Background: Over the past 40 years, there has been a dramatic increase in the number ofwomen incarcerated. The majority of incarcerated women are serving time on a drug-related charge, economic crime, or crime against public order. In addition to leading to criminal justice involvement, substance use can cause unstable housing, unemployment, economic losses, exposure to violence, social stigma, family and peer relationship problems, and decreased quality of life (QoL). Black women are more likely than other groups to use drugs that are highly addictive and associated with greater harm, and as a result, suffer more severe consequences. Further, research has found that Black women have among the lowest substance use treatment retention rates.

Recovery capital has been defined as the aggregate of resources a person can access that cansupport initiating treatment for substance use disorder, maintaining treatment and continuing abstinence. This three-paper dissertation investigated "recovery capital" outcomes among Black female participants in a longitudinal randomized controlled trial of a treatment linkage intervention. It was hypothesized that by participating in the intervention, participants would receive proactive linkage services in which substance use problems would be immediately identified, allowing women to access treatment sooner. In addition, involvement in treatment would reduce risk factors associated with persistent substance use, such as unstable housing and unemployment, low abstinence self-efficacy, lower quality of life, as well as problems with mental health and family problems.

Methods: Participants were Black adult females (N=400) recruited from the Cook County, IL jailsystem during two phases. For phase one, inclusion criteria required that participants were incarcerated adult females who participated in the Cook County jail-based SUD treatment program operated by the Department of Women’s Justice Services. Participants were randomized to receive recovery checkups or reentry as usual services and were assessed quarterly for 36-months. A Generalized Estimating Equations (GEE) procedure was used to estimate population-based parameters of the effects of the intervention on housing, employment, recovery and quality of life domains. For the abstinence self-efficacy outcome, an ordinal logistic regression was used to estimate the effect of the intervention on self-efficacy over time among participants in the experimental condition compared to those in the control group.

Results: The findings represent models that tested the predictive relationship withoutcomes over time by using time-varying covariates. Housing- After adjusting for covariates, housing decreased for both groups over time. More years of exposure to the criminal justice system, including being under legal supervision, was associated with decreased odds of housing. Employment- Having additional years of education was associated with higher odds of employment, but older participants had lower odds of employment. Participants who were housed had higher odds of employment suggesting greater stability over time. Social support was inversely related to employment. Over the course of the study, greater social support was strongly associated with abstinence self-efficacy, suggesting that such support increased the odds that participants would rate themselves as having higher self-efficacy. Lower levels of abstinence self-efficacy were linked to both older age and substance use, indicating that continued substance use and low levels of self-efficacy are mutually reinforcing. Abstinence self-efficacy was strongly associated with recovery, which was a composite variable defined as living in the community, past month abstinence from all substances, and no past month substance use problems. Quality of life (QoL)- After adjusting for covariates, there were no significant effects for the intervention across any of the models however, the variable of time was found to be associated with quality of life, with both groups improving in QoL over time. Mental distress which was negatively associated with QoL and there was a large and significant relationship with abstinence self-efficacy and QoL. Self-efficacy, social support, education, and employment (to a smaller degree) were found to be significantly associated with higher QoL across domains, while mental distress, substance use, and past year trauma symptoms were found to be significantly associated with lower QoL, but to a lesser extent.

Conclusions: These papers’ results highlight the need for recovery-oriented approaches tosubstance use disorder treatment that focus on enhancing recovery capital for Black women who are returning from jail to the community. Treatment services should be structured and monitored with the goal of building participants access to recovery capital such as stable housing, employment, self-efficacy, and quality of life. Future research should also focus on examining disparities among to better understand the experiences and needs of diverse groups as a way to address inequalities and support short and long-term recovery.

The goal of this secondary analysis is to describe the sociodemographic, psychosocial, HIV testing, alcohol and drug use, and sexual risk behavior characteristics in a sample of young Latino men who have sex with men (YLMSM) living in the San Diego-Tijuana border region. In addition, this study will examine the predictors of three distinct outcomes, which include unprotected anal intercourse, HIV infection, and never testing for HIV, among the sampled YLMSM. This study represents a first effort to describe and analyze HIV seroprevalence and HIV risk behavior in YLMSM (of which the majority also reported having sex with women) residing in this border region, an understudied population with unique risks that are not well understood.

The venue-based study collected information, via standardized questionnaire, on eligible participants (N=372) who self-identified as Latino, reported a history of having sex with another man in their lifetimes, resided in the San Diego-Tijuana border region, and were between the ages of 17 and 30 years. A bivariate analysis was done separately for each of the three outcomes to examine the sociodemographic, psychosocial, HIV testing, alcohol and drug use, and sexual risk behavior characteristics among the combined sample. Three separate multivariate analyses (hierarchical logistic regression analysis) examined predictors of unprotected anal intercourse, HIV infection, and never testing for HIV.

Results from the study showed that for the combined sample of both San Diego and Tijuana YLMSM 25% tested positive for HIV, 42% reported having unprotected anal intercourse with a male, and 44% never tested for HIV. Compared to San Diego YLMSM, Tijuana YLMSM reported lower levels of socioeconomic status (e.g., low level of education), condom self-efficacy, HIV seroprevalence, HIV testing rates, and unprotected anal intercourse, but higher levels of alcohol and drug use and sex with both men and women. Findings from the multivariate analysis showed that being young, having an incarceration history, and self-reported likelihood of being infected were the strongest predictors of HIV infection, while San Diego residence and income from exchange sex were the strongest predictors of unprotected anal intercourse. Tijuana residence and no access to care were some of the strongest predictors of never testing for HIV.

The current study provides compelling evidence that the control of the HIV epidemic in the San Diego-Tijuana border region must include primary and secondary HIV prevention efforts directed at YLMSM. There is an urgent need for HIV interventions to address unprotected anal intercourse, high HIV seroprevalence rates, and low HIV testing rates in YLMSM in the US--Mexico border region. These HIV interventions must be empirically-based, culturally and linguistically appropriate, and address the social context of HIV risk.

ABSTRACT

Problems associated with alcohol affect individuals, families and communities. Alcohol-related community problems include underage and excessive drinking, driving under the influence (DUI) crashes and injuries, violence, crime and negative effects on quality of life. Policy interventions to reduce and prevent community-level alcohol-related problems have been the focus of much research, resulting in the recognition of effective and promising prevention practices. Alcohol policies include laws: establishing a maximum blood alcohol concentration (BAC) allowed for driving, a minimum age for purchase and consumption of alcohol; and limiting sales to underage or intoxicated persons. Policy enforcement can deter DUI, sales of alcohol to underage or intoxicated persons, underage and excessive drinking, especially if the enforcement is highly visible to the public. A growing body of literature examines the amount and frequency, or “dosage” of interventions that is associated with improved health or reductions in problems. Much of the dosage research involves educational or treatment interventions that focus on individual or group behavior change, rather than on policy interventions designed to make change at the community level. The overarching goals of this dissertation research are to: 1) examine the existing alcohol policy enforcement literature; 2) explore certain community factors that may be associated with higher levels of dosage; and 3) compare how varying levels of alcohol policy enforcement dosage affect community alcohol-related outcomes.

Paper 1 examines research literature regarding the association between dosage of high-visibility alcohol policy enforcement and alcohol-related problems at the community level. A systematic review found support for consistent enforcement to achieve desired alcohol-related outcomes, and for “high” versus “low” levels of enforcement. However, there was no consensus found among the studies for a necessary threshold of enforcement dosage, due in part to the differences in problems addressed, existing policies in study communities, types of enforcement interventions used, and the designs and sizes of the studies. Findings support the need for additional research with rigorous study designs to determine effective levels of dosage of high-visibility alcohol policy enforcement.

Paper 2 investigates the association between dosage of high-visibility alcohol enforcement interventions and: level of alcohol problems at baseline, interagency collaboration, and additional grant funding from two state agencies, in 12 intervention cities funded by the California Strategic Prevention Framework State Incentive Grant (SPF SIG). Multi-level modeling is used to study the effects of these three community characteristics on levels of dosage over 12 months. Findings indicate that funding may lead to more high-visibility enforcement to reduce crashes, injury, and mortality associated with driving under the influence (DUI). Interagency collaboration may lead to more enforcement and visibility to reduce retail availability of alcohol (e.g., at convenience stores) to underage persons. Baseline levels of alcohol-related problems were not found to be significantly associated with higher levels of enforcement. None of the community characteristics studied here was significantly associated with higher levels of enforcement to reduce social availability of alcohol (e.g., at parties). Future studies that include larger samples of cities are needed to help explain how these and other community factors may influence implementation of high-visibility alcohol enforcement interventions.

Paper 3 focuses on the effects of four levels of dosage (zero, low, medium, and high) of a high-visibility DUI enforcement intervention on changes over 58 months in the proportion of DUI crashes and DUI injury crashes in the 24 cities of the California SPF SIG project. Multi-level modeling is used to examine the moderating effect of dosage level on the relationship between time and DUI crash and injury rates. Findings reveal a statistically significant moderating effect of medium dosage level (i.e., approximately 1 intervention per month) on the negative relationship between time and DUI crashes. Although not statistically significant, a high level of dosage is associated with an increase in the proportion of DUI crashes, while a low dosage level results in no change in the proportion of DUI crashes. Statistically significant moderating effects of both medium and high dosage levels are found on the negative relationship between time and injury DUI crashes. These findings suggest that implementing approximately 1 DUI enforcement intervention per month may be best for reducing both DUI crashes and DUI injury crashes, and that a higher number of interventions per month does not lead to better outcomes. Replication can help strengthen these findings, and may lead to practical policy enforcement recommendations for communities to reduce DUI injuries and related crashes.

Police violence refers broadly to state-sanctioned violence by officers of diverse law enforcement agencies, and includes neglect as well as physical, sexual, and psychological abuse. Police violence is a public health problem that affects Black women in the US disproportionately, and in ways that involve the multiplicative effects of race and gender as well as other systems of oppression. However, Black women are underrepresented as a population of interest in the literature on police violence. This research aims to help fill the gaps in the literature using an intersectional lens and the approaches of critical race theory and Black feminist thought to 1) review the literature on police violence affecting Black women, 2) investigate the mental health implications of police violence exposure for Black women, and 3) explore Black women’s views of policing and the implications for health and community life in the Bayview neighborhood of San Francisco.

The resulting dissertation comprises three papers. Paper 1 is a narrative literature review of peer- reviewed articles published between January 2000 and June 2021 that address the issue of police violence in the United States as it affects Black women. This paper reviews both qualitative and quantitative literature and the theoretical lenses applied to the subject. I concur with other scholars that applying the theoretical frameworks of Black feminist thought, critical race theory and its derivatives, especially intersectionality, a framework that considers multiple, simultaneous systems of oppression, can help generate effective, relevant solutions for systemic problems such as police violence.

Paper 2 presents quantitative data analysis from The Justice Study survey of experiences of police violence. The survey included two validated instruments for measuring psychological distress and post-traumatic stress disorder symptoms, as well as questions on experiences of police violence. Statistical analysis of the cross-sectional survey data found that Black women’s levels of exposure to police violence in the form of having known one or more persons killed by police and levels of psychological distress and PTSD symptomatology were significantly higher when compared to those among White women in the sample. Using logistic regression, I found no association between the exposure to police violence and the mental health measures examined. I suggest that the limitations of the small (n=91), non-random sample warranted further study to determine whether there is a relationship between the exposure and outcomes.

Paper 3 presents qualitative data derived by semi-structured one-on-one interviews with Black women in a historically racially residentially segregated neighborhood. Using thematic analysis of the transcripts, I address the following exploratory research questions: 1) What are Black women’s experiences and perceptions of policing? 2) What are the implications of policing for health and community life?; and 3) What do Black women think are the solutions to the public health problem of police violence? Participants shared positive or neutral experiences related to traffic stops or a call for help. They also related negative experiences of being profiled, being assaulted and ‘mothering while Black,’ as well as vicarious experiences of police violence. Despite neutral or positive experiences, and approval of recent developments such as increased outreach and bicycle patrols, participants held generally negative views of policing, which they considered racist in origin and practice and harmful to health and community life. Using the counterfactual and accounts of policing in the neighborhood, participants described racism at multiple levels and described policing as a threat community members manage by avoiding encounters with the police. Participants offered solutions to the problem of police violence that ranged from improved law enforcement training to diverting funding to social services.

The findings from this exploration of the uniquely racialized and gendered experiences of Black women affected by police violence call for further research that takes an intersectional approach. Further quantitative research is needed using large health surveys that oversample populations with the highest levels of exposure to violent policing. Further qualitative research is needed to bring to the center the narratives of those whose communities have been subjected to intersecting systems of oppression.

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