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Rural adolescents are at risk for firearm-related injury and death. In response, professional organizations have called for communication between adolescents, parents, and providers about firearms. A shared understanding of firearms between providers and families can facilitate effectiveness of health interventions. However, few studies engage adolescents in identifying their perception of common firearm terminology. The current study aimed to understand how adolescents in rural communities defined firearm-related terms including firearm, carrying, and handling, and differences in terms based on prior firearm training. Data were from a mixed methods community-based participatory study of 93 adolescents from rural Washington state. Thematic qualitative coding identified themes for firearm (gun, weapon, projectile, and tool), carrying (on you/your person, transportation, and holding), and handling (actively using, safe use, and holding) and differences between those with prior firearms training. Findings provide insight into perceptions of firearm-related terms for adolescents, an often-neglected voice, and inform rural policy and prevention efforts.

BACKGROUND: Extreme Risk Protection Orders (ERPOs) are civil court orders that prohibit firearm purchase and possession when someone is behaving dangerously and is at risk of harming themselves and/or others. As of June 2024, ERPOs are available in 21 states and the District of Columbia to prevent firearm violence. This paper describes the design and protocol of a six-state study of ERPO use. METHODS: The six states included are California, Colorado, Connecticut, Florida, Maryland, and Washington. During the 3-year project period (2020-2023), ERPO case files were obtained through public records requests or through agreements with agencies with access to these data in each state. A team of over four dozen research assistants from seven institutions coded 6628 ERPO cases, abstracting 80 variables per case under domains related to respondent characteristics, events and behaviors leading to ERPO petitions, petitioner types, and court outcomes. Research assistants received didactic training through an online learning management system that included virtual training modules, quizzes, practice coding exercises, and two virtual synchronous sessions. A protocol for gaining strong interrater reliability was used. Research assistants also learned strategies for reducing the risk of experiencing secondary trauma through the coding process, identifying its occurrence, and obtaining help. DISCUSSION: Addressing firearm violence in the U.S. is a priority. Understanding ERPO use in these six states can inform implementation planning and ERPO uptake, including promising opportunities to enhance safety and prevent firearm-related injuries and deaths. By publishing this protocol, we offer detailed insight into the methods underlying the papers published from these data, and the process of managing data abstraction from ERPO case files across the multi-state and multi-institution teams involved. Such information may also inform future analyses of this data, and future replication efforts. REGISTRATION: This protocol is registered on Open Science Framework ( https://osf.io/kv4fc/ ).

INTRODUCTION: Criminal convictions may be imperfect markers of criminalized behavior, in part because of criminal legal system processes (e.g., plea bargaining). In this retrospective cohort study of individuals convicted of misdemeanors, authors compared the risk of subsequent criminal charges for a violent crime among those initially charged with a felony with that among those initially charged with only misdemeanors, overall and by defendant race and ethnicity. METHODS: The study population included individuals aged ≥18 years who were convicted of a misdemeanor in Washington Superior Courts from January 1, 2015 to December 31, 2019. Those with and without initial felony charges were age/gender matched in a 4:1 ratio. The primary outcome was the first subsequent violent crime charge in Washington Superior Courts through December 31, 2020. Data were analyzed with Fine-Gray hazard models from June 2022 to November 2023. RESULTS: There were 3,841 individuals with initial felony charges and 956 with initial misdemeanor charges only. Median follow-up was 2.4 years for both groups. During follow-up, there were 166 new violent crime charges. In multivariable models, White defendants with initial felony charges had a greater risk of subsequent violent crime charges (subdistribution hazard ratio=2.58; 95% CI=1.24, 5.36) than White defendants with initial misdemeanor charges only. Among Black and Hispanic/Latinx defendants, initial felony versus misdemeanor charges were not associated with subsequent violent crime charges (subdistribution hazard ratio=0.93; 95% CI=0.44, 1.97 among Black defendants; subdistribution hazard ratio=0.49; 95% CI=0.15, 1.57 among Hispanic/Latinx defendants). CONCLUSIONS: Findings suggest differential associations between downgrading of felony charges to misdemeanor convictions and future violent crime charges by defendant race and ethnicity, with implications for inequitable collateral consequences of criminal convictions.

PURPOSE: Alcohol use and handgun carrying are more prevalent among youth in rural than urban areas and their association may be stronger among rural adolescents. Alcohol use may be modifiable with implications for reducing handgun carrying and firearm-related harm. We examined the association between lagged alcohol use and subsequent handgun carrying in rural areas and examined variation in the association by developmental stages, hypothesizing that it would be stronger among adolescents than youth adults. METHODS: We used a longitudinal sample of 2,002 adolescents from ages 12 to 26 growing up in 12 rural communities in 7 states with surveys collected from 2004 to 2019. We estimated the association of lagged past-month alcohol use on handgun carrying in the subsequent 12 months using population-average generalized estimating equations with logistic regression on multiply imputed data. FINDINGS: During adolescence (ages 12-18), those who drank heavily had 1.43 times the odds (95% CI = [1.01, 2.03]) of subsequent handgun carrying compared to those who did not drink alcohol, and those who consumed alcohol but did not drink heavily had 1.30 times the odds of subsequent handgun carrying compared to those who did not drink (95% CI = [0.98, 1.71]). During young adulthood (ages 19-26), associations of alcohol use (OR = 1.28; 95% CI = [0.94, 1.63]) and heavy drinking (OR = 1.38; 95% CI = [1.08, 1.68]) were similar to adolescence. CONCLUSIONS: Alcohol use and subsequent handgun carrying were positively associated during adolescence and young adulthood among individuals who grew up in rural areas, similar to findings in urban areas. Reducing alcohol use may be an important strategy to prevent handgun carrying and firearm-related harm among young people in rural areas.

BACKGROUND: Criminal legal system data are one source for measuring some types of firearm-related harms, including those that do not necessarily result in injury or death, but measurement can be hampered by imprecise criminal code statutes. We quantified the degree of misclassification in Washington state criminal codes for measuring firearm-related crime. FINDINGS: In this study of individuals aged 18 years and older who were convicted of a misdemeanor in Washington Superior Courts from 1/1/2015 through 12/31/2019, we compared firearm-related charges as measured with criminal codes and with manual review of probable cause documents, considered the gold standard. The sample included 5,390 criminal cases. Of these, 77 (1.4%) were firearm-related as measured with criminal codes and 437 (8.1%) were firearm-related as measured via manual record review. In the sample overall, the sensitivity of criminal codes was 17.6% (95% CI 14.2-21.5%), and negative predictive value (NPV) was 93.2% (95% CI 92.5-93.9%). Sensitivity and NPV were higher for cases with exclusively non-violent charges. For all cases and for cases with any violent crime charge, firearm-related crimes described in probable cause documents most often involved explicit verbal threats, firearm possession, and pointing a firearm at or touching a firearm to someone; almost 10% of all cases involved shooting/discharging a firearm. For cases with exclusively non-violent charges, the most common firearm-related crime was unlawful possession. CONCLUSIONS: Criminal records can be used for large-scale policy-relevant studies of firearm-related harms, but this study suggests Washington state criminal codes substantially undercount firearm-related crime, especially firearm-related violent crime.

Firearm violence is a major threat to global public health and safety. Several individual, family, peer, community, and societal risk and protective factors determine or modify the risk of firearm violence. Specifically, there is a strong relationship between poverty, income inequality, and firearm violence; as such, interventions that influence upstream determinants of health by providing income support may hold much promise in affecting multiple domains of risk that are on the causal pathway to firearm violence. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we conducted a scoping review to examine the current state of evidence on the relationship between income support policies and risk of firearm violence. We searched 8 databases related to health and social sciences from inception through March 30, 2022, and placed no time, language, setting, or other publication restrictions on our search, as long as the study was quantitative or mixed-methods and addressed firearm violence specifically, rather than violence more broadly, as an outcome in relation to income support policies. We found 4 studies; of those, 3 were conducted in the United States and 1 in Brazil. All 4 found associations of policy-relevant magnitude between income support policies and reductions in risk of inter-personal firearm violence. We propose future opportunities to enhance the substantive scope and methodologic rigor of this field of research and inform policy and practice for greater impact.

Background: Limited availability and poor quality of data in medical records and trauma registries impede progress to achieve injury-related health equity across the lifespan. Methods: We used a Nominal Group Technique (NGT) in-person workgroup and a national web-based Delphi process to identify common data elements (CDE) that should be collected. Results: The 12 participants in the NGT workgroup and 23 participants in the national Delphi process identified 10 equity-related CDE and guiding lessons for research on collection of these data. Conclusions: These high-priority CDE define a detailed, equity-oriented approach to guide research to achieve injury-related health equity across the lifespan.

Family- and neighborhood-level poverty are associated with youth violence. Economic policies may address this risk factor by reducing parental stress and increasing opportunities. The federal Earned Income Tax Credit (EITC) is the largest cash transfer program in the US providing support to low-income working families. Many states have additional EITCs that vary in structure and generosity. To estimate the association between state EITC and youth violence, we conducted a repeated cross-sectional analysis using the variation in state EITC generosity over time by state and self-reported data in the Youth Risk Behavior Surveillance System (YRBSS) from 2005 to 2019. We estimated the association for all youth and then stratified by sex and race and ethnicity. A 10-percentage point greater state EITC was significantly associated with 3.8% lower prevalence of physical fighting among youth, overall (PR: 0.96; 95% CI 0.94-0.99), and for male students, 149 fewer (95% CI: -243, -55) students per 10,000 experiencing physical fighting. A 10-percentage point greater state EITC was significantly associated with 118 fewer (95% CI: -184, -52) White students per 10,000 experiencing physical fighting in the past 12 months while reductions among Black students (75 fewer; 95% CI: -176, 26) and Hispanic/Latino students (14 fewer; 95% CI: -93, 65) were not statistically significant. State EITC generosity was not significantly associated with measures of violence at school. Economic policies that increase financial security and provide financial resources may reduce the burden of youth violence; further attention to their differential benefits among specific population subgroups is warranted.

ImportanceChildhood poverty is associated with poor health and behavioral outcomes. The Earned Income Tax Credit (EITC), first implemented in 1975, is the largest cash transfer program for working families with low income in the US.ObjectiveTo assess whether cumulative EITC payments received during childhood are associated with the risk of criminal conviction during adolescence.Design, setting, and participantsIn this cohort study, the analytic sample consisted of US children enrolled in the 1979 National Longitudinal Study of Youth. The children were born between 1979 and 1998 and were interviewed as adolescents (age 15-19 years) between 1994 and 2016. Data analyses were performed from May 2021 to September 2022.ExposureCumulative simulated EITC received by the individual's family from birth through age 14 years.Main outcomes and measuresThe main outcome was dichotomous, self-reported conviction for a crime during adolescence (age 14-18 years). A cumulative, simulated measure of mean EITC benefits received by a child's family from birth through age 14 years was derived from federal, state, and family-size differences in EITC eligibility and payments during the study period to capture EITC benefit variation due to differences in policy parameters but not endogenous factors such as changes in household income. Logistic regression models with fixed effects for state and year and robust SEs clustered by mother estimated relative risk of adolescent conviction. Models were adjusted for state-, mother-, and child-level covariates.ResultsThe analytical sample consisted of 5492 adolescents born between 1979 and 1998; 2762 (50.3%) were male, 1648 (30.0%) were Black, 1125 (20.5%) were Hispanic, and 2719 (49.5%) were not Black or Hispanic. Each additional $1000 of EITC received during childhood was associated with an 11% lower risk of self-reported criminal conviction during adolescence (adjusted odds ratio, 0.89; 95% CI, 0.84-0.95). Adjusted risk differences were larger among boys (-14.2 self-reported convictions per 1000 population [95% CI, -22.0 to -6.3 per 1000 population]) than among girls (-6.2 per 1000 population [95% CI, -10.7 to -1.6 per 1000 population]).Conclusions and relevanceThe findings suggest that income support from the EITC may be associated with reduced youth involvement with the criminal justice system in the US. Cost-benefit analyses of the EITC should consider these longer-term and indirect outcomes.

Introduction: Criminal convictions may be imperfect markers of criminalized behavior, in part because of criminal legal system processes (e.g., plea bargaining). In this retrospective cohort study of individuals convicted of misdemeanors, authors compared the risk of subsequent criminal charges for a violent crime among those initially charged with a felony with that among those initially charged with only misdemeanors, overall and by defendant race and ethnicity. Methods: The study population included individuals aged ≥18 years who were convicted of a misdemeanor in Washington Superior Courts from January 1, 2015 to December 31, 2019. Those with and without initial felony charges were age/gender matched in a 4:1 ratio. The primary outcome was the first subsequent violent crime charge in Washington Superior Courts through December 31, 2020. Data were analyzed with Fine–Gray hazard models from June 2022 to November 2023. Results: There were 3,841 individuals with initial felony charges and 956 with initial misdemeanor charges only. Median follow-up was 2.4 years for both groups. During follow-up, there were 166 new violent crime charges. In multivariable models, White defendants with initial felony charges had a greater risk of subsequent violent crime charges (subdistribution hazard ratio=2.58; 95% CI=1.24, 5.36) than White defendants with initial misdemeanor charges only. Among Black and Hispanic/Latinx defendants, initial felony versus misdemeanor charges were not associated with subsequent violent crime charges (subdistribution hazard ratio=0.93; 95% CI=0.44, 1.97 among Black defendants; subdistribution hazard ratio=0.49; 95% CI=0.15, 1.57 among Hispanic/Latinx defendants). Conclusions: Findings suggest differential associations between downgrading of felony charges to misdemeanor convictions and future violent crime charges by defendant race and ethnicity, with implications for inequitable collateral consequences of criminal convictions.

Intimate partner violence (IPV) is a serious public health problem in the United States with adverse consequences for affected individuals and families. Recent reviews of the literature suggest that economic policies should be further investigated as part of comprehensive strategies to address IPV. The Earned Income Tax Credit (EITC) is the nations largest anti-poverty program for working parents, and especially benefits low-income women with children, who experience an elevated risk of IPV. The EITC may prevent IPV by offering financial resources; such resources may help individuals experiencing IPV leave abusive relationships or address IPV risk factors, thereby preventing entry into abusive relationships. However, the association between EITC generosity and IPV has not been previously examined. We used state-level and individual-level datasets to examine the association between EITC generosity and IPV. Our state-level data source was the nationally representative National Crime Victimization Survey (NCVS; N = ~ 95,000 households per year). For NCVS, we used a difference-in-difference approach to investigate the relationship between state EITC generosity and IPV rates. We also used individual-level longitudinal data from the Fragile Families and Child Well-being Study (n = 13,422 person-waves). Using this cohort of US families at higher risk for IPV, we evaluated associations between estimated EITC benefits based on the mothers state of residence and number of children and self-reported IPV. In both state- and individual-level analyses, no significant association between state EITC benefits and IPV was found. Factors that may account for these null findings include program ineligibility for individuals who separate from abusive spouses. Future research efforts should more closely examine EITC policy implementation processes and the lived experience of participating in anti-poverty programs for people experiencing IPV.

The effects of violence exposure on the risk of self-harming behaviors of youth in low- and middle-income countries is not well-understood. Using household survey data from one nationally representative sample and one sample from conflict-affected areas, we examined violence exposure and self-harm among Colombian youth aged 13-24. Survey-weighted prevalence ratios comparing self-harming behaviors by exposure to violence were estimated with Poisson log-linear models, controlling for age, sex, education and food insecurity. Compared to unexposed youth, those exposed to violence in both home and community settings were 7.97 (95% confidence interval [CI]:2.72-23.36) times more likely in the conflict-affected sample, and 21.05 (95% CI: 8.80-50.34) times more likely in the national sample to report having attempted suicide. Among Colombian youth, exposure to violence as either witness or victim was associated with greater prevalence of self-harming behaviors. Youth suicide prevention programs can address exposures to violence as a risk factor for self-harm.

Abstract Background Criminal legal system data are one source for measuring some types of firearm-related harms, including those that do not necessarily result in injury or death, but measurement can be hampered by imprecise criminal code statutes. We quantified the degree of misclassification in Washington state criminal codes for measuring firearm-related crime. Findings In this study of individuals aged 18 years and older who were convicted of a misdemeanor in Washington Superior Courts from 1/1/2015 through 12/31/2019, we compared firearm-related charges as measured with criminal codes and with manual review of probable cause documents, considered the gold standard. The sample included 5,390 criminal cases. Of these, 77 (1.4%) were firearm-related as measured with criminal codes and 437 (8.1%) were firearm-related as measured via manual record review. In the sample overall, the sensitivity of criminal codes was 17.6% (95% CI 14.2–21.5%), and negative predictive value (NPV) was 93.2% (95% CI 92.5–93.9%). Sensitivity and NPV were higher for cases with exclusively non-violent charges. For all cases and for cases with any violent crime charge, firearm-related crimes described in probable cause documents most often involved explicit verbal threats, firearm possession, and pointing a firearm at or touching a firearm to someone; almost 10% of all cases involved shooting/discharging a firearm. For cases with exclusively non-violent charges, the most common firearm-related crime was unlawful possession. Conclusions Criminal records can be used for large-scale policy-relevant studies of firearm-related harms, but this study suggests Washington state criminal codes substantially undercount firearm-related crime, especially firearm-related violent crime.

Abstract Background“Lock to Live” (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians. ObjectiveThe goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters. MethodsThe L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)—a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model—ReachAdoptionImplementation ResultsThe initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) “have an open conversation,” (2) “validate their situation,” (3) “share what to expect,” (4) “make it accessible and memorable,” and (5) “walk through the tool.” Clinicians’ interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from

Abstract Background In the USA, firearms are commonly involved in many incidents of serious interpersonal harm. Federal law prohibits the purchase and possession of firearms by certain high-risk groups including those with prior felony or domestic violence misdemeanor convictions. Evidence supports the effectiveness of these prohibitions, but little is known about how often prohibited persons later seek to have their firearm rights restored. Main body For this commentary, we systematically searched the empirical literature for information about who requests firearm rights restoration in the USA, how often it is granted, and what its consequences are. We found a dearth of empirical literature on this topic. Conclusion We call for attention to this gap in the research. There is a need to build an evidence base that can help inform state policy and courtroom practices regarding the eligibility, appropriateness, and risk for subsequent harm following firearm rights restoration among persons who are prohibited based on a criminal conviction history.

Corollary victims represent approximately 20% of all intimate partner homicides (IPH), and many are children. We used National Violent Death Reporting System (NVDRS) data (2003-2017) to compare all IPH incidents with a child corollary victim (n = 227) to all IPH incidents where a child was present but not killed (n = 350). We examined risk factors for child fatality during an IPH. For each risk factor, we calculated the odds ratio for child death during the IPH, adjusting for multiple comparisons. Perpetrator history of suicidal behavior, rape of the intimate partner victim, a non-biological child of the perpetrator living in the home, and perpetrator job stressors increased odds while prior separation of the IPV victim from the perpetrator decreased the odds of a child death during an IPH incident. To our knowledge, this is the first case-control study using live-controls within NVDRS and can help direct prevention efforts for child death during IPH.

Research on intimate partner violence (IPV) and firearms has typically focused on homicide, so there is limited information on how firearms are used in nonfatal ways, particularly in community samples. We sought to estimate the prevalence of nonfatal firearm abuse in the context of IPV, understand how and against whom firearms are used, and examine consequences of this abuse. Using a national web-based survey of US adults who experienced IPV (n = 958), we asked respondents about experiences with nonfatal firearm abuse, including the frequency of firearm behaviors and consequences. Based on screening data weighted to be nationally representative, we estimated that 9.8% (95% CI: 9.0%, 10.6%) of US adults - or nearly 25 million - have experienced nonfatal firearm abuse by an intimate partner (i.e., were threatened with a firearm, had a firearm used on them, or were threatened by a partner who possessed or had easy access to a firearm). IPV victims who experienced nonfatal firearm abuse commonly reported experiencing other forms of IPV. The most common behaviors included the partner displaying a firearm (67.5%) and threatening to shoot the victim (63.0%). The majority (80.5%) of perpetrators were male, and 49.2% of respondents had a child at home at the time of abuse. The most common consequences of nonfatal firearm abuse were concerns for safety (86.2%) and feeling fearful (82.7%). Additionally, 43.1% of respondents reported physical injury, and 37.4% missed days of work or school. Practice and policy around firearm access for IPV perpetrators should attend to nonfatal firearm use against intimate partners.

PURPOSE: To determine differences among intimate partner homicides (IPH) by whether or not a firearm was used in and whether a protective order (PO) was filed prior to IPH. METHOD: We identified all incidents of IPH recorded in the National Violent Death Reporting System from 2003-2018, based on the relationship between victim and perpetrator. We characterized incidents, perpetrators and victims in IPH cases by whether or not a firearm was used, and whether a PO had been sought or issued prior to the IPH. RESULTS: We identified 8,375 IPH incidents with a total of 9,130 victims. Overall 306 (3.3%) victims were killed in a firearm IPH with PO, 4,519 (53.9%) in a firearm IPH without PO, 176 (2.1%) in a non-firearm IPH with PO and 3,416 (40.7%) in a non-firearm IPH without PO. Based on review of incident narratives, 5.4% (n=451) of incidents involved a previously-granted or sought PO, and none of which had explicitly mentioned firearm removal as a part of the PO. CONCLUSIONS: The majority of victims were killed with a firearm. Prior literature suggests that POs with firearm removal may be effective strategies for reducing risk of IPH, but we found no documentation in the narratives that firearm removal was a condition in the POs identified. As very few IPH narratives included documentation of a PO, it is likely that ascertainment of PO status is incomplete and could be an area for improvement in NVDRS data collection efforts.

Economic insecurity is a risk factor for intimate partner homicide (IPH). The Earned Income Tax Credit (EITC) is the largest cash transfer programme to low-income working families in the USA. We hypothesised that EITCs could provide financial means for potential IPH victims to exit abusive relationships and establish self-sufficiency. We conducted a national, quasiexperimental study of state EITCs and IPH rates in 1990-2016 using a difference-in-differences approach. The national rate of IPH decreased from 1.9 per 100 000 adult women in 1990 to 1.3 per 100 000 in 2016. We found no statistically significant association between state EITC generosity and IPH rates (coefficient indicating change in IPH rates per 100 000 adult female years for additional 10% in amount of state EITC, measured as the percentage of federal EITC: 0.02, 95% CI -0.03 to 0.08). Financial control associated with abuse and current EITC eligibility rules may prevent potential IPH victims from accessing the EITC.

Oral pre-exposure prophylaxis (PrEP) is highly efficacious but low adherence undermines effectiveness. Depression, common in African women, may be a barrier to consistent PrEP use. We aimed to assess the relationship between depression, psychosocial mediators, and PrEP adherence among South African women. We analyzed data from 174 South African women in HPTN 067, an open-label oral PrEP trial conducted from 2011 to 2013. Participants were followed for 24 weeks. PrEP adherence was measured via Wisepill™ and weekly self-report interview data. We considered participants "adherent" at week 24 if Wisepill™ and interviews indicated that ≥ 80% of expected doses were taken in the prior month. Elevated depressive symptoms were assessed using the 20-item Center for Epidemiological Studies-Depression (CES-D) scale. We used marginal structural models to estimate the effect of elevated symptoms at baseline on PrEP adherence at week 24 and to assess whether the direct effect changed meaningfully after accounting for mediating effects of stigma, social support, and PrEP optimism. High PrEP adherence occurred less often among women with elevated depressive symptoms (N = 35; 44.3%) compared with those without (N = 52; 54.7%; adjusted relative risk [aRR]: 0.79; 95% confidence interval [CI] 0.63-0.99). The effect of elevated depressive symptoms on PrEP adherence persisted in models accounting for the mediating influence of stigma (aRR: 0.74; 95% CI 0.51-0.97) and PrEP optimism (aRR: 0.75; 95% CI 0.55-0.99). We also found a direct effect of similar magnitude and direction when accounting for social support as the mediating variable, although this adjusted relative risk estimate was not statistically significant (aRR: 0.77; 95% CI 0.57-1.03). Depressive symptoms were common and associated with lower PrEP adherence among South African women. Future work is needed to determine whether depression services integrated with PrEP delivery could improve PrEP effectiveness among African women.

Limited research has been conducted on the state-level factors that may be associated with intentional school shootings. We obtained school shooting data from the "Washington Post" that identified any act of intentional interpersonal gunfire in a K-12 school over the course of two decades. We also compiled new data on active school shootings during the same twenty-year time period, which identified any attempted mass shooting incident in a K-12 school. We conducted a time-series analysis to measure the association of permissiveness of state firearm laws and state gun ownership with K-12 school shootings and active shootings. More permissive firearm laws and higher rates of gun ownership were associated with higher rates of both school shootings and active school shootings after controlling for critical covariates. Specific recommendations for K-12 schools to consider as they seek to prevent acts of intentional gunfire on school grounds are presented.

Abstract Background The aim of this protocol is to describe the study protocol changes made and subsequently implemented to the Pediatric Guideline Adherence and Outcomes (PEGASUS) Argentina randomized controlled trial (RCT) for care of children with severe traumatic brain injuries (TBI) imposed by the COVID-19 pandemic. The PEGASUS study group met in spring 2020 to evaluate available literature review guidance and the study design change or pausing options due to the potential interruption of research. Methods As a parallel cluster RCT, pediatric patients with severe TBIs are admitted to 8 control (usual care) and 8 intervention (PEGASUS program) hospitals in Argentina, Chile, and Paraguay. PEGASUS is an intervention that aims to increase guideline adherence and best practice care for improving patient outcomes using multi-level implementation science-based approaches. Strengths and weaknesses of proposed options were assessed and resulted in a decision to revert from a stepped wedge to a parallel cluster RCT but to not delay planned implementation. Discussion The parallel cluster design was considered more robust and flexible to secular interruptions and acceptable and feasible to the local study sites in this situation. Due to the early stage of the study, the team had flexibility to redesign and implement a design more compatible with the conditions of the research landscape in 2020 while balancing analytical methods and power, logistical and implementation feasibility, and acceptability. As of fall 2022, the PEGASUS RCT has been active for nearly 2 years of implementation and data collection, scheduled to be completed in in fall 2023. The experience of navigating research during this period will influence decisions about future research design, strategies, and contingencies. Trial registration Pediatric Guideline Adherence and Outcomes-Argentina. Registered with ClinicalTrials.gov Identifier NCT03896789 on April 1, 2019.

OBJECTIVES/GOALS: It is estimated that 357,000 children have experienced a school shooting since 1999, yet due to limitations in the firearm violence field broadly, the sequalae are not well understood. The objective of this work is to examine the mental health impacts of school shootings, providing insight into the lasting effects of firearm violence on our communities. METHODS/STUDY POPULATION: We will first conduct a quasi-experimental study using controlled interrupted time series with repeated cross-sectional data to assess school shootings’ impact on US mental health. School shooting data is from the K-12 School Shooting Database, and mental health data will be collected via the Behavioral Risk Factor Surveillance System. Second, we will conduct focus groups with community organizations, school administrators, and the public. Interview guides will be developed to explore the mental health impacts of school shootings, to guide the quantitative results interpretation, and assess educational materials’ usefulness. Qualitative analysis will occur in NVivo software with codebook refinement through thematic analysis. Results will be triangulated through convergence coding. RESULTS/ANTICIPATED RESULTS: This research is situated within the context of the pervasive mental health challenges in the US, where mental illness poses significant health, social, and economic burdens. Thus, we anticipate finding an association between school shootings and decreased self-reported mental well-being among US adults. Literature suggests that there may be a stronger association among specific subgroups, such as parents with school-aged children or individuals living in close proximity to such incidents. We expect to find heterogeneity in the effect estimate based on school shooting attributes, such as the number of casualties. Through focus groups, we anticipate furthering our comprehension of the broad-ranging effects of school shootings on less quantifiable outcomes and the unique trajectories of recovery. DISCUSSION/SIGNIFICANCE: This project will contribute needed information on the impact of school shootings and mental health and assist in reducing the frequency and impact of school shootings. Furthermore, we aim to extend our findings beyond the scientific community, translating them into educational resources advocating for policy and public health interventions.

Abstract More than one billion people rely on livestock for income, nutrition, and social cohesion, however livestock keeping can facilitate disease transmission and contribute to climate change. While data on the distribution of livestock have broad utility across a range of applications, efforts to map the distribution of livestock on a large scale are limited to the Gridded Livestock of the World (GLW) project. We present a complimentary effort to map the distribution of cattle and pigs in Malawi, Uganda, Democratic Republic of Congo, and South Sudan. In contrast to GLW, which uses dasymmetric modeling applied to census data to produce time-stratified estimates of livestock counts and spatial density, our work uses complex survey data and distinct modeling methods to generate a time-series of livestock distribution, defining livestock density as the ratio of animals to humans. In addition to favorable cross-validation results and general agreement with national density estimates derived from external data on national human and livestock populations, our results demonstrate extremely good agreement with GLW-3 estimates, supporting the validity of both efforts. Our results furthermore offer a high-resolution time series result and employ a definition of density which is particularly well-suited to the study of livestock-origin zoonoses.

Abstract Background Temporary, voluntary storage of firearms away from the home during times of risk is a recommended strategy for suicide prevention. Law enforcement agencies (LEAs) are often suggested as storage sites, and online maps in Colorado and Washington display LEAs willing to consider storage. Questions remain about the experiences and views of LEAs, including barriers to providing storage. Methods LEAs in Colorado and Washington were invited to complete a survey via mail or online from June to July 2021; invitations were sent by email and mail, with telephone calls to non-responders. Survey data were analyzed using descriptive statistics, with testing between states and other subgroups using Fisher’s exact tests. Results Overall, 168 LEAs in Colorado (n = 91) or Washington (n = 77) participated (40% participation rate). Of those, 53% provided temporary, voluntary storage upon request by community members at the time of the survey. More LEAs said they had ever provided storage when the requester was under a court order (74% overall). Over half (60%) of responding LEAs had received at least one storage request in the prior 12 months. Many (41%) said they had declined to return a firearm after temporary storage due to safety concerns. Most LEAs supported engagement in suicide prevention (89%) and provision of community services (77%), but they simultaneously preferred being a storage option of last resort (73%). Factors negatively influencing storage provision included liability and funding concerns. Conclusions In Colorado and Washington, half of LEAs currently offer temporary, voluntary firearm storage upon request. While LEAs support suicide prevention and community engagement, broader provision of storage and participation in online maps may be limited by logistic, liability, and financial concerns. Addressing these barriers may facilitate broader suicide prevention efforts.

Social workers are uniquely positioned to support clients in crisis to reduce firearm access. However, many report needing support in navigating conversations and awareness of available options. Authors sought to understand the decision-making process social workers use, to choose which interventions (e.g. out-of-home storage) are appropriate to reduce firearm access for clients in crisis. Ten individual and group semistructured interviews were conducted with 29 social workers in Washington State; participants discussed experiences with clients at risk of harming themselves and/or others with a firearm and responded to two case examples. Grounded theory was used to develop an action plan model describing how social workers choose which interventions to pursue. Participants described two categories that influence their decision-making process for reducing firearm access for clients in crisis. The first category, sociopolitical context , included structural intersectionality, policies, professional ethics, workplace environment, and values. These influenced the second category, collaborative safety planning intervention for reducing firearm access , a process that included considering client factors, social worker actions, and options for reducing firearm access. This model can be used to develop trainings for social workers to educate them on processes to reduce firearm access for clients in crisis. [ABSTRACT FROM AUTHOR]