The ecological nature of paper 3 precludes conclusive statements about the role of alcohol and tobacco retailers in neighborhoods. No direct measure of acquisition was included. This meant that I could not be certain respondents were necessarily purchasing substances from retailers closest to their home. Improvements on this dimension should include items designed to ascertain information about purchasing and/or acquiring behaviors, and whether they consumed these substances or acquired them for a third party, etc. Finally, does this obscure sample of Latino adolescents living along the US/Mexico border generalize to a larger population of Latinos? Adolescents in this study sample were recruited based on their latent tuberculosis infection diagnosis. Associations between LTBI and use of alcohol, tobacco, or marijuana have not been shown previously. As such, study sample adolescents were not expected to differ substantially from their peers. Indeed, sample characteristics were similar to the larger set of adolescents recruited for the tuberculosis screening , most of which were negative. To the extent the findings reported in these studies are consistent with extant literature there is a rational basis to believe that other findings, even if new, may be of substantial import. The true test of generalizability will be measured in the replication of these findings,horticulture trays or variants of them in future studies. As with much research, the final product raises equally as many questions as answers. Questions that in turn generate new research agendas and future directions. Results from paper 1 suggest that future studies investigate with more depth the nature of alcohol and tobacco uptake among adolescents, including an exploration of the differences between the two substances.
For example, are family influences really more important in determining alcohol use than tobacco? If so, what aspects of that influence? Part of clarifying these differences may include more precise measures related to alcohol and tobacco use. For example, the quantity, frequency, and conditions under which it was consumed. Such items may help to discriminate between low-risk experimentation and high-risk experimentation or use . These discriminations are important as the set of risk factors for the respective behaviors are different. Nevertheless, these findings suggest that tobacco prevention interventions be focused entirely on influences in the peer domain. Whereas alcohol prevention efforts must be multidimensional, addressing family, school and peer influence domains. In the event future science confirms family and parental influences are valid intervention targets for alcohol prevention , researchers should be aware of the potential in congruence between reports from parents and their own children about parenting practices. Such findings should serve as impetuses for the creation of new measures, or at least the application of existing measures that minimize error, e.g., direct observation. The added dimension of paper 3 in this dissertation, especially considering its classification as an exploratory study, generates many unanswered questions. Upon first inspection, it is confusing to think that females living in high-risk areas report lower rates of gateway drug use. This may be an example of the built environment interacting with the social environment, on multiple levels. Determining these mechanisms will most definitely require continued research in this area, and the ability to balance technology and theory. Future measures may include such things as markers of neighborhood social acceptability of drug use, and parental involvement. Once again, I see parents as a key influence in this process. A new research agenda moving forward should include inspection of differential parental controls of males versus females in high-risk neighborhoods. With future refinements and sequential iterations in future studies, measures, results, and intervention implications will become more precise and prescriptive, making meaningful behavior change through intervention more achievable.
The homeless population is aging . People born in the second half of the “baby‐boom” have an elevated risk of homelessness . Homeless adults develop aging‐related conditions, including functional impairment, earlier than individuals in the general population. For this reason, homeless adults aged 50 and older are considered “older” despite their relatively young age . The homeless population has a higher prevalence of mental health and substance use problems than the general population . Individuals experiencing homelessness report barriers to mental health services, due to lack of insurance coverage, high cost of care, and inability to identify sources of care . These barriers can prevent their using services to treat mental health and substance use problems, such as outpatient counseling, prescription medication, and community‐based substance use treatment. Without these, homeless populations may experience more severe behavioral health problems and rely on acute care to address these chronic conditions. Homeless individuals have higher rates of Emergency Department use for mental health and substance use concerns , and are more likely to use psychiatric inpatient or ED services and less likely to use outpatient treatment than those who are housed . Homeless adults with substance use disorders face multiple barriers to engaging in substance use treatment. Competing needs , financial concerns, lack of knowledge about or connection to available services, and lack of insurance are barriers to substance use treatment among homeless adults . Older adults face additional barriers to mental health or substance use treatment due to cognitive and functional impairment, such as difficulty navigating and traveling to healthcare systems . However, there is little known about older adults experiencing homelessness. According to Gelberg and Anderson’s Behavioral Model for Vulnerable Populations, predisposing factors, enabling factors, and need, shape health care utilization . Although prior research has used this model for homeless populations, this work has not included older homeless adults .
Little is known about the prevalence of mental health or substance use problems in older homeless adults, the level of unmet need for services, or the factors associated with that need. To understand the factors associated with unmet need for mental health and substance use treatment in older homeless adults, in a population‐based sample of homeless adults age 50 and older, we identified those with a need for mental health and substance use services. Then, we applied the Gelberg and Anderson model to examine predisposing and enabling factors associated with unmet need, which we defined as not receiving mental health and substance use treatment among participants with mental health or substance use problems .In a population‐based sample of older adults experiencing homelessness, we found a high prevalence of unmet need for mental health and substance use treatment. While the majority of participants had mental health and substance use problems, few received treatment. One‐third of those with mental health need received mental health care. Fewer than 13% of those with substance use need received substance use treatment. We identified predisposing and enabling factors associated with unmet treatment need. Adults aged 65 and over had a higher odds of unmet need for mental health treatment. Older adults are more likely to have competing demands, including higher physical health needs, which can interfere with receiving behavioral healthcare . Due to a shortage of geriatric psychiatrists and geriatric mental health care services,sliding grow tables older adults may not have access to treatment when they seek care . The homeless population age 65 and older is expected to triple by the year 2020 . Thus, there is a need to design care that meets the needs of this growing, but under served, population. We found that having a regular healthcare provider was associated with less unmet need. Having a regular provider can increase engagement because primary care providers may help identify needs and refer to care. In safety‐net systems, such as the ones in which our participants receive care, primary care providers may be the primary source of mental health treatment, by prescribing psychotropic medication. Primary care providers are responsible for an increasing proportion of prescriptions for psychotropic medication . In addition to prescribing medication for mental health conditions, primary care providers can refer patients to outpatient mental health counseling and treatment with specialist staff or providers. In some safety‐net settings, mental health services may be colocated with physical health services via collaborative care models.Collaborative care models can enhance information sharing and treatment plan collaboration and reduce barriers to care .CCMs are cost‐efficient and can increase the capacity of resource‐constrained settings to provide care for patients with complex needs .
Federally Qualified Health Centers can bill for both a medical and mental health visit on the same day , and recent changes to FQHC payment codes allow billing for behavioral health care management services in addition to the FQHC billable visit. Pay‐for‐performance programs link public hospitals’ payments to care coordination and mental health treatment metrics . It is possible that participants in our study were obtaining care in safety‐net primary care settings with CCMs. Alternatively, the reduced odds of unmet need amongst those who had regular care providers could reflect other factors that we did not measure. For example, having a regular care provider may be a marker for increased system engagement and reduced barriers to any type of care. Those who seek primary care may be more organized, knowledgeable about safety‐net service availability, and have more access to transportation and other enabling resources. . Having a case manager was associated with less mental health and substance use treatment need. In the case management brokerage model, case managers help people navigate care systems and provide a linkage to services. In the clinical case management model, case managers serve as care providers and may provide both mental health and substance use services directly . In some models, such as intensive case management, case managers provide both brokerage and direct services . It is possible that the association between having a case manager and decreased odds of unmet need for both mental health and substance use services is a result of reverse causality; treatment programs may assign a case manager. We found that participants who first became homeless at age 50 or older had a higher odds of unmet substance use treatment need. Those with late onset homelessness had led more “typical” lives, with a higher likelihood of having been continuously employed and having been married or partnered . They were less likely to have had early onset of substance use problems, thus, they may have developed substance use problems more recently. These individuals may have been less aware of safety‐ net resources in general or resources for substance use treatment in particular. Spending time in jail/prison in the past 6 months was associated with reduced unmet substance use treatment need. It is possible that participants initiated substance use treatment while incarcerated. However, most incarceration settings do not provide adequate treatment services. Alternatively, as a condition of release, participants may have been required to engage in substance use treatment. Our findings indicate there is a lack of community‐based pathways into substance use care. By giving medication‐assisted treatments, such as buprenorphine for opioid use disorder and naltrexone for alcohol use disorder in primary care settings, primary care providers can begin to address this unmet need . However, there is a need for greatly expanded substance use services. Our study has several limitations. We did not use a full psychiatric diagnostic interview. However, screening measures are important empirical tools for the referral of individuals to mental health treatment, especially when integrated care is available . We did not ask participants where they received mental health services, thus we cannot determine whether they received care colocated with primary care, or treatment in mental health specific settings.Methamphetamine is a potent psychostimulant and complications of chronic use and abuse include addiction, psychosis, and depression, as well as increased risk of medical problems including HIV, impaired immune system functioning, cardiomyopathy, neurocognitive dysfunction, and Parkinson Disease . Current treatment is limited to behavioral therapies and risk of relapse following behavioral treatment is high . Pharmacotherapy may improve outcomes with behavioral treatment but despite numerous clinical trials no effective medication is available for methamphetamine use disorder . Negative clinical trials to date have primarily tested medications approved for other indications and focused on medications targeting the monoamine neurotransmitter systems suggesting that the identification of new targets for medications is necessary for the successful development of effective medications for methamphetamine use disorder. Substance use disorders are influenced by both biological and social factors although studies estimating heritability in excess of 50% for substance use disorders suggest an important role for genetic influences . For example, a recent study estimated heritability for stimulant use disorder at 68% .