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Fear of crime has been associated with mental health outcomes. Yet, causal relationships have not been established. We examined the relationship between fear and mental health while accounting for potential endogeneity. A sample of 2329 adolescents from the Project on Human Development in Chicago Neighborhoods dataset was analyzed to assess the effect of fear of neighborhood violent crime on anxiety/depression. Instrumental variable (IV) methods were used to address endogeneity. There is evidence that the estimated effect of fear on depressive symptoms does not suffer from endogeneity bias in single-equation models. Adolescents who were more fearful had higher anxiety/depression scores. In adjusted analyses, for each one unit increase in fear (in this case, a move from one level of fear to the next), anxiety/depression scores increased by 1.32 points. There is support for the hypothesis that fear of neighborhood violent crime caused an increase in anxiety/depression scores among adolescents. Many programs address exposure to violence as a potential cause of depression, however few address the fear of violent victimization as a cause. Interventions and services should address fear as a root cause of anxiety/depression among adolescents.

BackgroundQUIT is the only primary care-based brief intervention that has previously shown efficacy for reducing risky drug use in the United States (Gelberg et al., 2015). This pilot study replicated the QUIT protocol in one of the five original QUIT clinics primarily serving Latinos.DesignSingle-blind, two-arm, randomized controlled trial of patients enrolled from March-October 2013 with 3-month follow-up.SettingPrimary care waiting room of a federally qualified health center (FQHC) in East Los Angeles.ParticipantsAdult patients with risky drug use (4-26 on the computerized WHO ASSIST): 65 patients (32 intervention, 33 control); 51 (78%) completed follow-up; mean age 30.8 years; 59% male; 94% Latino.Interventions and measuresIntervention patients received: 1) brief (typically 3-4 minutes) clinician advice to quit/reduce their risky drug use, 2) video doctor message reinforcing the clinician's advice, 3) health education booklet, and 4) up to two 20-30 minute follow-up telephone drug use reduction coaching sessions. Control patients received usual care and cancer screening information. Primary outcome was reduction in number of days of drug use in past 30days of the highest scoring drug (HSD) on the baseline ASSIST, from baseline to 3-month follow-up.ResultsControls reported unchanged HSD use between baseline and 3-month follow-up whereas Intervention patients reported reducing their use by 40% (p

BACKGROUND: Given the increased use of psychoactive substances on the United States-Mexico border, a binational study (Tijuana, Mexico-Los Angeles, USA) was conducted to identify the prevalence of substance use in primary care settings. OBJECTIVES: To compare the prevalence and characteristics of patients at risk for substance use disorders in Tijuana and East Los Angeles (LA) community clinics with special attention paid to drug use. METHODS: This was an observational, cross-sectional, analytical study, comparing substance use screening results from patients in Tijuana and LA. The settings were 2 community clinics in LA and 6 in Tijuana. Participants were 2,507 adult patients in LA and 2,890 in Tijuana eligible for WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) screening during March-October 2013. Patients anonymously self-administered the WHO ASSIST on a tablet PC in the clinic waiting rooms. RESULTS: Of eligible patients, 96.4% completed the ASSIST in Tijuana and 88.7% in LA (mean 1.34 minutes and 4.20 minutes, respectively). The prevalence of patients with moderate-to-high substance use was higher in LA than Tijuana for each substance: drugs 19.4% vs. 5.7%, alcohol 15.2% vs. 6.5%, tobacco 20.4% vs. 16.2%. LA patients born in Mexico had 2x the odds and LA patients born in the United States had 6x the odds of being a moderate-to-high drug user compared to Tijuana patients born in Mexico. CONCLUSIONS: Moderate-to-high drug use is higher in LA than in Tijuana but rates are sufficiently high in both to suggest that screening for drug use (along with alcohol and tobacco use) should be integrated into routine primary care of community clinics in both cities.

PURPOSE: Little is known about how permanent supported housing influences ambulatory care received by homeless persons. To fill this gap, we compared diagnoses treated in VA Greater Los Angeles (VAGLA) ambulatory care between Veterans who are formerly homeless-now housed/case managed through VA Supported Housing (VASH Veterans)-and currently homeless. METHODS: We performed secondary database analyses of homeless-experienced Veterans (n = 3631) with VAGLA ambulatory care use from October 1, 2010 to September 30, 2011. We compared diagnoses treated-adjusting for demographics and need characteristics in regression analyses-between VASH Veterans (n = 1904) and currently homeless Veterans (n = 1727). RESULTS: On average, considering 26 studied diagnoses, VASH (vs currently homeless) Veterans received care for more (P < .05) diagnoses (mean = 2.9/1.7). Adjusting for demographics and need characteristics, VASH Veterans were more likely (P < .05) than currently homeless Veterans to receive treatment for diagnoses across categories: chronic physical illness, acute physical illness, mental illness, and substance use disorders. Specifically, VASH Veterans had 2.5, 1.7, 2.1, and 1.8 times greater odds of receiving treatment for at least 2 condition in these categories, respectively. Among participants treated for chronic illnesses, adjusting for predisposing and need characteristics, VASH (vs currently homeless) Veterans were 9%, 8%, and 11% more likely to have 2 or more visits for chronic physical illnesses, mental illnesses, and substance use disorder, respectively. CONCLUSION: Among homeless-experienced Veterans, permanent supported housing may reduce disparities in the treatment of diagnoses commonly seen in ambulatory care.

Fear of violent crime is common among adolescents in urban settings; however, little is known about individual- and neighborhood-level determinants of fear. A generalized ordered logit model was used to analyze individual- and neighborhood-level variables among 2474 adolescents. Seeing violence significantly reduced the probability of feeling unafraid, as did higher levels of social disorder. The more block faces where police were visible, the higher the probability of feeling unafraid and lower the probability of feeling very afraid. Reducing fear could affect more people than just reducing crime. Fear-reduction strategies should target those most at risk of becoming fearful.

AimsTo assess the effect of a multi-component primary care delivered brief intervention for reducing risky psychoactive drug use (RDU) among patients identified by screening.DesignMulticenter single-blind two-arm randomized controlled trial of patients enrolled from February 2011 to November 2012 with 3-month follow-up. Randomization and allocation to trial group were computer-generated.SettingPrimary care waiting rooms of five federally qualified health centers in Los Angeles County (LAC), USA.ParticipantsA total of 334 adult primary care patients (171 intervention; 163 control) with RDU scores (4-26) on the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) self-administered on tablet computers. 261 (78%) completed follow-up. Mean age was 41.7 years; 62.9% were male; 37.7% were Caucasian.Intervention(s) and measurementIntervention patients received brief (typically 3-4 minutes) clinician advice to quit/reduce their drug use reinforced by a video doctor message, health education booklet and up to two 20-30-minute follow-up telephone drug use coaching sessions. Controls received usual care and cancer screening information. Primary outcome was patient self-reported use of highest scoring drug (HSD) at follow-up.FindingsIntervention and control patients reported equivalent baseline HSD use at 3-month follow-up. After adjustment for covariates, in the complete sample linear regression model, intervention patients used their HSD on 3.5 fewer days in the previous month relative to controls (P

ObjectivesExisting studies of disparities in access to oral health care for underserved populations often focus on supply measures such as number of dentists. This approach overlooks the importance of other aspects of the dental care delivery system, such as personal and practice characteristics of dentists, that determine the capacity to provide care. This study aims to assess the role of such characteristics in access to care of underserved populations.MethodsWe merged data from the 2003 California Health Interview Survey and a 2003 survey of California dentists in their Medical Study Service Areas (MSSAs). We examined the role of overall supply and other characteristics of dentists in income and racial/ethnic disparities in access, which was measured by annual dental visits and unmet need for dental care due to costs.ResultsWe found that some characteristics of MSSAs, including higher proportions of dentists who were older, white, busy or overworked, and did not accept public insurance or discounted fees, inhibited access for low-income and minority populations.ConclusionsThese findings highlight the importance of monitoring characteristics of dentists in addition to traditional measures of supply such as licensed-dentist-to-population ratios. The findings identify specific aspects of the delivery system such as dentists' participation in Medicaid, provision of discounted care, busyness, age, race/ethnicity, and gender that should be regularly monitored. These data will provide a better understanding of how the dental care delivery system is organized and how this knowledge can be used to develop more narrowly targeted policies to alleviate disparities.

ObjectivesExisting studies of disparities in access to oral health care for underserved populations often focus on supply measures such as number of dentists. This approach overlooks the importance of other aspects of the dental care delivery system, such as personal and practice characteristics of dentists, that determine the capacity to provide care. This study aims to assess the role of such characteristics in access to care of underserved populations.MethodsWe merged data from the 2003 California Health Interview Survey and a 2003 survey of California dentists in their Medical Study Service Areas (MSSAs). We examined the role of overall supply and other characteristics of dentists in income and racial/ethnic disparities in access, which was measured by annual dental visits and unmet need for dental care due to costs.ResultsWe found that some characteristics of MSSAs, including higher proportions of dentists who were older, white, busy or overworked, and did not accept public insurance or discounted fees, inhibited access for low-income and minority populations.ConclusionsThese findings highlight the importance of monitoring characteristics of dentists in addition to traditional measures of supply such as licensed-dentist-to-population ratios. The findings identify specific aspects of the delivery system such as dentists' participation in Medicaid, provision of discounted care, busyness, age, race/ethnicity, and gender that should be regularly monitored. These data will provide a better understanding of how the dental care delivery system is organized and how this knowledge can be used to develop more narrowly targeted policies to alleviate disparities.

BackgroundImprovement in quality of life (QOL) is a long term goal of drug treatment. Although some brief interventions have been found to reduce illicit drug use, no trial among adult risky (moderate non-dependent) drug users has tested effects on health-related quality of life.MethodsA single-blind randomized controlled trial of patients enrolled from February 2011 to November 2012 was conducted in waiting rooms of five federally qualified health centers. 413 adult primary care patients were identified as risky drug users using the WHO-ASSIST and 334 (81% response; 171 intervention, 163 control) consented to participate in the trial. Three-month follow-ups were completed by 261 patients (78%). Intervention patients received the QUIT intervention of brief clinician advice and up to two drug-use health telephone sessions. The control group received usual care and information on cancer screening. Outcomes were three-month changes in the Short Form Health Survey (SF-12) mental health component summary score (MCS) and physical health component summary score (PCS).ResultsThe average treatment effect (ATE) was non-significant for MCS (0.2 points, p-value=0.87) and marginally significant for PCS (1.7 points, p-value=0.08). The average treatment effect on the treated (ATT) was 0.1 (p-value=0.93) for MCS and 1.9 (p-value=0.056) for PCS. The effect on PCS was stronger at higher (above median) baseline number of drug use days: ATE=2.7, p-value=0.04; ATT=3.21, p-value=0.02.ConclusionsThe trial found a marginally significant effect on improvement in PCS, and significant and stronger effect on the SF-12 physical component among patients with greater frequency of initial drug use.

In 2011 and 2012, 147 patients in urban United States Community Health Centers who misused drugs, but did not meet criteria for drug dependence, received a brief intervention as part of a National Institute on Drug Abuse-funded clinical trial of a screening and brief intervention protocol. Potential study participants were identified using the World Health Organization (WHO) Alcohol, Smoking, and Substance Involvement Screening Test. Data gathered during brief interventions were analyzed using grounded theory strategies to identify barriers patients believed inhibited drug use behavior change. Numerous perceived barriers to drug use behavior change were identified. Study implications and limitations are discussed.

BackgroundThe US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program-the VA's Housing First effort-is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing.ObjectivesWe compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans.Research designWe performed a secondary database analysis of Veterans (n=62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status.ResultsHUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group.ConclusionsOur findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.

ObjectiveWe documented the prevalence, distribution, and correlates of hepatitis C virus (HCV) infection among urban homeless adults.MethodsWe sampled a community-based probability sample of 534 homeless adults from 41 shelters and meal programs in the Skid Row area of downtown Los Angeles, California. Participants were interviewed and tested for HCV, hepatitis B, and HIV. Outcomes included prevalence, distribution, and correlates of HCV infection; awareness of HCV positivity; and HCV counseling and treatment history.ResultsOverall, 26.7% of the sample tested HCV-positive and 4.0% tested HIV-positive. In logistic regression analysis, independent predictors of HCV infection for the total sample included older age, less education, prison history, and single- and multiple-drug injection. Among lifetime drug injectors, independent predictors of HCV infection included older age, prison history, and no history of intranasal cocaine use. Among reported non-injectors, predictors of HCV infection included older age, less education, use of non-injection drugs, and three or more tattoos. Sexual behaviors and snorting or smoking drugs had no independent relationship with HCV infection. Among HCV-infected adults, nearly half (46.1%) were unaware of their infection.ConclusionsDespite the high prevalence of HCV infection, nearly half of the cases were hidden and few had ever received any HCV-related treatment. While injection drug use was the strongest independent predictor, patterns of injection drug use, non-injection drug use, prison stays, and multiple tattoos were also independent predictors of HCV. Findings suggest that urgent interventions are needed to screen, counsel, and treat urban homeless adults for HCV infection.

While disparities in health and health care between vulnerable (e.g., minorities, low-income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the neediest within these generally needy populations, and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County California, in one of the largest, most comprehensive studies of the health of homeless women to date, this study examined the health and health care disparities among homeless African American, Latina, and white women. This study further explored if race/ethnicity and other factors that predispose homeless women to poor health, or enable them to obtain better health care, were associated with their unmet need for medical care. The study found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.

This paper explores associations among the vulnerabilities of being female, being a member of a minority group, and being a drug abuser in homeless women's hospitalizations. It uses a 1997 probability survey of 974 homeless females age 15-44 in Los Angeles. In unadjusted analyses, whites were more likely than other ethnic minority groups to be hospitalized, and drug abusers were more likely to be hospitalized than non-drug abusers. Multiple logistic regression analyses indicated that factors associated with hospitalization differed considerably among the ethnic and drug-abuse subgroups. For example, ethnic disparities in inpatient health care were found for drug-abusing women, but not for those who did not abuse drugs. Pregnancy was the only important determinant of hospitalization in all subgroups (OR, 2.9-17.4). Preventing unintended pregnancy appears to be the most inclusive means of reducing hospitalization and attendant costs among homeless women.

ObjectiveTo identify correlates of failure to use contraception among homeless women at risk for unintended pregnancy.Study designA representative sample of 974 homeless women surveyed in Los Angeles County in 1997 included 457 who were at risk for unintended pregnancy. Logistic regression modeling was used to identify important predictors of contraceptive nonuse or rare use in the past year.ResultsOne third of the sample used contraception rarely or never in the past year. Having a partner, being monogamous, and not engaging in sex trade predicted contraceptive nonuse or rare use (odds ratios 2.43-4.73, P < .05). Partner dislike and uncertainty about which contraceptive to use were also associated with failure to use contraception (odds ratios 2.64-2.96, P < .05). Having a regular source of care and having been encouraged to use contraception protected against failure to use contraception.ConclusionsHomeless women, including those at apparently low risk for unintended pregnancy, need to be targeted with integrated services that include education, a regular source of medical care, and encouragement to use contraception.

Where Californians live within the state plays an important role in determining their access to health care. This policy brief uses data from the 2001 California Health Interview Survey (CHIS 2001) to examine differences in four key measures of access to care related to the county in which a person with low- to moderate-household income resides. These measures are the percent of the county population who: 1) have a usual source of care, 2) use community or government clinics as their usual source of care, 3) are uninsured for all or part of a year, and 4) delayed any type of care because of cost or insurance issues. The study also found that health insurance played a major role in determining access to care. The study’s findings have significant implications for the ongoing political debate over potential cutbacks in the Medi-Cal and Healthy Families programs. These findings demonstrate that, for moderate-to-low income children and adults, counties differ in the levels of access experienced by their low- and moderate-income populations. Additionally, both persistent uninsurance and intermittent coverage reduce access to care and place a larger burden on community, public, and hospital-based clinics. The demands on this already-stretched safety net will likely rise with any increase in the number of uninsured people, whether that lack of coverage is short-term or long-term.