Does Implementation Matter? Associations Between Implementation of Maine's Anti- Bullying Law and Bullying Victimization Among High School Youth.

PURPOSE: To characterize the relationship between implementation of an antibullying law and bullying rates among high school youth. METHODS: School staff (administrators, counselors, and teachers) from public high schools in Maine completed a survey assessing: (1) the frequency with which they implemented 17 components of their district's antibullying policy as mandated by state law; and (2) confidence in implementing the law. Their responses were linked to data on bullying victimization among high school respondents to the Maine Integrated Youth Health Survey, which created a population-based dataset of 84 high schools with 29,818 student responses. RESULTS: Students in schools where administrators (adjusted odds ratio = 0.93; 95% CI: 0.89, 0.97) and counselors (adjusted odds ratio = 0.86; 95% CI: 0.81, 0.92) reported implementing more mandated components of the law experienced notable reductions in the odds of bullying, controlling for student-level characteristics (sex, race, grade) and for school-level bullying rates assessed prior to the passage of the law. With respect to specific implementation components, bullying was most consistently reduced in schools where staff reported increased referrals for counseling and other supports for targets of bullying and in schools where counselors and teachers were interviewed as part of bullying investigations. Students in schools where teachers reported increased confidence in implementing the antibullying law also had reduced odds of bullying. DISCUSSION: These data provide some of the first evidence that the efficacy of a state's antibullying law depends in part on the extent to which school personnel implement the law.

Recruitment of Row Crop Farmers into a Research Study to Assess Farm Hazards.

Farmers are at an elevated risk for injuries and are, therefore, highly sought after for research studies. However, their participation in research studies is low. We examine how characteristics of the farmer, farm location, and timing of recruitment contact impact the probability that farmers will engage and participate in a study of injuries and related farm hazards. Study data were obtained from the Farm Safety Study conducted at the University of Iowa between June 2019 and March 2020. We used recruitment data from participants enrolled using Farm Journal magazine subscription lists. Multinomial logistic regression was used for predictive modeling. Predictor variables included the time of day and the farm season in which phone contact for study recruitment was attempted, as well as the rurality of the farm. Two models were created to characterize screening and participation of farmers in the study. Farm season and time of day of the last recruitment call increased the likelihood of farmers being screened for study participation and completing the study. Specifically, contacting farmers during the growing season and during the daytime, regardless of farm rurality, resulted in higher probabilities of participation. Studies of agricultural injury may be more efficiently conducted, with higher participation responses, when circumstances of the recruitment call are considered. This work serves as a starting place for much-needed methodological research to identify factors that increase participation of farmers and farm workers in research studies.

Building A Comprehensive, Longitudinal Dataset to Advance Research on the Efficacy of State-Level Anti-bullying Legislation: 1999 to 2017.

Bullying is one of the most common forms of youth violence and is associated with myriad adverse consequences over the life course. There has been increasing interest in examining whether anti-bullying legislation is effective in preventing bullying victimization and its negative effects. However, a lack of data structures that comprehensively and longitudinally assess anti-bullying legislation and its provisions has hampered this effort. We provide 18 years of data (1999-2017) on anti-bullying legislation and amendments across 50 U.S. states and the District of Columbia, which we are making publicly available at LawAtlas.org. This article describes how the legal content analysis was conducted, provides information on the reliability of the coding, and details provisions of the legislation that were coded, such as funding provisions and enumerated groups (a total of 122 individual codes are provided). Over 90% of states had at least one amendment to their legislation during this 18-year period (range: 0-22; Mean = 6.1), highlighting both the evolving content of anti-bullying statutes and the importance of tracking these changes with longitudinal data. Additionally, we offer illustrative examples of the kinds of research questions that might be pursued with these new data. For instance, using survival analyses, we show that a variety of state characteristics (e.g., political leaning of state legislatures) predict time to adoption of key provisions of anti-bullying legislation (e.g., the comprehensiveness of legal provisions). Finally, we end with a discussion of how the dataset might be used in future research on the efficacy of anti-bullying legislation.

Examining Excess Mortality Among Critical Workers in Minnesota During 2020-2021: An Occupational Analysis.

Objectives. To understand the occupational risk associated with COVID-19 among civilian critical workers (aged 16-65 years) in Minnesota. Methods. We estimated excess mortality in 2020 to 2021 for critical occupations in different racial groups and vaccine rollout phases using death certificates and occupational employment rates for 2017 to 2021. Results. Excess mortality during the COVID-19 pandemic was higher for workers in critical occupations than for noncritical workers. Some critical occupations, such as transportation and logistics, construction, and food service, experienced higher excess mortality than did other critical occupations, such as health care, K-12 school staff, and agriculture. In almost all occupations investigated, workers of color experienced higher excess mortality than did White workers. Excess mortality in 2021 was greater than in 2020 across groups: occupations, vaccine eligibility tiers, and race/ethnicity. Conclusions. Although workers in critical occupations experienced greater excess mortality than did others, excess mortality among critical workers varied substantially by occupation and race. Public Health Implications. Analysis of mortality across occupations can be used to identify vulnerable populations, prioritize protective interventions for them, and develop targeted worker safety protocols to promote equitable health outcomes. (Am J Public Health. 2023;113(11):1219-1222. https://doi.org/10.2105/AJPH.2023.307395).

Impacts of COVID-19 on Stress in Middle School Teachers and Staff in Minnesota: An Exploratory Study Using Random Forest Analysis.

While the COVID-19 pandemic has negatively impacted many occupations, teachers and school staff have faced unique challenges related to remote and hybrid teaching, less contact with students, and general uncertainty. This study aimed to measure the associations between specific impacts of the COVID-19 pandemic and stress levels in Minnesota educators. A total of 296 teachers and staff members from eight middle schools completed online surveys between May and July of 2020. The Epidemic Pandemic Impacts Inventory (EPII) measured the effects of the COVID-19 pandemic according to nine domains (i.e., Economic, Home Life). The Kessler-6 scale measured non-specific stress (range: 0-24), with higher scores indicating greater levels of stress. Random forest analysis determined which items of the EPII were predictive of stress. The average Kessler-6 score was 6.8, indicating moderate stress. Three EPII items explained the largest amount of variation in the Kessler-6 score: increase in mental health problems or symptoms, hard time making the transition to working from home, and increase in sleep problems or poor sleep quality. These findings indicate potential areas for intervention to reduce employee stress in the event of future disruptions to in-person teaching or other major transitions during dynamic times.

Barriers and Facilitators to the Online Delivery of a School-Based Intervention to Reduce Racial Trauma.

Students of color face disproportionate rates of adverse childhood experiences, including racial discrimination in school settings. Effective interventions strategies are needed to address school-based racial trauma. Link for Equity was designed to be a culturally-responsive trauma-informed intervention that includes universal cultural humility training for teachers. As a result of the COVID-19 pandemic, the in-person trauma-informed cultural humility training was adapted for online delivery. The purpose of this study was to assess barriers and facilitators that impacted online delivery of the training. We conducted semi-structured interviews with 25 high school teachers from three public school districts in the Midwestern United States who participated in the online training. Interview transcripts were coded by two team members, and thematic analysis was utilized. Barriers and facilitators to online delivery were identified across five domains: receptivity, logistics, engagement, comfort, and application. The implications of these barriers and facilitators are discussed and tailored recommendations for the virtual delivery of culturally-responsive trauma-informed interventions to reduce racial discrimination in schools are provided.

Opioid-related Mortality in United States Death Certificate Data: A Quantitative Bias Analysis With Expert Elicitation of Bias Parameters.

BACKGROUND: Opioid-related mortality is an important public health problem in the United States. Incidence estimates rely on death certificate data generated by health care providers and medical examiners. Opioid overdoses may be underreported when other causes of death appear plausible. We applied physician-elicited death certificate bias parameters to quantitative bias analyses assessing potential age-related differential misclassification in US opioid-related mortality estimates. METHODS: We obtained cause-of-death data (US, 2017) from the National Center for Health Statistics and calculated crude opioid-related outpatient death counts by age category (25-54, 55-64, 65+). We elicited beliefs from 10 primary care physicians on sensitivity of opioid-related death classification from death certificates. We summarized elicited sensitivity estimates, calculated plausible specificity values, and applied resulting parameters in a probabilistic bias analysis. RESULTS: Physicians estimated wide sensitivity ranges for classification of opioid-related mortality by death certificates, with lower estimated sensitivities among older age groups. Probabilistic bias analyses adjusting for physician-estimated misclassification indicated 3.1 times more (95% uncertainty interval: 1.2-23.5) opioid-related deaths than the observed death count in the 65+ age group. All age groups had substantial increases in bias-adjusted death counts. CONCLUSIONS: We developed and implemented a feasible method of eliciting physician expert opinion on bias parameters for sensitivity of a medical record-based death indicator and applied findings in quantitative bias analyses adjusting for differential misclassification. Our findings are consistent with the hypothesis that opioid-related mortality rates may be substantially underestimated, particularly among older adults, due to misclassification in cause-of-death data from death certificates.

Link for Equity, a community-engaged waitlist randomized controlled trial of a culturally responsive trauma-informed care program for BIPOC students: Design features and characteristics of baseline sample.

BACKGROUND: Link for Equity is a multi-tiered, school-based program of trauma-informed care and cultural humility designed to reduce the impact of Adverse Child Experiences among Black Indigenous and other children of color (BIPOC). This report describes the program, its trial design, and the study participants' baseline characteristics. METHODS: We designed a nested waitlist-controlled trial to evaluate Link for Equity's effectiveness in reducing school violence among BIPOC students. Three pairs of school districts, matched on suspension rates and enrollment of Black/African American, Hispanic/Latinx, and American Indian/Alaska Native children, were randomized into either an intervention or delayed intervention (waitlist control) group. A community-engaged approach guided the development of protocols. Within intervention sites, BIPOC students who screened positive for ACEs or posttraumatic stress were also randomized into an immediate and waitlist control group to receive additional one-on-one support from trained school staff. RESULTS: The trial was implemented from 2019 to 2021, which overlapped with the pandemic and civil unrest in Minnesota. At baseline, 444 staff and 188 students enrolled in the study. Over a quarter of American Indian/Alaska Native students, 18% of multiple race, 12% of Black/African American, 14% of Hispanic/Latinx students reported 4+ ACEs. Between 44 and 53% of all the BIPOC students in the study were symptomatic for PTSD. Of the enrolled students, 78.7% qualified for one-on-one Link support. CONCLUSION: We implemented a multilevel waitlist-controlled trial of Link for Equity using community-engaged methods. Despite school closures during the pandemic, the study persisted with its methods now being employed in an expanded cohort of middle schools. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04026477, NCT04026490).

Economic Hardship and Violence: A Comparison of County-Level Economic Measures in the Prediction of Violence-Related Injury.

Economic hardship may lead to a wide range of negative outcomes, including violence. However, existing literature on economic hardship and violence is limited by reliance on official reports of violence and conflation of different measures of economic hardship. The goals of this study are to measure how violence-related injuries are associated with five measures of county-level economic shocks: unemployment rate, male mass layoffs, female mass layoffs, foreclosure rate, and unemployment rate change, measured cross-sectionally and by a 1-year lag. This study measures three subtypes of violence outcomes (child abuse, elder abuse, and intimate partner violence). Yearly county-level data were obtained on violence-related injuries and economic measures from 2005 to 2012 for all 87 counties in Minnesota. Negative binomial models were run regressing the case counts of each violence outcome at the county-year level on each economic indicator modeled individually, with population denominator offsets to yield incidence rate ratios. Crude models were run first, then county-level socio-demographic variables and year were added to each model, and finally fully-adjusted models were run including all socio-demographic variables plus all economic indicators simultaneously. In the fully-adjusted models, a county's higher foreclosure rate is the strongest and most consistently associated with an increase in all violence subtypes. Unemployment rate is the second strongest and most consistent economic risk factor for all violence subtypes. Lastly, there appears to be an impact of gender specific to economic impacts on child abuse; specifically, male mass-lay-offs were associated with increased rates while female mass-lay-offs were associated with decreased rates. Understanding the associations of different types of economic hardship with a range of violence outcomes can aid in developing more holistic prevention and intervention efforts.

Development of a Checklist to Identify Injury Hazards on Row Crop Farms in the Midwestern United States.

Agriculture is among the most dangerous industries in the U.S., yet routine surveillance of injury hazards is not currently being conducted on a national level. The objectives of this study were to describe a new tool, called the Hazard Assessment Checklist (HAC), to identify and characterize farm hazards that increase injury risk to farmers and farm workers, and (2) report the inter-rater reliability of the new tool when administered on row-crop farms in Iowa. Based on a literature review and a consensus of expert opinion, the HAC included hazards related to self-propelled vehicles, powered portable implements, fixed machinery and equipment, farm buildings and structures, fall risks, and portable equipment associated with fall risk. A scoring metric indicating the extent of compliance with recommended safety guidelines and standards was developed for each item of the HAC, which included compliant, minimal improvement needed, substantial improvement needed, and not compliant. Inter-rater reliability was assessed from data collected by research staff on 52 row crop farms in Iowa. Cohen's weighted Kappa values demonstrated high inter-rater reliability, ranging between 0.86 and 0.94, for all HAC sections. The HAC can be completed in 1.5-2 hours on each farm and requires about three hours of training, two hours of which are spent in field training. The ability to monitor injury-related hazards over time using an empirically driven tool will contribute significantly to injury prevention efforts in an industry with consistently high rates of fatal and nonfatal injury.

A serial cross-sectional study of trends and predictors of prescription controlled substance-related traumatic injury.

Pre-injury drug use is a key contributor to traumatic injury. However, limited research has examined trends and predictors of controlled substance-related trauma. The present study aims to provide better clarity on the specific role of prescription-controlled substances (PCS) in traumatic injury events. The data source was the American College of Surgeons National Trauma Data Bank. Trends by injury mechanism and intent for patients with PCS and no-confirmed substances were compared from 2007 to 2014. Logistic regression models were also performed to examine the association between substance use and injury mechanism and intent for data across the study period. Of 405,334 trauma patients, 328,623 (81.1%) had no-confirmed substances and 76,711 (18.9%) had PCS detected. The majority of events in the PCS and no-confirmed substance groups were classified as unintentional. Motor vehicle traffic (MVT), falls, other transport, and cut/pierce injuries accounted for approximately 80% of all injuries. From 2007 to 2014, the proportion of injuries with PCS increased for all injury mechanisms and injury intents. The injury mechanisms of fire/burn, firearm, machinery, poisoning, and other transport were significantly more likely to have PCS relative to MVT injuries. For injury intent, self-harm was more likely to have a toxicology test positive for PCS, while assault was less likely to have a toxicology test positive for PCS compared to unintentional injuries. PCS-related traumatic injuries increased significantly over time and across injury mechanisms and intents. These findings can be used to inform prescribing and understand risk factors to reduce the likelihood of PCS-related traumatic injury.

Violence in the Great Recession.

Substantial evidence suggests that economic hardship causes violence. However, a large majority of this research relies on observational studies that use traditional violence surveillance systems that suffer from selection bias and over-represent vulnerable populations, such as people of color. To overcome limitations of prior work, we employed a quasi-experimental design to assess the impact of the Great Recession on explicit violence diagnoses (injuries identified to be caused by a violent event) and proxy violence diagnoses (injuries highly correlated with violence) for child maltreatment, intimate partner violence, elder abuse, and their combination. We used Minnesota hospital data (2004-2014), conducting a difference-in-differences analysis at the county level (n = 86) using linear regression to compare changes in violence rates from before the recession (2004-2007) to after the recession (2008-2014) in counties most affected by the recession, versus changes over the same time period in counties less affected by the recession. The findings suggested that the Great Recession had little or no impact on explicitly identified violence; however, it affected proxy-identified violence. Counties that were more highly affected by the Great Recession saw a greater increase in the average rate of proxy-identified child abuse, elder abuse, intimate partner violence, and combined violence when compared with less-affected counties.

Cognitive factors influenced physical distancing adherence during the COVID-19 pandemic in a population-specific way.

Even early in the COVID-19 pandemic, adherence to physical distancing measures was variable, exposing some communities to elevated risk. While cognitive factors from the Health Belief Model (HBM) and resilience correlate with compliance with physical distancing, external conditions may preclude full compliance with physical distancing guidelines. Our objective was to identify HBM and resilience constructs that could be used to improve adherence to physical distancing even when full compliance is not possible. We examined adherence as expressed through 7-day non-work, non-household contact rates in two cohorts: 1) adults in households with children from Minnesota and Iowa; and 2) adults ≥50 years-old from Minnesota, one-third of whom had Parkinson's disease. We identified multiple cognitive factors associated with physical distancing adherence, specifically perceived severity, benefits, self-efficacy, and barriers. However, the magnitude, and occasionally the direction, of these associations was population-dependent. In Cohort 1, perceived self-efficacy for remaining 6-feet from others was associated with a 29% lower contact rate (RR 0.71; 95% CI 0.65, 0.77). This finding was consistent across all race/ethnicity and income groups we examined. The barriers to adherence of having a child in childcare and having financial concerns had the largest effects among individuals from marginalized racial and ethnic groups and high-income households. In Cohort 2, self-efficacy to quarantine/isolate was associated with a 23% decrease in contacts (RR 0.77; 95% CI 0.66, 0.89), but upon stratification by education level, the association was only present for those with at least a Bachelor's degree. Education also modified the effect of the barrier to adherence leaving home for work, increasing contacts among those with a Bachelor's degree and reducing contacts among those without. Our findings suggest that public health messaging tailored to the identified cognitive factors has the potential to improve physical distancing adherence, but population-specific needs must be considered to maximize effectiveness.

A Test of Social Cognitive Theory to Increase Hearing Protection Use in Swine Buildings.

Farming ranks among the top occupations for which workers are at risk for noise-induced hearing loss (NIHL), an irreversible yet preventable condition. Hearing Protection Devices (HPDs) (i.e., earmuffs and ear plugs) are effective at preventing expo- sure to noise; however, few farmers report consistent use. The purpose of this study was to test an intervention based on Social Cognitive Theory with interactive smartphone technology to increase the use of HPDs among swine facility workers. A pilot, quasi-experimental study was implemented among 72 younger adult swine workers. Participants were randomly assigned to one of three groups. Group 1 received HPDs (e.g., earmuffs and ear plugs). Group 2 received the same HPDs as Group 1 and was also instructed to use a smartphone application to track their use of hearing protection for 60 days. Group 3 received the HPDs and instructions on using a smartphone app for tracking the use of hearing protection and setting daily goals for hearing protection use. Use of hearing protection was assessed via an online survey prior to the intervention (i.e., "baseline"), immediately after the post-intervention, and at a 3-month follow-up. Compared to baseline use, all three groups reported increased use of hearing protection immediately post-intervention. However, this increase was not maintained at a 3-month follow-up for two of the study groups. Group 3 (HPD, tracking, and goal-setting app) showed the greatest increase in the use of HPDs from baseline to immediate post-intervention; however, Group 1 (HPD only) showed the greatest sustained increase from baseline to the 3-month follow-up. Modifying the environment by supplying HPDs was effective in increasing HPD use among swine facility workers. Improving access to hearing protection devices alone may lead to sustained changes in behavior.

The Importance of Anti-Racism in Trauma-Informed Family Engagement.

Students of color are disproportionately affected by exposure to adverse childhood experiences (ACEs), racial trauma, and traumatic stress. Trauma-informed interventions in schools can promote healing among ACE-impacted students of color. These interventions require collaboration with family members to decide upon services and referrals; however, educators commonly face challenges with engaging families. The study purpose is to understand barriers and facilitators to engaging families in trauma-informed mental health interventions for ACE-impacted students of color. As part of a larger school-based trauma-informed trial (Link for Equity), 6 focus groups were conducted with parents/guardians of color and school staff (n = 39) across 3 Midwestern school districts. Participants were asked open-ended questions about trauma, discrimination, school supports, and family engagement. Transcripts were coded by two team members, and thematic analysis was used to identify barriers/facilitators to family involvement. Results indicated that families of ACE-impacted students of color commonly experienced racism including microaggressions and stereotypes from the school community, which deterred engagement and prevented trusting relationships between families and school staff. Parents highlighted feeling excluded from decisions related to their child's education and that their voices were not heard or understood. Participants discussed the need for schools to consider how family obstacles (such as mental health and trauma) may prevent families from engaging with staff, and they recommended structural changes, such as anti-racism trainings for educators. Findings highlight the need for anti-racist work that addresses interpersonal and structural racism in schools, in order to promote family engagement in trauma-informed mental health interventions.

School-Based Diversity Education Activities and Bias-Based Bullying Among Secondary School Students.

Bias-based bullying (e.g., bullying related to race, weight, sexual orientation) is a common experience among youth, yet few school-based prevention programs explicitly address this type of bullying. This study explores whether schools that offer diversity education activities have lower rates of bias-based bullying among students compared to schools that do not offer these activities. Data came from two sources: the 2018 CDC School Profiles Survey (N = 216 schools) and the 2019 Minnesota Student Survey (N = 64,510 students). Multilevel logistic regression tested associations between diversity education activities (diversity clubs, lessons, or special events) and eight types of bias-based bullying among students, with attention to effect modification by relevant demographic characteristics. Students attending schools that offer a wider variety of diversity education opportunities had significantly lower odds of bullying about race, ethnicity, or national origin among boys of color (OR = 0.89, CI: 0.80, 1.00), about sexual orientation for gay, bisexual, and questioning boys (OR = 0.81, CI: 0.67, 0.97), and about disability for boys with a physical health problem (OR = 0.86, CI: 0.76, 0.99). Attending a school with more types of diversity education activities may protect vulnerable students against specific types of bias-based bullying and advance health equity. A diversity education is recommended as a key component of antibullying efforts and policy.

Differential effectiveness of the Minnesota Safe Patient Handling Act by health care setting: An exploratory study.

BACKGROUND: The Minnesota Safe Patient Handling (MN SPH) Act requires health care facilities to implement comprehensive programs to protect their workers from musculoskeletal injuries caused by lifting and transferring patients. Nursing homes, hospitals, and outpatient facilities each face unique challenges implementing and maintaining SPH programs. The objective of the study was to compare patient handling injuries in these three health care settings and determine whether change in injury rate over time differed by setting following enactment of the law. METHODS: Workers' compensation data from a Minnesota-based insurer were used to describe worker and claim characteristics in nursing homes, hospitals, and outpatient facilities. Negative binomial models were used to compare claims and estimate mean annual patient handling claim rates by health care setting and time period following enactment of the law. RESULTS: Consistent with national data, the patient handling claim rate was highest in Minnesota nursing homes (168 claims/$100 million payroll [95% confidence interval: 163-174]) followed by hospitals (35/$100 million payroll [34-37]) and outpatient facilities (2/$100 million payroll [1.8-2.2]). Patient handling claims declined by 38% over 10 years following enactment of the law (vs. 27% for all other claims). The change in claims over time did not differ by health care setting. CONCLUSIONS: In this single-insurer sample, declines in workers' compensation claims for patient handling injuries were consistent across health care settings following enactment of a state SPH law. Though nursing homes experienced elevated claim rates overall, results suggest they are not lagging hospitals and outpatient facilities in reducing patient handling injuries.

Farm vehicle crashes on public roads: Analysis of farm-level factors.

PURPOSE: Rural public roads experience higher crash fatality rates than other roadways, with agricultural equipment adding greater risk of injury and fatality. This study set out to describe farmers' experiences with farm equipment crashes and predictors of crashes at the farm level. METHODS: A survey of farm operators was conducted in 9 Midwestern states (IL, IA, KS, MN, MO, NE, ND, SD, and WI) in collaboration with the US Department of Agriculture's National Agricultural Statistical Service. FINDINGS: From 1,282 farms operating equipment on public roads in 2013, 7.6% of farmers reported that equipment from their farm had ever been in a crash (n = 97). Crashes occurred most often in June-August (44.0%) and were most often reported as being during the daytime (71.3%), on dry roads (79.4%), or in clear weather (71.4%). While most farmers responded that they were driving the farm equipment at the time of the crash (52.0%), nearly half of crashes involved their employees as the driver (48.0%). Crashes often went unreported to law enforcement (28.6%). CONCLUSION: To illustrate crash probabilities for farms with different profiles, we included farm acreage, crop farming, vehicle horsepower, annual miles driven, and the total number of farm vehicles driven on public roads in a predictive model. Large crop farms of 241+ acres, those who drove farm vehicles 1,430+ miles per year, and those with 20 or more farm vehicles had the highest probability of crash of 0.14.

Measuring the hidden burden of violence: use of explicit and proxy codes in Minnesota injury hospitalizations, 2004-2014.

PURPOSE: Commonly-used violence surveillance systems are biased towards certain populations due to overreporting or over-scrutinized. Hospital discharge data may offer a more representative view of violence, through use of proxy codes, i.e. diagnosis of injuries correlated with violence. The goals of this paper are to compare the trends in violence in Minnesota, and associations of county-level demographic characteristics with violence rates, measured through explicitly diagnosed violence and proxy codes. It is an exploration of how certain sub-populations are overrepresented in traditional surveillance systems. METHODS: Using Minnesota hospital discharge data linked with census data from 2004 to 2014, this study examined the distribution and time trends of explicit, proxy, and combined (proxy and explicit) codes for child abuse, intimate partner violence (IPV), and elder abuse. The associations between county-level risk factors (e.g., poverty) and county violence rates were estimated using negative binomial regression models with generalized estimation equations to account for clustering over time. RESULTS: The main finding was that the patterns of county-level violence differed depending on whether one used explicit or proxy codes. In particular, explicit codes suggested that child abuse and IPV trends were flat or decreased slightly from 2004 to 2014, while proxy codes suggested the opposite. Elder abuse increased during this timeframe for both explicit and proxy codes, but more dramatically when using proxy codes. In regard to the associations between county level characteristics and each violence subtype, previously identified county-level risk factors were more strongly related to explicitly-identified violence than to proxy-identified violence. Given the larger number of proxy-identified cases as compared with explicit-identified violence cases, the trends and associations of combined codes align more closely with proxy codes, especially for elder abuse and IPV. CONCLUSIONS: Violence surveillance utilizing hospital discharge data, and particularly proxy codes, may add important information that traditional surveillance misses. Most importantly, explicit and proxy codes indicate different associations with county sociodemographic characteristics. Future research should examine hospital discharge data for violence identification to validate proxy codes that can be utilized to help to identify the hidden burden of violence.

Comparative Effectiveness of Parent-Based Interventions to Support Injured Children.

OBJECTIVES: A comparative effectiveness trial tested 2 parent-based interventions in improving the psychosocial recovery of hospitalized injured children: (1) Link for Injured Kids (Link), a program of psychological first aid in which parents are taught motivational interviewing and stress-screening skills, and (2) Trauma Education, based on an informational booklet about trauma and its impacts and resources. METHODS: A randomized controlled trial was conducted in 4 children's hospitals in the Midwestern United States. Children aged 10 to 17 years admitted for an unintentional injury and a parent were recruited and randomly assigned to Link or Trauma Education. Parents and children completed questionnaires at baseline, 6 weeks, 3 months, and 6 months posthospitalization. Using an intent-to-treat analysis, changes in child-reported posttraumatic stress symptoms, depression, quality of life, and child behaviors were compared between intervention groups. RESULTS: Of 795 injured children, 314 children and their parents were enrolled into the study (40%). Link and Trauma Education was associated with improved symptoms of posttraumatic stress, depression, and pediatric quality of life at similar rates over time. However, unlike those in Trauma Education, children in the Link group had notable improvement of child emotional behaviors and mild improvement of conduct and peer behaviors. Compared with Trauma Education, Link was also associated with improved peer behaviors in rural children. CONCLUSION: Although children in both programs had reduced posttrauma symptoms over time, Link children, whose parents were trained in communication and referral skills, exhibited a greater reduction in problem behaviors.