Recent Publications

"Improving Native American elder access to and use of health care through effective health system navigation"
   BMC Health Services Research (2018)
    Willging, C. E. ; Sommerfeld, D. H.; Jaramillo, E. T. ; Lujan, E.; Bly, R. S.; Debenport, E. K.; Verney, S. P.; Lujan, R.
Public insurance reforms of the past two decades have failed to substantively address the healthcare needs of American Indians in general, let alone the particular needs of American Indian elders, ages 55 years and older. Historically, this population is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other United States aging populations, representing a neglected group within the healthcare system. Despite the pervasive belief that the Indian Health Service will address all their health-related needs, American Indian elders are negatively affected by gaps in insurance and lack of access to health care. While the 2010 Patient Protection and Affordable Care Act included provisions to ameliorate disparities for American Indians, its future is uncertain. In this context, American Indian elders with variable health literacy must navigate a complex and unstable healthcare system, regardless of where they seek care. This community-driven study features a mixed-method, participatory design to examine help-seeking behavior and healthcare experiences of American Indian elders in New Mexico, in order to develop and evaluate a tailored intervention to enhance knowledge of, access to, and use of insurance and available services to reduce healthcare disparities. This study includes qualitative and quantitative interviews combined with concept mapping and focus groups with American Indian elders and other key stakeholders. The information gathered will generate new practical knowledge, grounded in actual perspectives of American Indian elders and other relevant stakeholders, to improve healthcare practices and policies for a population that has been largely excluded from national and state discussions of healthcare reform. Study data will inform development and evaluation of culturally tailored programming to enhance understanding and facilitate negotiation of the changing landscape of health care by American Indian elders. This work will fill a gap in research on public insurance initiatives, which do not typically focus on this population, and will offer a replicable model for enhancing the effects of such initiatives on other underserved groups affected by healthcare inequities. This protocol does not include the collection of health outcome data.

A Mixed-Method Assessment of a Pilot Peer Advocate Intervention for Rural Gender and Sexual Minorities
   Community Mental Health Journal (2018)
    Willging, C. E. ; Harkness, A.; Israel, T.; Ley, D.; Hokanson, P. S. ; DeMaria, C.; Joplin, A.; Smiley, V.
Mental health disparities affect lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in rural America. There are few empirically-based mental health interventions for this population. This exploratory study uses a mixed-method approach to assess implementation issues related to the feasibility, acceptability, appropriateness, and preliminary impacts of a novel peer-based intervention designed to enhance support and treatment engagement among rural LGBTQ people with mental distress and/or addiction issues. Quantitative and qualitative results illuminate intervention strengths and areas for improvement. Strengths centered on enhancing social support, advocacy behaviors, and engagement in treatment. Implementation challenges and recommendations to advance the intervention model are discussed.

Achieving advance care planning in diverse, underserved populations
   Nursing Outlook (2018)
   Wicks, M. N.; Alejandro, J.; Bertrand, D.; Boyd, C. J.; Coleman, C. L.; Haozous, E. ; Meade, C. D.; Meek, P. M.

Rapid assessment for establishing evidence of an underground cigarette market in Oakland Chinatown: A dual approach
   Journal of Healthcare for the Poor and Underserved (2018)
    Wang-Schweig, Meme ; Lipperman-Kreda, S. ; Lee, Juliet P.
We conducted a preliminary study to rapidly assess (1) whether an underground cigarette market exists in the area known as Oakland Chinatown in Oakland, California; and if so, (2) who consumes untaxed cigarettes in this ethnic enclave to provide a basis for further investigation.

Methods for investigating crash risk: Comparing case control with responsibility analysis
   Traffic Injury Prevention (2018)
    Voas, Robert ; Yao, Jie ; Scherer, Michael ; Romano, Eduardo ; Lacey, John
Objective: There are two primary methods for establishing relative risk: case-control studies where crash and matched control data are collected separately, and responsibility analysis, which exploits a single existing crash database by using non-responsible drivers as an “induced exposure” control group (which is less expensive and therefore more feasible for examining the large number of substances that can impact driving behavior). Though both approaches are scientifically sound and methodologically valid, each approach has its own inherent obstacles to overcome. In this effort, we examine in detail how different criteria for the development of control cases influence the accuracy of crash-risk estimates for drivers with positive BACs. Methods: We applied responsibility analysis to crash-involved drivers in a recent crash case-control study, thereby providing two sets of control cases: those from responsibility analysis and those from the case control study. Results: Case control and responsibility analysis crash risk curves did not differ significantly, indicating that both systems generate valid estimates of the relative crash risk of drivers on the road. Conclusions: The results suggest that when researchers are faced with finance or time constraints that make case-control studies infeasible, responsibility analysis should be considered a viable alternate methodological approach.

Do associations between drinking event characteristics and underage drinking differ by drinking location?
   Journal of Studies on Alcohol and Drugs (2018)
   Thrul, J.; Lipperman-Kreda, S. ; Grube, J.
OBJECTIVE: We investigated how associations between social and situational characteristics (number of people, adult supervision, group gender composition, group age composition, ease of alcohol access, and weekend) and underage drinking are moderated by the specific locations in which drinking occurs. METHOD: Using a case-crossover design and retrospective surveys, a sample of 385 adolescents (mean age = 16.5 years; 47.3% female) from 24 mid-size California cities reported the last time they drank alcohol in a specific location (restaurant, outdoors, home) and the last time they were at the same type of location without drinking, as well as characteristics of each drinking and nondrinking event (N = 1,096 events). RESULTS: Results of multilevel regression models indicated that perceived ease of alcohol access was associated with drinking across all locations (adjusted odds ratios [aORs] = 2.11-2.75, all p < .01). Weekend (vs. weekday) increased the odds of drinking outdoors (aOR = 3.75, p < .001) and in the home (aOR = 4.37, p < .001), as did a lack of adult supervision (aOR = 1.70, p < .05 for outdoors; aOR = 1.64, p < .01 for home). Larger groups (aOR = 1.06, p < .001) and being with older people (aOR = 2.28, p < .001) increased the odds of drinking in the home only. Significant cross-level interaction effects between location and group size (aOR = 0.96; p < .001), group gender composition (aOR = 0.78, p < .05), group age composition (aOR = 0.70, p < .01), ease of alcohol access (aOR = 0.88, p < .05), and weekend (aOR = 0.66, p < .05) suggested that these predictors were less significant in outdoor locations compared with the home. CONCLUSIONS: Locations moderate the social and situational characteristics of events and are important for underage drinking. Results can inform targeted prevention efforts.

Latent classes of polydrug users as a predictor of crash involvement and alcohol consumption
   Journal of Studies on Alcohol and Drugs (2018)
    Scherer, M. ; Romano, E. ; Voas, R. B. ; Taylor, E.
Objective: Polydrug users have been shown to be at higher risk for alcohol consumption and crash involvement. However, research has shown that polydrug groups differ in some important ways. It is currently unknown how polydrug-using groups differ in terms of crash involvement and alcohol consumption. Method: The current study used latent class analysis to examine subgroups of polydrug users (n = 384) among a sample of drivers in Virginia Beach, Virginia (N = 10,512). A series of logistic regression analyses were conducted to determine the relationship between polydrug use categories and crash involvement and alcohol consumption. Results: Four distinct subclasses of users were identified among polydrug-using drivers: Class 1 is the “marijuana-amphetamines class” and accounts for 21.6% of polydrug users. Class 2 is the “benzo-antidepressant class” and accounts for 39.0% of polydrug users. Class 3 is the “opioid-benzo class” and accounts for 32.7% of polydrug users. Finally, Class 4 is the “marijuana-cocaine class” and accounts for 6.7% of the study sample. Drivers in the opioid-benzo class were significantly more likely than those in any other class as well as non–drug users and single-drug users to be involved in a crash and were more likely than those in most other conditions to consume alcohol. No significant difference was found between marijuana-amphetamine users or benzo-antidepressant users and non–drug users on crash risk. Conclusions: Some polydrug users are indeed at greater risk for crash involvement and alcohol consumption; however, not all polydrug users are significantly worse than single-drug users and/or non–drug users, and the practice of lumping polydrug users together when predicting crash risk runs the risk of inaccurately attributing crash involvement to certain drivers.

Intercorrelation of alcohol and other drug use disorders among a national sample of drivers
   Journal of Psychoactive Drugs (2018)
    Scherer, M. ; Canham, S.; Voas, R.B. ; Furr-Holden, C.D.
This study examined the relationship between alcohol, marijuana, cocaine, and painkiller use disorders in a sample of drivers. We studied nighttime drivers aged 16 to 87 (n = 4,277) from the 2007 National Roadside Survey who reported substance use behaviors and provided breath tests for alcohol. Logistic regression analyses assessed the relationships between (1) substance (i.e., alcohol/marijuana/cocaine/pain killer) use disorders; (2) demographic characteristics; and (3) BAC levels. Overall, 13.2% of participants met criteria for marijuana use disorder, 7% met criteria for cocaine use disorder, and 15.4% met criteria for extra-medicinal painkiller use disorder. When self-report data were analyzed, three reciprocal associations emerged: (1) marijuana use disorders and alcohol use disorders were correlated; (2) marijuana use disorders and cocaine use disorders were correlated; and (3) cocaine use disorders and painkiller use disorders were correlated. BAC data revealed that marijuana and cocaine use disorders were both associated with positive BAC levels, but only cocaine use disorders were associated with BAC levels over the legal limit. Results suggest significant poly-substance use disorders in a sample of nighttime drivers, with variations by demographic characteristics. The individual and public health consequences of multiple substance use disorders among drivers are significant.

Alcohol-related risk of driver fatalities in motor vehicle crashes: Comparing data from 2007 and 2013-2014
   Journal of Studies on Alcohol and Drugs (2018)
    Romano, Eduardo ; Torres-Saavedra, Pedro; Calderón-Cartagena, Hilda I; Voas, Robert B ; Ramírez, Anthony
Objective: Using data from 2013–2014, this article aims to update alcohol-related fatal crash relative risk estimates, defined as the risk of dying in those crashes at different blood alcohol concentrations (BACs) relative to the risk of dying in a crash when sober (BAC = .00 g/dl), and to examine any change in risk that could have taken place between 2007 and 2013–2014. More specifically, we examine changes in risk among BAC = .00 g/dl drivers and among BAC > .00 g/dl drivers. Method: We matched and merged crash data from the Fatality Analysis Reporting System (FARS) and exposure data from the National Roadside Survey (NRS). To the matched database we applied logistic regression to estimate the changes in relative risk. Results: We found that among sober (BAC = .00 g/dl) drivers, the risk of dying in a fatal crash decreased between 2007 and 2013–2014. For drinking drivers, however, no parallel reduction in the overall contribution of alcohol to the fatal crash risk occurred. Compared with 2007, in 2013–2014 the oldest group of drivers (age = 35 years) were at an elevated crash risk when driving at low BACs (.00 g/dl < BAC < .02 g/dl). Conclusions: Although the decrease in crash risk for drivers with a BAC of .00 g/dl is encouraging, the consistency of the alcohol-related risk estimates over the last two decades suggests the need to substantially strengthen current efforts to abate drinking and driving.

Method overtness, forensic autopsy, and the evidentiary suicide note: A multilevel National Violent Death Reporting System analysis
   PLOS ONE (2018)
   Rockett, Ian R. H.; Caine, Eric D.; Stack, Steven; Connery, Hilary S.; Nolte, Kurt B.; Lilly, Christa L.; Miller, Ted R. ; Nelson, Lewis S.; Putnam, Sandra L.; Nestadt, Paul S.; Jia, Haomiao
Objective Higher prevalence of suicide notes could signify more conservatism in accounting and greater proneness to undercounting of suicide by method. We tested two hypotheses: (1) an evidentiary suicide note is more likely to accompany suicides by drug-intoxication and by other poisoning, as less violent and less forensically overt methods, than suicides by firearm and hanging/suffocation; and (2) performance of a forensic autopsy attenuates any observed association between overtness of method and the reported presence of a note. Methods: This multilevel (individual/county), multivariable analysis employed a generalized linear mixed model (GLMM). Representing the 17 states participating in the United States National Violent Death Reporting System throughout 2011–2013, the study population comprised registered suicides, aged 15 years and older. Decedents totaled 32,151. The outcome measure was relative odds of an authenticated suicide note. Results: An authenticated suicide note was documented in 31% of the suicide cases. Inspection of the full multivariable model showed a suicide note was more likely to manifest among drug intoxication (adjusted odds ratio [OR], 1.70; 95% CI, 1.56, 1.85) and other poisoning suicides (OR, 2.12; 1.85, 2.42) than firearm suicides, the referent. Respective excesses were larger when there was no autopsy or autopsy status was unknown (OR, 1.86; 95% CI, 1.61, 2.14) and (OR, 2.25; 95% CI, 1.86, 2.72) relative to the comparisons with a forensic autopsy (OR, 1.62, 95% CI, 1.45, 1.82 and OR, 2.01; 95% CI, 1.66, 2.43). Hanging/suffocation suicides did not differ from the firearm referent given an autopsy. Conclusions: Suicide requires substantial affirmative evidence to establish manner of death, and affirmation of drug intoxication suicides appears to demand an especially high burden of proof. Findings and their implications argue for more stringent investigative standards, better training, and more resources to support comprehensive and accurate case ascertainment, as the foundation for developing evidence-based suicide prevention initiatives.

Spatial epidemiology of alcohol and drug-related health problems among Northern Plains American Indians: Nebraska and South Dakota, 2007-2012
   Alcoholism - Clinical and Experimental Research (2018)
    Ponicki, W. ; Henderson, J.A.; Tilsen, N.; Davids, S.; Gaidus, A.J. ; Gruenewald, P. ; Moore, R. S. ; Lee, J.P.
BACKGROUND: Despite high abstinence rates, American Indians experience elevated rates of many alcohol and other drug problems. American Indians also predominantly reside in poor and rural areas, which may explain some observed health disparities. We investigated whether geographic areas including reservations or large American Indian populations exhibited greater incidence of alcohol- and drug-related hospitalizations. METHODS: We obtained inpatient hospitalization records for 2 Northern Plain states (Nebraska and South Dakota) for the years 2007 to 2012. We constructed zip code counts for 10 categories of hospitalization with diagnoses or injury causation commonly associated with alcohol or drug use. We related these to community sociodemographic characteristics using Bayesian Poisson space-time regression models and examined associations with and without controls for whether each zip code was located within an American Indian reservation. RESULTS: Controlling for other demographic and economic characteristics, zip codes with greater percentage of American Indians exhibited greater incidence for all 10 substance abuse-related health outcomes (9 of 10 well supported); zip code areas within American Indian reservations had greater incidence of self-inflicted injury and drug dependence and abuse, and reduced incidence of alcohol cirrhosis and prescription opioid poisoning. However, the analyses generally demonstrated no well-supported differences in incidence associated with local residence percentages of American Indian versus African American. CONCLUSIONS: In our analyses, ethnicity or heredity alone did not account for alcohol- and drug-related hospitalizations among Native populations. Aspects of social, economic, and political dimensions of Native lives must be considered in the etiology of alcohol- and drug-related problems for rural-dwelling indigenous peoples.

Evaluating short- and long-term impacts of a Medicaid "lock-in" program on opioid and benzodiazepine prescriptions dispensed to beneficiaries
   Drug and Alcohol Dependence (2018)
   Naumann, R. B.; Marshall, S. W.; Lund, J. L.; Gottfredson, N. C.; Ringwalt, C. L. ; Skinner, A. C.
Insurance-based "lock-in" programs (LIPs) have become a popular strategy to address controlled substance (CS) (e.g., opioid) misuse. However, little is known about their impacts. We examined changes in CS dispensing to beneficiaries in the 12-month North Carolina Medicaid LIP. We analyzed Medicaid claims linked to Prescription Drug Monitoring Program (PDMP) records for beneficiaries enrolled in the LIP between October 2010 and September 2012 (n=2702). Outcomes of interest were 1) number of dispensed CS prescriptions and 2) morphine milligram equivalents (MMEs) of dispensed opioids while a) locked-in and b) in the year following release. Compared to a period of stable CS dispensed prior to LIP enrollment, numbers of dispensed CS during lock-in and post-release were lower (count difference per person-month: -0.05 (95% CI: -0.11, 0.01); -0.23 (95% CI: -0.31, -0.15), respectively). However, beneficiaries' average daily MMEs of opioids were elevated during both lock-in and post-release (daily mean difference per person: 18.7 (95% CI: 13.9, 23.6); 11.1 (95% CI: 5.1, 17.1), respectively). Stratification by payer source revealed increases in using non-Medicaid (e.g., out-of-pocket) payment during lock-in that persisted following release. While the LIP reduced the number of CS dispensed, the program was also associated with increased acquisition of CS prescriptions using non-Medicaid payment. Moreover, beneficiaries acquired greater dosages of dispensed opioids from both Medicaid and non-Medicaid payment sources during lock-in and post-release. Refining LIPs to increase beneficiary access to substance use disorder screening and treatment services and provider use of PDMPs may address important unintended consequences.

Prevention of Underage Drinking on California Indian Reservations Using Individual- and Community-Level Approaches
   American Journal of Public Health (2018)
    Moore, Roland S. ; Gilder, David A.; Grube, Joel W. ; Lee, Juliet P. ; Geisler, Jennifer A.; Friese, Bettina ; Calac, Daniel J.; Finan, Laura J. ; Ehlers, Cindy L.
Objectives: To evaluate combined individual- and community-level interventions to reduce underage drinking by American Indian/Alaska Native (AI/AN) youths on rural California Indian reservations. Methods: Individual-level interventions included brief motivational interviewing and psychoeducation for Tribal youths. Community-level interventions included community mobilization and awareness activities, as well as restricting alcohol sales to minors. To test effects, we compared 7 waves of California Healthy Kids Survey data (2002-2015) for 9th and 11th-grade AI/AN and non-AI/AN students in intervention area schools with California AI/ANstudents outside the intervention area (n = 617, n = 33469, and n = 976, respectively). Results: Pre- to postintervention mean past 30-day drinking frequency declined among current drinkers in the intervention group (8.4-6.3 days) relative to comparison groups. Similarly, heavy episodic drinking frequency among current drinkers declined in the intervention group (7.0-4.8 days) versus the comparison groups. Conclusions: This study documented significant, sustained past 30-day drinking or heavy episodic drinking frequency reductions among AI/AN 9th- and 11th-grade current drinkers in rural California Indian reservation communities exposed to multilevel interventions. Public Health Implications. Multilevel community-partnered interventions can effectively reduce underage alcohol use in this population.

Trends in future health financing and coverage: Future health spending and universal health coverage in 188 countries, 2016-40
   The Lancet (2018)
    Miller, T ; Global Burden of Disease Health Financing Collabor
Background: Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040. Methods: We extracted historical data on gross domestic product (GDP) and health spending for 188 countries from 1995 to 2015, and projected annual GDP, development assistance for health, and government, out-of-pocket, and prepaid private health spending from 2015 through to 2040 as a reference scenario. These estimates were generated using an ensemble of models that varied key demographic and socioeconomic determinants. We generated better and worse alternative future scenarios based on the global distribution of historic health spending growth rates. Last, we used stochastic frontier analysis to investigate the association between pooled health resources and UHC index, a measure of a country's UHC service coverage. Finally, we estimated future UHC performance and the number of people covered under the three future scenarios. Findings: In the reference scenario, global health spending was projected to increase from US$10 trillion (95% uncertainty interval 10 trillion to 10 trillion) in 2015 to $20 trillion (18 trillion to 22 trillion) in 2040. Per capita health spending was projected to increase fastest in upper-middle-income countries, at 4·2% (3·4–5·1) per year, followed by lower-middle-income countries (4·0%, 3·6–4·5) and low-income countries (2·2%, 1·7–2·8). Despite global growth, per capita health spending was projected to range from only $40 (24–65) to $413 (263–668) in 2040 in low-income countries, and from $140 (90–200) to $1699 (711–3423) in lower-middle-income countries. Globally, the share of health spending covered by pooled resources would range widely, from 19·8% (10·3–38·6) in Nigeria to 97·9% (96·4–98·5) in Seychelles. Historical performance on the UHC index was significantly associated with pooled resources per capita. Across the alternative scenarios, we estimate UHC reaching between 5·1 billion (4·9 billion to 5·3 billion) and 5·6 billion (5·3 billion to 5·8 billion) lives in 2030. Interpretation: We chart future scenarios for health spending and its relationship with UHC. Ensuring that all countries have sustainable pooled health resources is crucial to the achievement of UHC.

Social and situational characteristics associated with adolescents' drinking at party and non-party events
   Addictive Behaviors (2018)
    Lipperman-Kreda, S. ; Finan, L. ; Grube, J.
We investigated social and situational characteristics associated with adolescents' drinking at party and non-party events and whether these associations vary by party location (homes versus other locations). Ecological momentary assessment data were obtained over two weekends from 149 adolescents in California (46% female, M age = 16.4 years), using smartphone surveys administered early and late in the evening and the following morning. We assessed whether, where, and with whom adolescents drank alcohol. Social contexts with more people (RRR = 1.05, p = 0.005) and with mixed gender composition (RRR = 3.15, p = 0.05) were positively associated with increased risks of alcohol use at parties, but not at non-party events. Conversely, social contexts with friends were positively associated with alcohol use at non-party events (RRR = 4.32, p = 0.005), but not at parties. Perceived access to alcohol was associated with increased risks for alcohol use at both party and non-party events, but the association was stronger for alcohol use at parties than non-parties (RRR = 1.85, p < 0.005 versus 4.01, p = 0.005). Additional analyses showed that contexts with mixed gender composition were positively associated with alcohol use at parties not in homes (RRR = 11.29, p = 0.05), and perceptions of getting caught by parents or police were negatively associated with non-party alcohol use in homes (RRR = 0.57, p = 0.005). This study identified social-ecological contexts of underage drinking parties, which are high risk settings for heavier drinking and other alcohol-related problems. Findings can inform context-based interventions to target these high-risk settings, whether at homes or other locations.

The role of multiple social identities in discrimination and perceived smoking-related stigma among sexual and gender minority current or former smokers
   Drugs: Education, Prevention and Policy (2018)
    Lipperman-Kreda, Sharon ; Antin, Tamar M. J. ; Hunt, Geoffrey P.
Aims: We investigated how intersections of being a racial minority (i.e. being African American) and economically disadvantaged (i.e. housing insecurity) may influence experiences with discrimination and perceptions of smoking-related stigma among sexual and gender minority (SGM) current and former smokers. Methods: Survey data were collected from 227 SGM current and former smokers in California (19-65 years old), oversampling African American participants. Participants reported their race, ethnicity, past month housing insecurity, number of lifetime experiences with SGM discrimination, and perceptions of smoking-related stigma. Findings: Using univariate General Linear Models and controlling for age, ethnicity, and SGM visibility, we found a significant interaction between being African American and facing housing insecurity on experiences with SGM discrimination [F(1,220)=7.21, p=.01], perceived smoker stigma [F(1,220)=5.48, p=.02], perceived differential treatment due to smoking [F(1,220)=10.03, p=.00], and social withdrawal from nonsmokers [F(1,220)=6.18, p=.01]. These interactions suggest that economically disadvantaged African American SGM current or former smokers experience increased levels of SGM discrimination and perceive more smoking-related stigma compared with other SGM current and former smokers. Conclusions: Results suggest that people's multiple identities intersect to intensify oppression and inequities for some people and raise questions about the unintended consequences of stigmatizing smokers for reducing smoking among SGM adults.

Sleep disturbances after deployment: National Guard soldiers' experiences and strategies
   Sleep Health (2018)
    Lincoln, Martha L. ; Moore, Roland S. ; Ames, Genevieve M.
Sleep deprivation and sleep disturbance are pervasive among military personnel during and after combat deployment. However, occupational and other constraints often influence military workers to decline behavioral health services and prescription pharmaceutical sleep aids. This article, drawing on ethnographic interviews with National Guard veterans of combat deployment, demonstrates that soldiers with sleep disturbance frequently manage symptoms without medical supervision and by using ad hoc methods including alcohol use. Findings suggest the potential significance of further research into the sleep management practices of military populations, who face both high risk for sleep disturbance and occupational and cultural constraints in effectively managing these serious health concerns.

Impacts of alcohol availability on Tribal lands where alcohol is prohibited: A community-partnered qualitative investigation
   International Journal of Drug Policy (2018)
    Lee, Juliet P. ; Pagano, Anna ; Moore, Roland S. ; Tilsen, Nick; Henderson, Jeffrey A.; Iron Shell, Andrew; Davids, Sharice; LeBeaux, Lyle; Gruenewald, Paul
On a Northern Plains reservation where alcohol was prohibited, we investigated community members' views on the impacts of alcohol availability. Our methods combined elements of Tribal community participatory research with qualitative inquiry to elicit these perspectives. We used rapid appraisal techniques to conduct confidential interviews with 31 key leaders representing 7 relevant major community systems, and representing a variety of perspectives. Topics included respondents' understandings of the current systems of alcohol availability and use on the reservation, the impacts of these systems on reservation residents, and possible ways to measure these impacts. Respondents reported impacts on individuals, families, and the tribe overall. Alcohol-related problems shaped and were shaped by a constellation of social-ecological conditions: kinship, housing, employment, public/social service capacity, and the supply of alcohol in nearby off-reservation areas, as well as inter-governmental relationships and the spiritual life of reservation residents. A variety of social-structural determinants magnified alcohol impacts, so that the problem drinking of a small number of individuals could have broad effects on their families and the entire community. Our participatory qualitative methods enabled us to directly include the voices as well as the personal experiences and expertise of community members in this presentation. These methods may be broadly applied within policy analysis to identify ways to reduce harms related to alcohol and other drugs for Indigenous communities.

Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women
   Implementation Science (2018)
   Johnson, Jennifer E.; Wiltsey-Stirman, Shannon; Sikorskii, Alla; Miller, Ted ; King, Amanda; Blume, Jennifer L.; Pham, Xuan; Moore Simas, Tiffany A.; Poleshuck, Ellen; Weinberg, Rebecca; Zlotnick, Caron
BACKGROUND: More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women. METHODS: All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership. DISCUSSION: This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population.

Queer youth, intoxication and queer drinking spaces
   Journal of Youth Studies (2018)
   Hunt, G.; Antin, T. ; Sanders, E. ; Sisneros, M.
Research on intoxicating substances and gender has developed considerably in the last 30 years, especially in the social sciences as feminist scholars highlighted the contradictory discourses about young women's intoxication. Nevertheless, there still remain significant gaps if we are to fully understand the role and meaning of intoxication for all young people and not merely for heterosexual, cisgender young people. As a way of exploring the possible limitations of this legacy, we will examine the qualitative data from 52 in-depth interviews with self-identified LGBTQ young people. Our analysis explores the relationships between meanings of intoxication and sexual and gender identities, drinking spaces, and the extent to which notions of masculinity and femininity influence alcohol consumption and drinking practices among LGBTQ youth. As gender expressions among young people, especially those who identify as LGBTQ, become increasingly nuanced and fluid, understanding the role of social and cultural practices of alcohol consumption in the performance of sexual and gender identities may increase our understanding of the ways in which sexuality and gender influence alcohol consumption.

A longitudinal examination of decisions to ride and decline rides with drinking drivers
   Alcoholism: Clinical and Experimental Research (2018)
   Hultgren, Brittney; Turrisi, Rob; Mallett, Kimberly; Ackerman, Sarah; Larimer, Mary; McCarthy, Denis; Romano, Eduardo
BACKGROUND: Riding with a drinking driver (RWDD) is a serious concern that leads to numerous preventable deaths every year. There is a significant gap in research on empirically tested predictors of RWDD that could be implemented in prevention efforts. College students are in need of such prevention efforts, as they have some of the highest rates of alcohol-related crash fatalities and may engage in RWDD more than their noncollege peers. This study utilized behavioral decision-making approach to examine predictors of RWDD and declining a ride from a drinking driver (Decline) in older college students. METHODS: Students (n = 791) in their third year of college were enrolled from 3 large and diverse universities. Psychosocial (e.g., expectancies, norms) and decision-making variables (willingness to RWDD and intentions to use alternatives) were assessed in the fall of their third year. One year later, RWDD and Decline behaviors were assessed. Zero-inflated Poisson analyses were used to assess how decision-making variables predicted RWDD and Decline behavior. Associations between psychosocial and decision-making variables were also assessed. RESULTS: Thirteen percent of students reported RWDD and ~28% reported Decline behavior. Willingness to RWDD and typical weekly drinking were both associated with increases in RWDD (odds ratio [OR] = 1.58 and 1.40, respectively), whereas intentions to use alternatives, sex, and ethnicity were not associated with RWDD. Only weekly drinking was associated with Decline, with an increase in drinking associated with increased Decline (OR = 1.48). All psychosocial variables were significantly associated with the decision-making variables except positive expectancies. CONCLUSIONS: Results provide evidence that willingness to RWDD is a predictor of future RWDD, even if students intend to use safe alternatives. Future research is needed to better understand decision-making factors that influence Decline. Results also suggest prevention and interventions efforts, such as brief motivational intervention, Parent-Based Interventions, and normative feedback interventions could be adapted to reduce RWDD.

Effects of a responsible retailing mystery shop intervention on age-verification behavior by servers and clerks in alcohol outlets
   Drug and Alcohol Review (2018)
    Grube, J.