A mixed-methods analysis of risk-reduction strategies adopted by syringe services program participants and non-syringe services program participants in New York City.

BACKGROUND: Since the emergence of fentanyl in the drug market, syringe services programs (SSPs) have been at the forefront of providing life-saving tools such as naloxone and fentanyl test strips to people who use drugs (PWUD). It is still unclear, however, how the adoption of risk-reduction practices has differed among PWUD in the context of increasing presence of non-pharmaceutical fentanyl in the drug supply. This study aims to assess the adoption of risk-reduction tools (e.g., naloxone) among those engaged with SSP services and those not engaged with SSP services. METHODS: We conducted a mixed-methods study following a convergent parallel design integrating both quantitative and qualitative data. Interviews were conducted with 80 people who used street opioids (i.e., heroin or opioid pills not prescribed), 32 of whom were not engaged in SSP services. Quantitative differences between those engaged and those not engaged in SSPs were assessed using independent samples t tests and Fisher's exact tests. A thematic analytic approach was employed to compare qualitative responses between the two groups. RESULTS: Three main themes emerged in our analysis: (1) Both groups expressed an interest in fentanyl test strips (FTS), but those engaged in SSP services found them to be more accessible; (2) there was greater adoption of and enthusiasm for naloxone among SSP participants; and (3) SSP participants were more likely to have or be interested in having someone check in on them when using alone, but stigma and perceived personal risk of overdose prevented widespread adoption of this practice among all participants. CONCLUSION: SSPs provide a vital function by facilitating naloxone and FTS distribution to participants who often have little control over their exposure to fentanyl. However, stigma and misconceptions regarding drug use are barriers to people adopting risk-reduction practices, particularly among those not engaged with SSPs.

Understanding Vaccine Perceptions and Willingness to Receive COVID-19 Vaccination: Opportunities to Strengthen Public Health Responses and COVID-19 Services for People Who Use Drugs.

Background: People who use drugs (PWUD) are at high risk for COVID-19 infection, morbidity, and mortality. COVID-19 vaccines are safe and effective at reducing serious illness and death from COVID-19. There are sparse data on the perceptions and willingness of PWUD to receive COVID-19 vaccination. Materials and Methods: In order to assess the perceptions of, and willingness to receive, COVID-19 vaccination among PWUD, we conducted a rapid survey-based assessment of 100 PWUD in NYC (Spring 2021) who reported not having received COVID-19 vaccination and who reported past 30-day illicit drug use. Results: More than 80% of respondents agreed that personally receiving a COVID-19 vaccine was important for the health of others in the community, and endorsing this belief was significantly associated with COVID-19 vaccine willingness reflecting a high prevalence of altruistic beliefs (p-value: 0.01). Other reported perceptions that were significantly associated with COVID-19 vaccine willingness were believing that COVID-19 vaccines are safe for PWUD and trusting COVID-19 information from their healthcare providers (p-values < 0.05). That said, 62% reported being unwilling to receive a COVID-19 vaccine, and 70−83% had concerns about general vaccine safety/efficacy. Examining pairs of questions to explore potential ambivalence between vaccine endorsement and vaccine concerns identified that 56−65% simultaneously reported vaccine safety/efficacy concerns and beliefs that vaccination was an important intervention. Of the 75 respondents who reported past 30-day use of harm reduction and/or substance use disorder (SUD) programs, nearly 90% reported these programs as trusted sources of COVID-19 information. Conclusion: Most participants reported altruistic beliefs about the role of vaccines for community health, including COVID-19 vaccines, and this altruism was associated with willingness to be vaccinated against COVID-19. These findings suggest a complex relationship between beliefs about the role of vaccination in community health and the safety/efficacy of vaccines; this ambivalence suggests that COVID-19 vaccine willingness may not be firmly fixed, indicating potential opportunities to address questions and build vaccine confidence. Harm reduction and SUD programs could be leveraged to further engage PWUD in receipt of COVID-19 information and/or vaccination. Recognizing vaccine ambivalence, emphasizing collective and individual benefits of vaccination, and messaging from trusted sources may be promising approaches to increase vaccination in this population.

Fentanyl preference among people who use opioids in New York City.

BACKGROUND: Several studies have pointed to a sub-sample of people who use drugs (PWUD) who prefer the use of non-pharmaceutical fentanyl (NPF) and, as such, pose a unique challenge for public health initiatives amidst the continued rise in overdose mortality. However, matters of drug preference and autonomy of choice remain under-studied and often misunderstood. This paper examined the experiences of PWUD reporting a preference for NPF or an NPF-heroin mixture, specifically how they navigate the perceived benefits of NPF and its established risks. METHODS: 22 in-depth interviews were conducted in New York City between March 2018 and August 2019 with PWUD who self-reported a preference for NPF or an NPF-heroin mix. Interviews were audio-recorded, and the resulting transcripts analyzed using a thematic approach. RESULTS: Participants highlighted various factors that contributed to expressed preference for NPF or an NPF-heroin mix, including a desire to feel good, financial resources, drug availability, decreased consumer autonomy, and physiological demand. Participants reported practicing several risk reduction strategies; however, they highlighted that many, particularly carrying naloxone and always using with someone else, were difficult to implement in the context of illicit drug use. CONCLUSIONS: Our results demonstrate participants' decreased consumer agency and greater exposure to systemic factors in the illicit markets, highlighting the need for expansion of various services, including drug checking resources and systems of outreach for PWUD who do not use intravenously. To promote tailored interventions, continued efforts in overdose prevention ought to more thoughtfully consider the context, perceptions, preferences, and behaviors of PWUD.

"I didn't feel like a number": The impact of nurse care managers on the provision of buprenorphine treatment in primary care settings.

BACKGROUND AND OBJECTIVE: To promote increased access to and retention in buprenorphine treatment for opioid use disorder, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) implemented the Buprenorphine Nurse Care Manager Initiative (BNCMI) in 2016, in which nurse care managers (NCMs) coordinate buprenorphine treatment in safety-net primary care clinics. To explore how patients experienced the care they received from NCMs, DOHMH staff conducted in-person, in-depth interviews with patients who had, or were currently receiving, buprenorphine treatment at BNCMI clinics. Participants were patients who were receiving, or had received, buprenorphine treatment through BNCMI at one of the participating safety-net primary care practices. METHODS: The study team used a thematic analytic and framework analysis approach to capture concepts related to patient experiences of care received from NCMs, and to explore differences between those who were in treatment for at least six consecutive months and those who left treatment within the first six months. RESULTS: Themes common to both groups were that NCMs showed care and concern for patients' overall well-being in a nonjudgmental manner. In addition, NCMs provided critical clinical and logistical support. Among out-of-treatment participants, interactions with the NCM were rarely the catalyst for disengaging with treatment. Moreover, in-treatment participants perceived the NCM as part of a larger clinical team that collectively offered support, and the care provided by NCMs was often a motivating factor for them to remain engaged in treatment. CONCLUSION: Findings suggest that by providing emotional, clinical, and logistical support, as well as intensive engagement (e.g., frequent phone calls), the care that NCMs provide could encourage retention of patients in buprenorphine treatment.

"NO BROKERS TO MOVE OUT OF HERE.": A MIXED METHOD ANALYSIS OF THE IMPACT OF HOMELESSNESS POLICY AND SHELTER GOVERNANCE ON FAMILIES RESIDING IN NYC SHELTERS.

Homelessness in the United States has been increasing at an exponential rate over the past three decades, and the US has not experienced the current level of homelessness since the Great Depression of the 1930's. With this rise in homelessness has come an increase in the number of rules, regulations, and strict and punitive policies within shelters. Given the historic levels of homelessness nationally and increased bureaucracy, this paper aims to expand on the current literature related to governance of homeless shelters to examine: 1) how families residing in the shelters are impacted by policies related to homelessness, and governance within shelters (i.e., shelter rules), and 2) determine potential points of intervention to improve policy and programming and shelter governance that better address the growing needs of homeless families. Using a convergent parallel design, we conducted a mixed methods study with caregiver residents and their children (ages 13 - 17 years), as well as staff, from two family shelters located in a large urban city in the US. Findings from the study revealed that policies and programs aimed at assisting homeless families often did not adequately respond to the needs of families (e.g., finding permanent housing, continuity in education for youth), and residents (both caregivers and youth) found shelter rules to be overly restrictive. Policy and programming recommendations are provided.

The Joint Effect of Childhood Abuse and Homelessness on Substance Use in Adulthood.

BACKGROUND: Childhood abuse and homelessness are independently associated with substance use. Though childhood abuse and homelessness are strongly correlated, research on the joint effect of exposure to both traumatic life events on substance use is limited. Objective: To estimate independent and joint effects of childhood abuse and homelessness on substance use risk during emerging adulthood and adulthood. Methods: Using the National Longitudinal Study of Adolescent to Adult Health (N = 12,288), we measured associations between exposure to physical or sexual abuse in childhood, homelessness in childhood or emerging adulthood, or exposure to both traumas and outcomes of binge drinking, marijuana use, cocaine use, methamphetamine use, and prescription opioid misuse during emerging adulthood (Wave III, ages 18-26 years) and adulthood (Wave IV, ages 24-32 years). Results: In adjusted analyses, exposure to childhood abuse alone, homelessness alone, and both childhood abuse and homelessness were significant correlates of most substance use indicators in emerging adulthood. Those jointly exposed to childhood abuse and homelessness had disproportionate risk of substance use, particularly use of cocaine (adjusted odds ratio (AOR)=4.25, 95% confidence interval (CI): 2.70, 6.71) and methamphetamine (AOR = 6.59, 95% CI: 3.87, 11.21). The independent and combined effects of abuse and homelessness generally persisted into adulthood though associations tended to weaken. Conclusions/Importance: Those with exposure to abuse, homelessness, and both adverse outcomes constitute a high-risk population for substance use. Addressing abuse and homelessness should be a component of preventing drug risk for screening, treatment, and prevention efforts.

Society of Behavioral Medicine (SBM) position statement: SBM urges Congress to preserve and increase the financing of federally funded nutrition assistance programs and services.

Deep cuts have been proposed to federally funded nutrition assistance programs, including the Supplemental Nutrition Assistance Program (SNAP); the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and federally subsidized school breakfast and lunch programs. Yet, these programs help parents afford healthy meals for their families, pregnant and postpartum mothers access supplemental foods and health services for themselves and their infants and young children, and children obtain the nutrition necessary for optimal school performance. Participation in these programs is linked with reductions in perinatal morbidity and mortality, improved childhood growth trajectories, enhanced school performance, and reductions in food insecurity and poverty. Given these compelling health and economic benefits, the Society of Behavioral Medicine urges Congress to protect and increase funding for federally funded nutrition assistance programs, specifically SNAP, WIC, and school breakfast and lunch programs. Per the recent (2017) recommendations of the School Nutrition Association, Congress should also resist any attempts to "block-grant" subsidized school breakfast and lunch programs, which could reduce access to these programs. It is further recommended that Congress improve the scope of implementation- and outcomes-based assessments of these programs. Finally, we recommend efforts to increase awareness of and participation in SNAP, WIC, and federally funded school meal programs for eligible individuals, children, and families.

Society of Behavioral Medicine (SBM) position statement: SBM urges Congress to preserve and extend funding for Medicaid services.

In May 2017, the Trump administration proposed steep cuts to Medicaid funding. This proposal was met with bipartisan criticism, as this program provides vital healthcare coverage for vulnerable children, adults, and families, including those living below the federal poverty line. In addition to the proposed funding cuts, federally authorized state restrictions to Medicaid access (e.g., work requirements) have been proposed, putting the Medicaid coverage of scores of enrollees at risk. Overwhelming health costs from inadequate or absent insurance are found to contribute to financial problems, including bankruptcy. Financial strain, in turn, is related to serious and life-threatening health problems in both children and adults. Given these impacts, the Society of Behavioral Medicine (SBM) urges Congress to protect and extend Medicaid funding. To maintain subscriber access, SBM recommends that Congress continue to use percentage rather than block funding determinants and eliminate states' authority to enforce program qualification requirements, including work provisions and stipulations for locking out subscribers who do not pay their premiums on time. It is also recommended that Congress increase and improve the scope and quality of reporting Medicaid's evidence base. This could be achieved through regular evaluations, focusing on Medicaid's impact on the health and economic well-being of its participants. SBM further recommends efforts to increase the public's awareness of and participation in Medicaid for eligible individuals, children, and families.

Associations of Adolescent Exposure to Severe Violence with Substance Use From Adolescence into Adulthood: Direct Versus Indirect Exposures.

BACKGROUND: While previous research has documented the impact of violence on substance use, none has looked longitudinally across the lifespan to measure independent effects of direct and indirect violence exposure. OBJECTIVE: To examine independent associations between adolescent experiences of violence and subsequent substance use in adolescence and adulthood in the United States. METHOD: Using the National Longitudinal Study of Adolescent to Adult Health (N = 12,288), we examined being shot or stabbed ("experienced"), being threatened with a knife or gun ("threatened"), and seeing someone either shot or stabbed ("witnessed") during adolescence (Wave I) as correlates of substance use in adolescence and adulthood (Wave IV) via logistic regression. RESULTS: Violence exposure was a significant correlate of drug use in adolescence and several associations remained significant in adulthood. Witnessing violence had the highest point estimates in the adjusted models in adolescence for each substance use outcome (e.g., Cocaine-Adjusted Odds Ratios [AOR] = 2.59, 95% confidence interval [CI] = 1.21, 5.54). However, the point estimates for threatened with violence or experienced violence were highest in three out of the four drug outcomes in adulthood (e.g., Threatened with violence: Binge drinking-AOR = 1.41, 95% CI = 1.08, 1.83). Conclusion/Importance: Adolescent exposure to witnessing violence had stronger effects on substance use in adolescence, while experiencing and being threatened with violence in adolescence had stronger effects on substance use in adulthood. Violence prevention efforts targeted toward adolescents may lead to a reduction in substance use throughout the life-course, and clinicians and policy makers should be aware of the downstream effects of violence experienced in adolescence.

Society of Behavioral Medicine (SBM) position statement: restore CDC funding for firearms and gun violence prevention research.

The Society for Behavioral Medicine (SBM) urges restoration of Centers for Disease Control and Prevention (CDC) funding for firearms and gun violence prevention research. Gun violence in the United States is an important and costly public health issue in need of research attention. Unfortunately, there have been no concerted CDC-funded research efforts in this area since 1996, due to the passage of the Dickey Amendment. To remedy the information-gathering restrictions caused by the Dickey Amendment bans, it is recommended that Congress remove 'policy riders' on federal appropriations bills that limit firearms research at the CDC; expand NVDRS firearms-related data collection efforts to include all fifty states; fund CDC research on the risk and protective factors of gun use and gun violence prevention; fund research on evidence-based primary, secondary, and tertiary prevention and treatment initiatives for communities that are seriously impacted by the effects of gun violence; and support the development of evidence-based policy and prevention recommendations for gun use and ownership.

Childhood traumatic experiences and the association with marijuana and cocaine use in adolescence through adulthood.

BACKGROUND AND AIMS: Examination of longitudinal relationships between childhood traumatic experiences and drug use across the life-course at the national level, with control of confounding by other forms of trauma, is needed. We aimed to estimate the prevalence of nine typologies of childhood traumas and the cumulative number experienced, correlation between traumas and associations between individual and cumulative number of traumas with drug use during adolescence, emerging adulthood and adulthood. DESIGN: Secondary data analysis using the National Longitudinal Study of Adolescent to Adult Health. SETTING: United States. PARTICIPANTS: A nationally representative sample of individuals in grades 7-12 (aged 11-21 years) during 1994-95, who were re-interviewed during emerging adulthood (2001-02; aged 18-28) and adulthood (2007-08; aged 24-34). The analytical sample comprised 12 288 participants with data at all three waves. MEASUREMENTS: Nine typologies of childhood traumas: neglect; emotional, physical and sexual abuse; parental incarceration and binge drinking; and witnessing, being threatened with and experiencing violence. Indicators of each were summed to measure cumulative dose. Outcomes were marijuana and cocaine use during adolescence, emerging adulthood and adulthood. FINDINGS: Approximately half experienced at least one childhood trauma; traumas were not highly correlated. We observed a dose-response relationship between the number of traumas and drug use in adolescence [marijuana, adjusted odds ratio (aOR) one trauma versus none = 1.65, 95% confidence interval (CI) = 1.42, 1.92; two traumas = 2.58, 95% CI = 2.17, 3.06; ≥ four traumas = 6.92, 95% CI = 5.17, 9.26; cocaine, aOR one trauma = 1.87, 95% CI = 1.23, 2.84; two traumas = 2.80, 95% CI = 1.74, 4.51; ≥ four traumas = 9.54, 95% CI = 5.93, 15.38]. Similar dose-response relationships with drug use were observed in emerging adulthood and adulthood. Each individual trauma was associated independently with either marijuana or cocaine use in adolescence, emerging adulthood and/or adulthood. CONCLUSIONS: Childhood trauma is prevalent in the United States, and individual types as well as the total number experienced are associated significantly with marijuana and cocaine use throughout the life-course.

Child Sexual Abuse and HIV-Related Substance Use and Sexual Risk Across the Life Course Among Males and Females.

Child sexual abuse is associated with substance use and sexual risk behaviors during adolescence and adulthood, but no known studies have documented associations across the life course in a nationally representative U.S. SAMPLE: We used the National Longitudinal Study of Adolescent to Adult Health to measure associations between child sexual abuse and substance use and sexual risk behaviors during adolescence, young adulthood, and adulthood among males and females (n = 11,820). Approximately 10% of females and 7% of males reported child sexual abuse. Associations with substance use were strongest during adolescence and lessened over time. Increased odds of sexual risk among those with a history of child sexual abuse remained consistent through the life course. Significant gender differences existed for some associations (e.g., adulthood multiple partners: males adjusted odds ratio (AOR) = 1.73, 95%CI:1.18, 2.53; females AOR = 1.11, 95%CI:0.79, 1.56). Trauma-informed prevention interventions should address child sexual abuse among both males and females to prevent substance use and sexual risk behavior throughout the life course.

A Protective Association between SNAP Participation and Educational Outcomes Among Children of Economically Strained Households.

With the recent cuts to the Supplemental Nutrition Assistance Program (SNAP), more information is needed to assess the impact these policies have on vulnerable children. As such, this study assesses the potential moderating effect of SNAP participation on the association between material deprivation and educational outcomes among children living in poverty (n = 10 971, and n = 14 928). SNAP participation was found to moderate the association between material deprivation and grade retention, indicating that SNAP may be contributing to grade retention among children living in poverty, which can have positive lifelong consequences.

The Association Between Shelter Rules and Psychosocial Outcomes Among Homeless Youth Residing in Family Shelters.

Despite growing numbers of homeless youth living in shelters with caregivers, little research has explored the impact of the shelter environment on emotional well-being. As such, this study assesses the relationship between shelter rules and two psychosocial outcomes among youth in New York City family shelters. Additionally, the direct effect of trauma and the moderating effect of difficulty following shelter rules on psychosocial outcomes was assessed. Youth with difficulty following shelter rules reported significantly more depressive symptoms, but less substance use. Trauma was found to be associated with increased depression and substance use. Difficulty following shelter rules was found to moderate the association between trauma and substance use. Recommendations for future interventions and the creation of shelter policies are discussed.

The relationships of childhood trauma and adulthood prescription pain reliever misuse and injection drug use.

BACKGROUND: We examined associations between childhood trauma and adulthood prescription pain reliever misuse (PPRM) and injection drug use (IDU) in a nationally-representative U.S. sample to further understanding of factors associated with these epidemics. METHODS: National Longitudinal Study of Adolescent to Adult Health data (N=12,288) yielded nine childhood traumas: neglect; emotional, physical, sexual abuse; parental incarceration and binge drinking; witnessed, threatened with, and experienced violence. We estimated adjusted odds ratios (AOR) and 95% confidence intervals for the association of each trauma and cumulative trauma and drug initiation in emerging and later adulthood. RESULTS: Outcome prevalences were 20% (PPRM) and 1% (IDU) in emerging adulthood and 10% PPRM in adulthood. We observed dose-response relationships that varied across outcomes. Cumulative trauma (referent=none) was associated with 34-79% greater odds of PPRM (emerging adulthood) across one to five+ trauma categories. The gradient was most consistent and associations strongest for adulthood PPRM: one trauma AOR=1.46(1.12, 1.91); two AOR=1.71(1.23, 2.36); three AOR=2.16(1.43, 2.36); four AOR=2.70(1.42, 5.62); five+ AOR=3.09(1.52, 6.30). Dose-response was less consistent for IDU, but 4 and 5+ traumas were associated with approximately seven and five times the odds of IDU. Neglect, emotional abuse, and parental incarceration and binge drinking were associated with 25-55% increased odds of PPRM. Sexual abuse and witnessed violence were associated with nearly 3 and 5 times the odds of IDU. CONCLUSIONS: Associations between childhood trauma and PPRM/IDU highlight the need for trauma-informed interventions for drug users and early trauma screening and treatment for prevention of drug misuse over the life course.

Assessing the Relationship Between the Perceived Shelter Environment and Mental Health Among Homeless Caregivers.

Little attention has been given to how the environment of homeless shelters may impact the mental health of their residents. This study addresses this gap in the literature and presents a cross-sectional analysis of 209 caregivers nested within 10 family shelters across New York City. Multivariate regression was employed using hierarchical modeling to test the association between two shelter related variables (ie, the perceived social environment of the shelter and difficulty following shelter rules) and the mental health status of the caregiver residents. Less favorable perceptions of the social environment of the shelter and difficulty following shelter rules were both found to be associated with poorer mental health after controlling for demographic covariates as well as time in the shelter and first time in the shelter. These findings highlight the potential impact of the perceived social environment of shelters and methods of governance of shelters on the mental health of caregiver residents. In addition, the findings support the notion that interventions such as trauma informed care could potentially aid in addressing the mental health challenges that residents face.

Lessons Learned from a Student-Led Breastfeeding Support Initiative at a US Urban Public University.

Despite US laws requiring most workplaces to provide "reasonable" unpaid break time and a private space for female employees to express breast milk, much of the statutory language is vague and open to interpretation, potentially leading to suboptimal implementation. College and university campuses in the US represent a particular concern, as students are typically not employed by their school and thus not protected by state and federal labor laws. This article describes the work of 2 graduate students to successfully establish a dedicated space at their US urban public university for the purpose of expressing breast milk. A 3-pronged strategy was implemented to create a dedicated lactation space: (1) collecting data to support the establishment of the room, (2) raising awareness of legislation related to protection of breastfeeding, and (3) community organizing and advocacy. After nearly 18 months of advocacy and planning, the campus' dedicated lactation room was opened for use in March 2012. Two years later, the room remains a valuable resource and is used, on average, 8.4 times per weekday during a typical school week. Several lessons learned are described, and the strategies employed can be tested and applied in other US academic settings to assist in advocating for more supports for breastfeeding mothers. However, it is also imperative that US legislation be amended to include language that explicitly protects students so that women do not need to make the choice between continuing their education and continuing to breastfeed.

Improving Youth Mental Health through Family-Based Prevention In Family Homeless Shelters.

This exploratory study examines changes in suicidal ideation among a sample (N = 28) of homeless youth, ages 11-14, residing within family shelters in a large metropolitan area. Changes in suicidal ideation from pretest to posttest are compared across two group approaches to delivering HIV prevention. Youth and their families participating in the HOPE Family Program, incorporating a family strengthening approach, are compared to those receiving a traditional health education-only approach. Multivariate analyses reveal that youth in the HOPE Family Program were 13 times more likely to report a decrease of suicidal ideation. These findings indicate that health education programs integrating a family strengthening approach hold promise for positively impacting mental health outcomes for vulnerable youth.

Youth Substance Use in a Context of Family Homelessness.

OBJECTIVE: This study examines the relationship between family processes and youth substance use debuts among a sample of youth residing in urban family homeless shelters. METHOD: Data regarding shelter experiences, youth and family characteristics, and the use of three substances (i.e., cigarettes, alcohol, and marijuana) were gathered from a sample of youth (11-14 years) and their respective parents residing in an urban family homeless shelter system. Multinomial logistic regression analysis was used to examine the influences on youth substance use. RESULTS: Of the 198 youth included in the statistical analysis, 72% (n=143) reported no substance use debuts, while 18% (n=35) indicated one and 10% (n=20) indicated two to three substance use debuts. Within the final model, greater substance use debut was associated with being older (13-14 vs. 11-12; OR=7.5; 95% CI =1.8-30.9) and stressors exposure (OR=4.8; 95% CI =1.5-14.7). Furthermore, youth of adult caretakers that reported low levels of the three family processes considered were almost four and a half more likely (OR=4.4; 95% CI =1.2-16.5) to have made two to three substance use debuts. CONCLUSIONS: Family processes may be a particularly important intervention target toward reducing the rate of substance use among youth residing in urban family homeless shelters.

Developing the Support, Teambuilding, and Referral (STAR) Intervention: A Research/Community Partnership.

This paper describes the process by which child mental health researchers partnered with paraprofessionals called peer family advisors to create a stress-reducing intervention for caregivers of children and adolescents with mental health challenges. The issues that arose as the team strove to develop an intervention that was both relevant to the issues that these caregivers grapple with, as well as palatable and feasible for peers to deliver, are discussed.