my W. Tam

ALCOHOL AND NON-FATAL INJURY IN THE U.S. GENERAL POPULATION: A RISK FUNCTION ANALYSIS

This paper reports a risk function analysis of average daily volume of alcohol consumed and the frequency of consuming 5 or more drinks during a single day with reporting an injury in a probability sample of the U.S. adult household population living in the 48 contiguous states. The data are from the 1990 National Alcohol Survey on a weighted sample of 1150 respondents, 748 of whom were current drinkers. Risk of injury was found to increase with an average daily volume of 1 drink for both males and females and for those 30 and younger and those over 30, and to increase with a frequency of consuming 5 or more drinks on one day more often than twice a year. These data suggest that risk for injury may be increased at relatively low levels of consumption and, if so, that preventive efforts aimed at more moderate drinkers may have a greater impact on the reduction of alcohol-related accidents than efforts focused on heavier drinkers who are fewer in number.

Disaffiliation, Substance Use, and Exiting Homelessness

This study tested whether social affiliation was associated with exits from homelessness for a county-wide probability sample of 397 homeless adults who were followed over a 15-month period culminating in 1992. For the total sample, support from family or friends and service use were related to an increased likelihood of exiting from homelessness. Surprisingly, exits from homelessness were associated with social affiliation (i.e., support from family/friends and services use) only among homeless adults who did not have current substance-use disorders. This relationship did not hold for those with current substance-use disorders. Findings suggest that homeless adults without current substance-use disorders may be better able to engage services and support from family/friends to exit homelessness than homeless adults who have current substance-use disorders. Perhaps service providers who are targeting homeless adults with substance-use disorders and want to help them exit homelessness need to emphasize initiating substance-use treatment before addressing other issues.

DSM-IV alcohol dependence and drinking in the U.S. population: A risk analysis

PURPOSE This paper examines the relationship between alcohol dependence according to the criteria found in the 4th edition of the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association and drinking in the U.S. general population. METHODS The data set under analysis is the 1988 National Health Interview Survey, which interviewed a probability sample of 22,102 adult drinkers in the U.S. household population. The response rate was 86%. RESULTS Results indicate that there is a linear relationship between DSM-IV dependence and the mean number of drinks consumed per day, or the number of days drinking five or more glasses of alcohol in the past 12 months. Respondents who reported consuming five or more drinks in a day have about six times more chances of being dependent than respondents who did not report such pattern of drinking. Older drinkers are less at risk than younger drinkers. CONCLUSIONS There is a risk of alcohol dependence at relatively low volumes of consumption. The risk increases gradually with the volume of consumption. An added and higher risk exists when drinkers engage in a pattern of consumption involving the ingestion of five or more drinks per day.

Longitudinal perspective: adverse childhood events, substance use, and labor force participation among homeless adults

Objectives: We examined the long‐term effects of adverse childhood events on adulthood substance use, social service utilization, and subsequent labor force participation. Methods: A county‐wide probability sample of 397 homeless adults was interviewed three times in a 15‐month period. By using a path model, literature‐based relationships between adverse childhood events and labor force participation with the mediating effects of adulthood substance use and service use were tested. Results: Adverse childhood events were precursors to adulthood alcohol and drug use. Consistent substance use was negatively associated with long‐term labor force participation and with social service utilization among homeless adults. Adverse events at childhood, however, were positively associated with service use. Conclusions: Adverse childhood events may contribute to negative adulthood consequences, including consistent substance use and reduced labor force participation. Agencies that are involved in halting the abuse or neglect also should participate in more preventive interventions. Job‐related assistance is particularly important to facilitate employment and labor force participation among homeless adults.

Substance use and separation of homeless mothers from their children.

OBJECTIVES This study examined whether homeless mothers with substance use problems were more likely to experience separations from their children and whether recent substance use had an impact on the familys ability to receive public entitlement income consistently over the 15-month study period. METHODS This study used an existing longitudinal data set consisting of a county-wide probability sample of 104 homeless women who had children under 18 years old. RESULTS Only 29.1% of women had all their children with them throughout the 15-month study period. Mothers who had been separated from their children were more likely to have a current substance use disorder and to have been homeless for at least a year compared to other homeless mothers. CONCLUSIONS Because many women with recent substance use had already had lost custody of their children, substance use contributed to loss of child custody among mothers who did not have substance use disorders.

Common needs but divergent interventions for U.S. homeless and foster care children: results from a systematic review

Many children living in homeless situations in the U.S. have temporary stays in foster care, and both populations suffer disproportionately higher rates of physical, psychological and social difficulties compared with other children. However, very little is known about which specific interventions achieve the best outcomes for children in these overlapping transitional living situations. To address this gap, we review existing literature to identify the most promising practices for children living in transition. A standardised vocabulary specific to each of three electronic databases (i.e. Medline, PsychINFO and CINAHL) was employed to identify studies that described an intervention specifically targeting foster care or homeless children and families. Separate systematic searches were conducted for homeless and foster children, and only studies published in English between January 1993 and February 2009 were selected. The final sample (n = 43) of articles described interventions that fell into two categories: mental health (n = 17) and case management (n = 26). No article included a sample containing both homeless and foster care children, and most studies on homeless children used case management interventions while most studies on foster care children focused on mental health interventions. Few articles employed rigorous study designs. Although repeatedly studies have demonstrated the overlap between populations of homeless and foster care children, studies focused on one population or the other. Virtually all studies on both homeless and foster children devised interventions to reduce trauma and family instability; yet, no evidence-based practice addresses the overlapping needs and potentially relevant evidence-based practice for these two populations. An important and vital next step is to establish an effective evidence-based intervention that reduces the impact of trauma on both U.S. populations of children living in transition.

The Link Between Homeless Women's Mental Health and Service System Use

OBJECTIVE With high rates of psychiatric and substance use problems, homeless women need a wide variety of services. This study, focusing on homeless women with and without symptoms of mental illness, examined the association of predisposing, enabling, and need factors (based on Aday-Andersens health services utilization model) with use of behavioral, medical, and human services. METHODS Data from 738 homeless women from the National Survey of Homeless Assistance Providers and Clients were analyzed. RESULTS Homeless women with symptoms of mental illness showed higher rates of service use in behavioral, medical, and human domains, a finding that indicates that there are stronger service linkages for this group than for women without symptoms of mental illness. Predictors associated with service use differed by psychiatric symptoms among homeless women: predisposing and enabling factors influenced service use among homeless women without symptoms of mental illness, whereas need factors influenced service use among women with symptoms of mental illness. CONCLUSIONS Mental illness symptoms may be a trigger for receiving an array of services for homeless women once they gain entrance into a service system. There was a negative association between symptoms of mental illness and use of behavioral health services among homeless mothers, which may be the result of the fear of child welfare service intervention and loss of child custody. This service distribution inequity among homeless women using mental health services deserves attention by policy makers, researchers, and providers.

Substance use and labor force participation among homeless adults

Objectives: We measured the proportion of homeless adults in the labor force and examined the impact of substance use on labor force participation. Methods: A county-wide probability sample of 397 homeless adults was interviewed three times in a 15-month period. Results: Almost 80% of homeless adults were employed or looking for work at one point in time; however, only 47.7% remained in the labor force over the 15-month study period. Recent drug users were only 5% as likely as other homeless adults to be in the labor force; and consistent public entitlement recipients were only 18% as likely as other homeless adults to be in the labor force. Conclusions: Recent illicit drug use posed a deterrent to labor force participation among homeless adults, but heavy alcohol use did not. Most homeless adults were not consistently in the labor force and those who were, did not receive public entitlement benefits. This finding poses an interesting dilemma since previous studies indicated that homeless adults, who are consistent public entitlement recipients, were more likely to get housed than those who are not.

Disparities in the Use and Quality of Alcohol Treatment Services and Some Proposed Solutions to Narrow the Gap

OBJECTIVES This study assessed racial-ethnic disparities in access to high-quality treatment for at-risk drinking and alcohol abuse in the United States and simulated strategies to narrow the gap. METHODS Longitudinal data collected in 2001-2002 and 2004-2005 from the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed to examine racial-ethnic disparities in receipt of alcohol interventions that were provided in primary care and specialty treatment settings and that met published clinical guidelines. The sample consisted of 9,116 respondents who met criteria for at-risk drinking or alcohol abuse in 2001-2002. Simulation analyses projected how disparities in treatment services utilization might change if clinical guidelines promoted access to care in more varied health and human service settings. RESULTS Compared with whites, members of racial-ethnic minority groups had less than two-thirds the odds of receiving an alcohol intervention over the roughly four-year study period (odds ratio [OR]=.62, p<.05). This disparity increased after adjustment for socioeconomic confounders and frequency of heavy drinking (adjusted OR=.47, p=.003). The most pronounced disparities were between whites and U.S.-born and foreign-born Hispanics. Simulation analyses suggested that these disparities could be partially mitigated by extending care into nonmedical service venues. CONCLUSIONS Current efforts to extend evidence-based alcohol interventions into medical settings address an important need but are likely to increase racial-ethnic disparities in access to high-quality treatment. Partial solutions may be found in expanding the range and quality of alcohol-related services provided in alternative delivery sites, including faith-based and social service institutions.

Toward a better understanding of when to apply propensity scoring: a comparison with conventional regression in ethnic disparities research.

PURPOSE Despite growing popularity of propensity score (PS) methods used in ethnic disparities studies, many researchers lack clear understanding of when to use PS in place of conventional regression models. One such scenario is presented here: When the relationship between ethnicity and primary care utilization is confounded with and modified by socioeconomic status. Here, standard regression fails to produce an overall disparity estimate, whereas PS methods can through the choice of a reference sample (RS) to which the effect estimate is generalized. METHODS Using data from the National Alcohol Surveys, ethnic disparities between White and Hispanics in access to primary care were estimated using PS methods (PS stratification and weighting), standard logistic regression, and the marginal effects from logistic regression models incorporating effect modification. RESULTS Whites, Hispanics, and combined White/Hispanic samples were used separately as the RS. Two strategies utilizing PS generated disparities estimates different from those from standard logistic regression, but similar to marginal odd ratios from logistic regression with ethnicity by covariate interactions included in the model. CONCLUSIONS When effect modification is present, PS estimates are comparable with marginal estimates from regression models incorporating effect modification. The estimation process requires a priori hypotheses to guide selection of the RS.