly fewer substance problems than bds combined with met/cbt5 at all visits and significantly lower use at 12 months.Our results demonstrate significant improvement on substance use outcomes associated with BDS and offer preliminary evidence that BDS, particularly standalone BDS, may be an effective form of drug treatment for adolescents. Further work, including randomized studies, should explore the optimal format of administering BDS to adolescents to achieve maximum effectiveness.

Summary Objectives Test the association between coronary heart disease (CHD) risk scores and neighborhood socioeconomic status (NSES) in a US nationally-representative sample and describe whether the association varies by gender and race/ethnicity. Study design Cross-sectional study. Methods We use Health and Nutrition Examination Survey (NHANES) data from 1999 to 2004 linked with Census tract data. Multivariable regression models and propensity score adjusted models are employed to test the association between NSES and 10-year risk of CHD based on the Framingham Risk Score (FRS), adjusting for individual-level characteristics. Results An individual living in a neighborhood at the 75th percentile of NSES (high NSES) has, on average, a 10-year CHD risk that is 0.16 percentage points lower (95% Confidence Interval 0.16, 0.17) than a similar person residing in a neighborhood at the 25th percentile of NSES (low NSES). Race/ethnicity and gender were found to significantly modify the association between NSES and CHD risk: the association is larger in men than women and in whites than minorities. Propensity score models showed that findings on the main effects of NSES were robust to self-selection into neighborhoods. Similar results were observed between NSES and risk of cardiovascular disease events. Conclusions NSES is significantly associated with CHD risk, and the relationship varies by gender and race/ethnicity.

This study evaluates the effectiveness of Motivational Enhancement Therapy/Cognitive Behavioral Therapy-5 (MET/CBT-5) when delivered in community practice settings relative to standard community-based adolescent treatment. A quasi-experimental strategy was used to adjust for pre-treatment differences between the MET/CBT-5 sample (n = 2293) and those who received standard care (n = 458). Results suggest that youth who received MET/CBT-5 fared better than comparable youth in the control group on five out of six 12-month outcomes. A low follow-up rate (54%) in the MET/CBT-5 sample raised concerns about nonresponse bias in the treatment effect estimates. Sensitivity analyses suggest that while modest differences in outcomes between the MET/CBT-5 nonrespondents and respondents would yield no significant differences between the two groups on two of the six outcomes, very large differences in outcomes between responders and nonresponders would be required for youth receiving MET/CBT-5 to have fared better had they received standard outpatient care.

We develop a new tool for assessing the sensitivity of findings on treatment effectiveness to differential follow-up rates in the two treatment conditions being compared. The method censors the group with the higher response rate to create a synthetic respondent group that is then compared with the observed cases in the other condition to estimate a treatment effect. Censoring is done under various assumptions about the strength of the relationship between follow-up and outcomes to determine how informative differential dropout can alter inferences relative to estimates from models that assume the data are missing at random. The method provides an intuitive measure for understanding the strength of the association between outcomes and dropout that would be required to alter inferences about treatment effects. Our approach is motivated by translational research in which treatments found to be effective under experimental conditions are tested in standard treatment conditions. In such applications, follow-up rates in the experimental setting are likely to be substantially higher than in the standard setting, especially when observational data are used in the evaluation. We test the method on a case study evaluation of the effectiveness of an evidence-supported adolescent substance abuse treatment program (Motivational Enhancement Therapy/Cognitive Behavioral Therapy-5 [MET/CBT-5]) delivered by community-based treatment providers relative to its performance in a controlled research trial. In this case study, follow-up rates in the community based settings were extremely low (54%) compared to the experimental setting (95%) giving raise to concerns about non-ignorable drop-out.

Developing consistent, valid, and efficient implementation outcome measures is necessary to advance implementation science. However, development of such measures has been limited to date, especially for validating the extent to which such measures are associated with important improvements in client outcomes. This study seeks to address this gap by developing one or more evidence-based measures of implementation (EBMIs; i.e., implementation outcome measure that is predictive of improvements in key client outcomes) for the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based practice (EBP) for adolescent substance use.Data for the current study were collected as part of a large-scale federally funded EBP dissemination and implementation initiative. The multilevel dataset included 65 substance use treatment organizations, 308 clinicians, and 5873 adolescent clients. Adjusted multilevel regression analyses were used to examine the extent to which client-level outcome measures assessed at 6-month follow-up (i.e., substance use, emotional problems) could be predicted by four implementation outcomes: two measures of fidelity (i.e., session exposure, procedure exposure) and two measures of penetration (i.e., absolute client penetration, absolute staff penetration).Adjusting for client substance use at intake, as well as several client characteristics (e.g., age, race, criminal justice involvement), client substance use at follow-up was significantly lower for treatment organizations that had higher procedure exposure (B=-1.227, standard error [SE]=0.583, 95% confidence interval=-2.370, 0.252; p.05). None of the other three implementation outcome measures were found to predict improvements in client outcomes.The current study provides support for procedure exposure as an organizational-level EBMI for A-CRA. Thus, future efforts focused on implementing A-CRA could be improved by measuring and monitoring the extent to which A-CRA procedures are being delivered to clients. Additionally, given the dearth of studies that have examined the relationship between organizational-level measures of implementation and client outcomes, this article provides a prototype for future research to identify EBMIs for other behavioral treatments.

This study investigates whether high-risk young adults’ perceptions of their likelihood of living to age 35 and of acquiring HIV are related to their substance abuse problems and risky sexual behaviors. The sample consists of data from the 72- and 87-month follow-up assessments of 449 juvenile offenders referred to probation in 1999 and 2000. Results indicate that believing one is likely to get HIV is associated with having more concurrent substance use problems and engaging in more risky sexual behaviors. Longitudinal analyses indicate that youth who think they are likely to get HIV are at greater risk for later substance abuse problems and risky sexual behaviors, though these results are only marginally significant. The results demonstrate that respondents are aware of some of the risks associated with their recent substance using and sexual behaviors, but that holding these perceptions does not result in a reduction of these behaviors.

Objective We sought to determine disparities in detection and treatment histories among a group of racial and ethnically diverse mothers with major depression. Method Our sample included 276 racially and ethnically diverse mothers who participated in the Los Angeles Family and Neighborhood Survey and who were classified with major depression based on the Comprehensive International Diagnostic Interview—Short Form. We used logistic regression to assess the association between demographic factors and previous detection with major depression, mental health specialty use, and the use of a primary care physician among these women. The demographic factors examined included race and ethnicity, immigration status, marital status, education, income, body mass index (BMI), maternal age, number of children, children's ages, history of emotional problems, and history of diabetes. Results Results indicated that 69% of mothers had not been previously detected with major depression nor had they sought mental health treatment in the 12 months before the interview. The odds of having been previously diagnosed with major depression were significantly higher among White and single mothers, as well as among mothers with higher BMIs and those with a history of emotional problems. Nonimmigrant mothers without emotional problems had a higher odds of having seen a mental health specialist in the 12 months before the interview compared with immigrant mothers without emotional problems; no differences in mental health treatment were found between nonimmigrant and immigrant mothers with emotional problems. Finally, African-American mothers and those with a history of diabetes had significantly higher odds of seeing a primary care physician compared with Hispanic mothers and those with no history of diabetes, respectively. Conclusion Our analyses of a population of depressed mothers living in Los Angeles highlight the need for identification and treatment of racial minority and immigrant mothers.