Alison J. Culyba

Association of Drug and Alcohol Use With Adolescent Firearm Homicide at Individual, Family, and Neighborhood Levels

Importance Homicide is the third leading cause of death for adolescents in the United States and the leading cause of death for adolescents who are African American. Large cities have disproportionate homicide rates. Objective To determine the relationships between exposures to drugs and alcohol at the individual, family, and neighborhood levels and adolescent firearm homicide and to inform new approaches to preventing firearm violence. Design, Setting, and Participants Population-based case-control study from January 2010 to December 2012 of all 13- to 20-year-olds who were homicide victims in Philadelphia during the study period matched to randomly selected 13- to 20-year-old controls from the general population. Exposures Individual drug and alcohol use at the time of injury, history of drug and alcohol use, caregiver drug and alcohol use, and neighborhood availability of alcohol and illegal drugs. We also controlled for age, race, school suspensions, arrests, and neighborhood ethnicity. Main Outcomes and Measures Adolescent firearm homicide identified from police and medical examiner’s reports. Results We enrolled 161 adolescent homicide cases, including 157 (97.5%) firearm homicide cases and 172 matched controls, including 166 (96.5%) firearm homicide controls. Adolescents with a history of alcohol use (adjusted odds ratio [AOR], 4.1; 95% CI, 1.2-14.0) or drug use (AOR, 4.4; 95% CI, 1.7-11.6) had increased odds of firearm homicide. Adolescents whose caregiver had a history of drug use had increased odds of firearm homicide (AOR, 11.7; 95% CI, 2.8-48.0). Adolescents in neighborhoods with high densities of alcohol outlets (AOR, 3.2; 95% CI, 1.1-9.1) and moderate or high drug availability had increased odds of firearm homicide (AOR, 3.4; 95% CI, 1.1-10.3 vs AOR, 7.5; 95% CI, 2.2-25.8). Conclusions and Relevance Almost all adolescent homicides in Philadelphia between 2010 and 2012 were committed with a firearm. Substance use at the individual, family, and neighborhood levels was associated with increased odds of adolescent firearm homicide; drug use was associated at all 3 levels and alcohol at the individual and neighborhood levels. Expanding violence prevention efforts to target drug and alcohol use at multiple levels may help to reduce the firearm violence that disproportionately affects adolescents in minority populations in large US cities.

Protective effects of adolescent-adult connection on male youth in urban environments

PURPOSE Positive adult connection has been linked with protective effects among U.S. adolescents. Less is known about the impact of adult connection across multiple health domains for youth in low-resource urban environments. We examined the associations between adult connection and school performance, substance use, and violence exposure among youth in low-resource neighborhoods. METHODS We recruited a population-based random sample of 283 male adolescents in Philadelphia. Age-adjusted logistic regression tested whether positive adult connection promoted school performance and protected against substance use and violence exposure. RESULTS Youth with a positive adult connection had significantly higher odds of good school performance (odds ratio [OR], 2.8; p < .05), and lower odds of alcohol use (OR, .4; p < .05), violence involvement (OR, .3-.4; p < .05), and violence witnessing (OR, .3; p < .05). CONCLUSIONS Promoting adult connection may help safeguard youth in urban contexts. Youth-serving professionals should consider assessing adult connection as part of a strengths-based approach to health promotion for youth in low-resource neighborhoods.

Examining the Role of Supportive Family Connection in Violence Exposure Among Male Youth in Urban Environments

Family connection has demonstrated protective effects on violence perpetration, victimization, and witnessing in the general U.S. adolescent population. However, several studies examining the impact of family connection on violence exposure in adolescents living in low-resource urban environments have failed to demonstrate similar protective effects. We interviewed male youth in low-resource neighborhoods in Philadelphia recruited through household random sampling. Adjusted logistic regression was used to test whether a supportive relationship with an adult family member was inversely associated with violence involvement and violence witnessing. In 283 youth participants aged 10 to 24 years, 33% reported high violence involvement, 30% reported high violence witnessing, and 17% reported both. Youth who identified at least one supportive adult family member were significantly less likely to report violence involvement (odds ratio [OR] = 0.35; 95% confidence interval [CI] = [0.18, 0.69]) and violence witnessing (OR = 0.46; 95% CI = [0.24, 0.88]). Youth with two supportive parents, and those with supportive mothers only, also demonstrated significant inverse associations with violence involvement. Supportive parental relationships were inversely but not significantly related to witnessing violence. The findings suggest that supportive parental relationships may not prevent youth in low-resource neighborhoods from witnessing violence but may help prevent direct violence involvement. Next studies should be designed such that the mechanisms that confer protection can be identified, and should identify opportunities to bolster family connection that may reduce adolescent violence involvement among youth in low-resource urban environments.

Comparing residence-based to actual path-based methods for defining adolescents’ environmental exposures using granular spatial data

&NA; This paper uses data from a population‐based case control study of daily activities and assault injury to examine residence‐based versus actual path‐based approaches to measuring environmental exposures that pose risks for violence among adolescents. Defining environmental exposures based on participant home address resulted in significant misclassification compared to gold standard daily travel path measures. Dividing participant daily travel paths into origin‐destination segments, we explore a method for defining spatial counterfactuals by comparing actual trip path exposures to shortest potential trip path exposures. Spatial methods explored herein can be utilized in future research to more accurately quantify environmental exposures and associations with health outcomes. HighlightsExamines residence vs. path‐based approaches to measure environmental violence risks.Home address resulted in significant misclassification compared to daily paths.Trip path analyses provided a method for generating spatial counterfactuals.Proposed actual path‐based methods can be applied to future injury research.

Adult Connection in Assault Injury Prevention among Male Youth in Low-Resource Urban Environments

Strengths-based strategies to reduce youth violence in low-resource urban communities are urgently needed. Supportive adolescent-adult relationships may confer protection, but studies have been limited by self-reported composite outcomes. We conducted a population-based case-control study among 10- to 24-year-old males in low-resource neighborhoods to examine associations between supportive adult connection and severe assault injury. Cases were victims of gunshot assault injury (n = 143) and non-gun assault injury (n = 206) from two level I trauma centers. Age- and race-matched controls (n = 283) were recruited using random digit dial from the same catchment. Adolescent-adult connections were defined by: (1) brief survey questions and (2) detailed family genograms. Analysis used conditional logistic regression. There were no significant associations between positive adult connection, as defined by brief survey questions, and either gunshot or non-gun assault injury among adolescents with high prior violence involvement (GSW OR = 2.46, 95% CI 0.81–7.49; non-gun OR = 1.59, 95% CI 0.54–4.67) or low prior violence involvement (GSW OR = 0.92, 95% CI 0.34–2.44; non-gun OR = 1.96, 95% CI 0.73–5.28). In contrast, among adolescents with high levels of prior violence involvement, reporting at least one supportive adult family member in the family genogram was associated with higher odds of gunshot assault injury (OR = 4.01, 95% CI 1.36–11.80) and non-gun assault injury (OR = 4.22, 95% CI 1.48–12.04). We were thus unable to demonstrate that positive adult connections protected adolescent males from severe assault injury in this highly under-resourced environment. However, at the time of injury, assault-injured adolescents, particularly those with high prior violence involvement, reported high levels of family support. The post-injury period may provide opportunities to intervene to enhance and leverage family connections to explore how to better safeguard adolescents.

12 Overcoming barriers to addressing youth-identified mental health needs following violent injury through multisystem partnerships

Statement of purpose To identify and address barriers to meeting mental health (MH) needs of violently injured youth participating in a post-injury hospital-based case management program. Methods/approach Utilising de-identified case notes from a stratified random sample of youth (n=24) receiving hospital-based case management following violent injury, we applied a social-ecological framework to code recurring themes pertaining to individual, family, and system barriers and facilitators to successful resolution of youth-identified MH needs. Results Common barriers included: school/work schedules; limited transportation; prior negative experiences with MH care; insufficient provider availability; premature termination of care; and challenging communication between program staff, MH providers, and families. Notably, insurance and cost barriers were infrequently documented, as most youth were insured via a widely accepted public payer. Barriers to initiation of MH care were addressed by streamlining referral processes to community-based MH providers and providing a warm-hand off to reduce youth and family hesitancy to initiate care. To promote engagement and adherence, staff highlighted positive MH experiences and validated therapeutic outcomes, provided logistical support such as transportation and, when possible, provided short-term in-home therapy. Staff also routinely communicated with local MH providers to coordinate care, support transition planning, and encourage adherence. Conclusions We observed individual, family, and systems barriers to youths’ ability to engage in MH care. Support of strong, consistent, positive interpersonal relationships between program staff, injured youth, families, and MH providers addressed many barriers and supported resolution of youths’ MH needs. Significance and Contributions to Injury and Violence Prevention Science Access to trauma-focused mental health services for violently injured youth is essential to facilitate recovery. Partnerships between hospital- and community-based programs may be particularly valuable in addressing mental health barriers among youth following violent injury. Further efforts to systematise and replicate multisystem partnerships will be important in promoting well-being and recovery following violent injury.

101 Comparing novel to conventional methods for defining adolescents’ environmental exposures using granular spatial data

Statement of Purpose Examine conventional versus innovative approaches to measuring environmental exposures posing violence risks during adolescents’ daily activities. Methods/approach Using data from a case-control study of daily activities and assault injury among 283 10–24 years old males in Philadelphia, we compared participants’ exposure to 27 environmental risk factors using three Methods home address-based measurement (kernel density (KD)/inverse distance weighting (IDW)), minute-by-minute GIS activity path-based measurement (KD/IDW), and measured differences between actual and potential shortest trip paths (60 ft/660 ft buffers). First, we used R-squared to quantify the extent to which home address-based measures explained gold standard activity path-based measurement. Next, we divided participant’s activity paths into origin-destination segments and used intercept-only linear regressions to test for differences in environmental exposures along actual versus shortest potential trip paths. Results Defining environmental exposures based on participant home address resulted in significant misclassification compared to activity path measures, with home address-based measures only partially explaining exposures (R-squared range: 0.05–0.81). Additionally, we found that participants’ actual trip paths often differed from shortest potential trip paths, and resulted in statistically significant differences in exposure to vandalism, narcotics arrests, disorderly conduct, public drunkenness, alcohol outlets, and vacant properties (p<0.05). Conclusions Defining environmental exposures based on participant home address fails to fully account for individual variability in exposure levels accrued over daily activity. Participants often selected trip paths that differed from the shortest potential trip paths, resulting in statistically significant differences in calculated exposures. Significance/Contribution to Injury and Violence Prevention Science Selecting among different methods for ascribing environmental risk factors to measure participants’ experiences can yield different exposure estimates, and impair our ability to accurately assess associations between environmental exposures and violence. Future research on how environments relate to injury outcomes can utilise the innovative spatial methods explored herein to measure exposures more accurately for a given hypothesis.

68 Examining the role of supportive adults in violence exposure among male youth in urban environments

Statement of purpose Adult connexion has demonstrated a protective effect on multiple adolescent health outcomes. We examine how the nature of relationships with adults impacts violence exposure. Methods/approach 283 adolescent males in Philadelphia, ages 10–24, were enrolled via household random-digit dial and interviewed in person. Relationships with key family members were divided into supportive, unsupportive, and mixed, as defined by youth. Reported violence involvement and violence witnessing scores were created using 17 self-reported items, and dichotomized using natural breakpoints. Logistic regressions examined how relationships with adult family members corresponded to violence involvement and witnessing violence. Results Median participant age was 18 and 98% were African American. 68% of youth identified at least one supportive adult family member including mothers (60%), fathers (27%), and maternal grandmothers (15%). 33% of youth reported high violence involvement, 30% reported high violence witnessing, and 17% reported both. Youth who reported at least one supportive adult had significantly decreased odds of violence involvement (OR = 0.38; 95% CI = 0.23–0.65) and violence witnessing (OR = 0.49; 95% CI = 0.29–0.83). Compared to youth with unsupportive maternal relationships, those with supportive relationships had decreased odds of violence involvement (OR = 0.17; 95% CI = 0.05–0.57). Having a supportive paternal relationship trended towards decreased odds of violence involvement (OR = 0.47, 95% CI = 0.10–2.31), but was relatively uncommon. Findings adjusted for age were consistent. Conclusions Supportive family connexion is strongly associated with decreased odds of violence exposure and violence witnessing. Youth who characterised supportive maternal relationships had significantly less violence involvement; those who characterised supportive paternal relationships also trended towards less violence involvement. Significance and contributions Next studies should fully evaluate the impact of supportive fathers, investigate causal mechanisms underlying the observed relationships, and identify opportunities to bolster family connexion that may reduce adolescent violence exposure.