Strategies for recruiting adolescents in rural areas in firearm injury research.

BACKGROUND: Participant recruitment is a central aspect of human sciences research. Barriers to participant recruitment can be categorised into participant, recruiter and institutional factors. Firearm injury research poses unique barriers to recruitment. This is especially true for rural adolescents, who are at high risk for firearm-related injury and death, and whose voice is often absent in firearms research. In particular, recruitment strategies targeting adolescents should align with developmental changes occurring during this life stage. Identifying strategies to address recruitment barriers tailored to firearm-related research can help future researchers engage rural adolescents in injury prevention efforts. PURPOSE: The purpose of the current methodology paper is to outline barriers and provide strategies for recruiting rural adolescents in firearms research informed by the Youth Experiences in Rural Washington: Research on Firearm Safety project, a mixed-methods, community-based participatory research study of 13-18 year-olds residing in rural Washington. STRATEGIES: Recruitment barriers and related strategies were organised by participant-related and recruiter-related/institutional-related factors. While carrying out the study, key considerations or strategies which addressed multiple participant and recruiter/institutional factors, emerged with potential to enhance firearm-related research with rural adolescents more broadly. Key considerations included logistics (ie, scheduling flexibility, adequate and aligned incentives), use of a community-based participatory research approach and accounting for developmental stage. CONCLUSION: Reducing the burden of firearm injury and death for rural adolescents and developing effective interventions requires understanding and navigating recruitment barriers. Strategies used in the current project can guide future qualitative or mixed methods data collection informing firearm injury prevention.

Family-Focused Universal Substance Use Prevention in Primary Care: Advancing a Pragmatic National Healthcare Agenda.

This article advances ideas presented at a National Academies of Sciences, Engineering, and Medicine workshop in 2022 that highlighted clinical practice and policy recommendations for delivering universal, family-focused substance use preventive interventions in pediatric primary care. Pediatric primary care is a natural setting in which to offer families universal anticipatory guidance and links to systematic prevention programming; also, several studies have shown that offering effective parenting programs in primary care is feasible. The article describes a blueprint for designing a pragmatic national agenda for universal substance use prevention in primary care that builds on prior work. Blueprint practice schematics leverage efficacious family-focused prevention programs, identify key program implementation challenges and resources, and emphasize adopting a core element approach and utilizing digital interventions. Blueprint policy schematics specify avenues for improving cross-sector policy and resource alignment and collaboration; expanding, diversifying, and strengthening the prevention workforce; and enhancing financing for family-focused prevention approaches. The article then draws from these schematics to assemble a candidate universal prevention toolkit tailored for adolescent patients that contains four interlocking components: education in positive parenting practices, parent and youth education in substance use risks, a parent-youth structured interaction task, and parent and youth linkage to in-person and web-based prevention resources.

Anxiety, depression, and suicidal ideation among early adolescents during the COVID-19 pandemic.

BACKGROUND: Anxiety and depression are among the most common and debilitating psychiatric disorders affecting youth, with both related to increased suicide risk. While rates of youth anxiety and depression were increasing before the COVID-19 pandemic, the pandemic further negatively impacted adolescent mental health. Unfortunately, few studies have examined prevalence of these concerns among early adolescents (ages 10-13) longitudinally during the pandemic. METHOD: The current study examined self-reported anxiety and depression symptoms, and suicidal ideation amongst a general pediatrics population of 11- to 13-year-olds (n = 623) from March through September 2020 (early-pandemic) and approximately 7 months later (September 2020 through May 2021; mid-pandemic). Paired samples proportions were used to examine changes in prevalence of moderate to severe anxiety, depression, and suicidal ideation from early- to mid-pandemic. RESULTS: Results highlight high initial rates and stability in anxiety and suicidal ideation, as well as a significant increase in depression (42.9% increase; p < .05) among the full sample during the COVID-19 pandemic. Prevalance of concerns were greatest for females and Hispanic youth during the early-pandemic, and generally highest for females and Medicaid insured youth at mid-pandemic. DISCUSSION: Results extend recent research and underscore the need for continued monitoring of mental health concerns across development for youth who grew up during the COVID-19 pandemic; highlighting the need for sustainable, effective, and accessible early detection, prevention, and intervention strategies. Improving these services is critical to support youth who experienced pandemic-related stressors, and to prepare for supporting youth during future disruptive and isolating events.

Bullying and physical violence and their association with handgun carrying among youth growing up in rural areas.

OBJECTIVES: This study builds on prior research showing a strong relationship between handgun carrying and delinquent behaviors among urban youth by examining the association between handgun carrying trajectories and various types of violence in a rural sample. METHODS: This study uses data from a longitudinal cohort study of 2002 public school students in the United States from 12 rural communities across 7 states from ages 12-26 (2005-2019). We used logistic regressions to assess associations of various bullying and physical violence behaviors with latent trajectories of handgun carrying from adolescence through young adulthood. RESULTS: Compared to youth with very low probabilities of carrying a handgun in adolescence and young adulthood, trajectories with high probabilities of handgun carrying during adolescence or young adulthood were associated with greater odds of using bullying (odds ratios (ORs) ranging from 1.9 to 11.2) and higher odds of using physical violence during adolescence (ORs ranging from 1.5 to 15.9) and young adulthood (ORs ranging from 1.9 to 4.7). These trajectories with higher probabilities of handgun carrying were also associated with greater odds of experiencing physical violence like parental physical abuse and intimate partner violence, but not bullying. CONCLUSION AND IMPLICATION: Experiencing and using bullying and physical violence were associated with specific patterns of handgun carrying among youth growing up in rural areas. Handgun carrying could be an important focus of violence prevention programs among those youth.

Economic Evaluation Design within the HEAL Prevention Cooperative.

The rapid rise in opioid misuse, disorder, and opioid-involved deaths among older adolescents and young adults is an urgent public health problem. Prevention is a vital part of the nation's response to the opioid crisis, yet preventive interventions for those at risk for opioid misuse and opioid use disorder are scarce. In 2019, the National Institutes of Health (NIH) launched the Preventing Opioid Use Disorder in Older Adolescents and Young Adults cooperative as part of its broader Helping to End Addiction Long-term (HEAL) Initiative ( https://heal.nih.gov/ ). The HEAL Prevention Cooperative (HPC) includes ten research projects funded with the goal of developing effective prevention interventions across various settings (e.g., community, health care, juvenile justice, school) for older adolescent and young adults at risk for opioid misuse and opioid use disorder (OUD). An important component of the HPC is the inclusion of an economic evaluation by nine of these research projects that will provide information on the costs, cost-effectiveness, and sustainability of these interventions. The HPC economic evaluation is integrated into each research project's overall design with start-up costs and ongoing delivery costs collected prospectively using an activity-based costing approach. The primary objectives of the economic evaluation are to estimate the intervention implementation costs to providers, estimate the cost-effectiveness of each intervention for reducing opioid misuse initiation and escalation among youth, and use simulation modeling to estimate the budget impact of broader implementation of the interventions within the various settings over multiple years. The HPC offers an extraordinary opportunity to generate economic evidence for substance use prevention programming, providing policy makers and providers with critical information on the investments needed to start-up prevention interventions, as well as the cost-effectiveness of these interventions relative to alternatives. These data will help demonstrate the valuable role that prevention can play in combating the opioid crisis.

Valuing the cross-sector benefits from improving youth health to drive investment in place-based preventive interventions in the US: A simulation modeling study.

Healthcare payment reform has not produced incentives for investing in place-based, or population-level, upstream preventive interventions. This article uses economic modeling to estimate the long-term benefits to different sectors associated with improvements in population health indicators in childhood. This information can motivate policymakers to invest in prevention and provide guidance for cross-sector contracting to align incentives for implementing place-based preventive interventions. A benefit-cost model developed by the Washington State Institute for Public Policy was used to estimate total and sector-specific benefits expected from improvements to nine different population health indicators at ages 17 and 18. The magnitudes of improvement used in the model were comparable to those that could be achieved by high-quality implementation of evidence-based population-level preventive interventions. Benefits accruing throughout the lifecycle and over a ten-year time horizon were modelled. Intervention effect sizes of 0.10 and 0.20 demonstrated substantial long-term benefits for eight of the nine outcomes measured. At an effect size of 0.10, the median lifecycle benefit per participant across the ten indicators was $3080 (ranged: $93 to $14,220). The median over a 10-year time horizon was $242 (range: $14 to $1357). Benefits at effect sizes of 0.20 were approximately double. Policymakers may be able to build will for additional investment based on these cross-sector returns and communities may be able to capture these cross-sector benefits through contracting to better align incentives for implementing and sustaining place-based preventive interventions.

Substance-Specific Risk Factors among Young Adults: Potential Prevention Targets across Cannabis-Permissive Environments.

PURPOSE: This study examined levels of substance-specific risk factors such as perception of harm from substance use among young adults in a range of cannabis-permissive environments. The main objective was to inform future preventive interventions aimed at reducing cannabis use in the context of increasingly permissive environments. METHODS: Data came from the Community Youth Development Study (CYDS) collected in 2016 when participants were about 23 years old (n = 1,722 participants residing in 46 U.S. states). Young adults self-reported their perceptions about the harms related to cannabis, alcohol, and cigarette use; attitudes about and ease of access to cannabis and other substances; and perceived wrongfulness and social acceptability of cannabis, alcohol, and cigarette use and of selling of cannabis and other illegal drugs. RESULTS: Young adults in more permissive cannabis contexts reported higher levels of all cannabis-specific risk factors (e.g., greater access to and more favorable attitudes about cannabis use), except for perception of harm from regular cannabis use. However, permissiveness of the cannabis environment was not associated with heightened levels of risk factors for other substance use (such as alcohol, cigarettes, and opioids). CONCLUSIONS: Future preventive interventions for young adults living in more permissive cannabis contexts may need to focus on cannabis-specific risk factors in particular and go beyond considerations of harm from regular use. Future studies should replicate these findings with other samples.

Long-term Impacts and Benefit-Cost Analysis of the Communities That Care Prevention System at Age 23, 12 Years After Baseline.

This study estimated sustained impacts and long-term benefits and costs of the Communities That Care (CTC) prevention system, implemented and evaluated in a longitudinal cluster-randomized trial involving 24 communities in seven states. Analyses utilized reports from a longitudinal panel of 4407 participants, followed since the study's baseline in grade 5, with most recent follow-up 12 years later at age 23. Impacts on lifetime abstinence from primary outcomes of substance use and antisocial behavior were estimated using generalized linear mixed Poisson regression analysis, adjusted for individual and community-level covariates. Possible cascading effects on 4-year college completion, major depressive disorder, and generalized anxiety disorder through age 23 were evaluated as secondary outcomes. CTC had a statistically significant global effect on primary outcomes and also on combined primary and secondary outcomes. Among primary outcomes, point estimates suggested absolute improvements in lifetime abstinence of 3.5 to 6.1% in the intervention arm and relative improvements of 13 to 55%; 95% confidence intervals revealed some uncertainty in estimates. Among secondary outcomes, 4-year college completion was 1.9% greater among young adults from intervention communities, a 20% relative improvement. Mental health outcomes were approximately the same across trial arms. Although CTC had small sustained effects through age 23, benefit-cost analyses indicated CTC was reliably cost beneficial, with a net present value of $7152 (95% credible interval: $1253 to $15,268) per participant from primary impacts and $17,919 ($306 to $39,186) when secondary impacts were also included. It remained cost beneficial even when impacts were adjusted downward due to the involvement of CTC's developer in the trial. Findings suggest that broader dissemination of CTC could improve public health and individual lives in the long term and generate positive net benefits to society.

Supporting Strategic Investment in Social Programs: a Cost Analysis of the Family Check-Up.

High-quality evidence about the costs of effective interventions for children can provide a foundation for fiscally responsible policy capable of achieving impact. This study estimated the costs to society of the Family Check-up, an evidence-based brief home-visiting intervention for high-risk families implemented in the Early Steps multisite efficacy trial. Intervention arm families in three sites were offered 4 consecutive years of intervention, when target children were ages 2 through 5. Data for estimating total, average, and marginal costs and family burden (means and standard deviations, 2015 USD, discounted at 3% per year) came from a detailed database that prospectively documented resource use at the family level and a supplemental interview with trial leaders. Secondary analyses evaluated differences in costs among higher and lower risk families using repeated measures analysis of variance. Results indicated annual average costs of $1066 per family (SD = $400), with time spent by families valued at an additional $84 (SD = $99) on average. Costs declined significantly from ages 2 through 5. Once training and oversight patterns were established, additional families could be served at half the cost, $501 (SD = $404). On the margin, higher risk families cost more, $583 (SD = $444) compared to $463 (SD = $380) for lower risk families, but prior analyses showed they also benefited more. Sensitivity analyses indicated potential for wage-related cost savings in real-world implementation compared to the university-based trial. This study illustrates the dynamics of Family Check-up resource use over time and across families differing in risk.

Comprehensive Cost Analysis of First Step Next for Preschoolers with Disruptive Behavior Disorder: Using Real-World Intervention Data to Estimate Costs at Scale.

While the long-term societal costs for youth with disruptive behavior disorders are well documented, there is a dearth of information about the comprehensive costs of implementing even the most well-regarded early intervention programs, and the costs of scaling effective interventions are even less well understood. This study estimated the costs of delivering and disseminating First Step Next (FSN), an established tier two school-based early intervention, in preschool and kindergarten settings, including the training and ongoing technical assistance that support sustained, high-quality implementation. Using the Ingredients Method, we estimated (a) the per student costs of implementation, (b) the incremental cost of offering FSN to an additional student, and (c) the cost to disseminate FSN to 40 preschool and kindergarten students, including a sensitivity analysis to examine potential areas of cost savings. The per child cost to implement the FSN intervention with 29 triads in two cohorts was $4330. The incremental cost per additional student was only $2970, highlighting efficiencies gained once intervention infrastructure had been established. The cost of disseminating the intervention to a single cohort of 40 students was $170,106, or $4253 per student. The range in sensitivity analysis was $3141-$7829 per student, with variability in personnel wages having the greatest impact on cost estimates. This research expands on existing literature by providing a more comprehensive understanding of the cost of effective disruptive behavior interventions based on real-world implementation data, using these data to estimate dissemination costs, and showing how dissemination costs are particularly sensitive to personnel wages.

Long-Term Effects of the Communities That Care Trial on Substance Use, Antisocial Behavior, and Violence Through Age 21 Years.

OBJECTIVES: To evaluate whether the effects of the Communities That Care (CTC) prevention system, implemented in early adolescence to promote positive youth development and reduce health-risking behavior, endured through age 21 years. METHODS: We analyzed 9 waves of prospective data collected between 2004 and 2014 from a panel of 4407 participants (grade 5 through age 21 years) in the community-randomized trial of the CTC system in Colorado, Illinois, Kansas, Maine, Oregon, Utah, and Washington State. We used multilevel models to evaluate intervention effects on sustained abstinence, lifetime incidence, and prevalence of past-year substance use, antisocial behavior, and violence. RESULTS: The CTC system increased the likelihood of sustained abstinence from gateway drug use by 49% and antisocial behavior by 18%, and reduced lifetime incidence of violence by 11% through age 21 years. In male participants, the CTC system also increased the likelihood of sustained abstinence from tobacco use by 30% and marijuana use by 24%, and reduced lifetime incidence of inhalant use by 18%. No intervention effects were found on past-year prevalence of these behaviors. CONCLUSIONS: Implementation of the CTC prevention system in adolescence reduced lifetime incidence of health-risking behaviors into young adulthood. Clinicaltrials.gov identifier: NCT01088542.

Standards of Evidence for Conducting and Reporting Economic Evaluations in Prevention Science.

Over a decade ago, the Society for Prevention Research endorsed the first standards of evidence for research in preventive interventions. The growing recognition of the need to use limited resources to make sound investments in prevention led the Board of Directors to charge a new task force to set standards for research in analysis of the economic impact of preventive interventions. This article reports the findings of this group's deliberations, proposes standards for economic analyses, and identifies opportunities for future prevention science. Through examples, policymakers' need and use of economic analysis are described. Standards are proposed for framing economic analysis, estimating costs of prevention programs, estimating benefits of prevention programs, implementing summary metrics, handling uncertainty in estimates, and reporting findings. Topics for research in economic analysis are identified. The SPR Board of Directors endorses the "Standards of Evidence for Conducting and Reporting Economic Evaluations in Prevention Science."

Effects of Communities That Care on Males' and Females' Drug Use and Delinquency 9 Years After Baseline in a Community-Randomized Trial.

UNLABELLED: This study tested sustained effects of the Communities That Care (CTC) prevention system on health-risking behaviors 9 years after baseline in a community-randomized trial involving 24 towns in seven states. Earlier analyses found sustained effects on abstinence from drug use and delinquency through Grade 12 in a panel of fifth graders. At age 19, 91 % (n = 3986) of the living panel completed the survey. Data were analyzed using generalized linear mixed models. The prevalence of lifetime and current substance use and delinquency were the primary outcomes. Secondary outcomes included substance use disorders, major depression, suicidality, educational attainment, and sexual risk behaviors. CTC had a significant overall effect across lifetime measures of the primary outcomes for males, but not for females or the full sample, although lifetime abstinence from delinquency in the full sample was significantly higher in CTC communities (ARR = 1.16). Males in CTC communities also continued to show greater lifetime abstinence from cigarette smoking (ARR = 1.22). CTC did not have a sustained effect on current substance use and delinquency nor did it improve the secondary outcomes at age 19 for either gender. Communities using CTC may need to extend their prevention planning to include the high school years to sustain effects on drug use and delinquency beyond high school for both genders. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01088542.

Benefit-Cost Analysis of a Randomized Evaluation of Communities That Care: Monetizing Intervention Effects on the Initiation of Delinquency and Substance Use Through Grade 12.

OBJECTIVE: To determine whether the Communities That Care (CTC) prevention system is a cost-beneficial intervention. METHODS: Data were from a longitudinal panel of 4,407 youth participating in a randomized controlled trial including 24 towns in 7 states, matched in pairs within state and randomly assigned to condition. Significant differences favoring intervention youth in sustained abstinence from delinquency, alcohol use, and tobacco use through Grade 12 were monetized and compared to economic investment in CTC. RESULTS: CTC was estimated to produce $4,477 in benefits per youth (discounted 2011 dollars). It cost $556 per youth to implement CTC for 5 years. The net present benefit was $3,920. The benefit-cost ratio was $8.22 per dollar invested. The internal rate of return was 21%. Risk that investment would exceed benefits was minimal. Investment was expected to be recouped within 9 years. Sensitivity analyses in which effects were halved yielded positive cost-beneficial results. CONCLUSIONS: CTC is a cost-beneficial, community-based approach to preventing initiation of delinquency, alcohol use, and tobacco use. CTC is estimated to generate economic benefits that exceed implementation costs when disseminated with fidelity in communities.

Research priorities for economic analyses of prevention: current issues and future directions.

In response to growing interest in economic analyses of prevention efforts, a diverse group of prevention researchers, economists, and policy analysts convened a scientific panel, on "Research Priorities in Economic Analysis of Prevention" at the 19th annual conference of the Society for Prevention Research. The panel articulated four priorities that, if followed in future research, would make economic analyses of prevention efforts easier to compare and more relevant to policymakers and community stakeholders. These priorities are: (1) increased standardization of evaluation methods, (2) improved economic valuation of common prevention outcomes, (3) expanded efforts to maximize evaluation generalizability and impact as well as (4) enhanced transparency and communicability of economic evaluations. In this paper, we define three types of economic analyses in prevention, provide context and rationale for these four priorities as well as related sub-priorities, and discuss the challenges inherent in meeting them.

The longitudinal association of cumulative depression with cannabis use disorder among young adults.

OBJECTIVE: This study examined whether the cumulative experience of elevated depressive symptoms from age 19 to 23 was associated with cannabis use disorder (CUD) at age 26, and whether the association varied by perceived ease of access to cannabis and perceived risk for harms from cannabis use. METHOD: Data were from 4407 young adults participating in the Community Youth Development Study. Cumulative experience of elevated depressive symptoms was calculated by summing the number of times a participant scored 10+ on the 9-item Patient Health Questionnaire across three biennial survey waves (age 19 to 23). To assess CUD, the Diagnostic Interview Schedule was used. Participants also self-reported their ease of access to cannabis and the perceived harm of regular cannabis use at the age 19, 21, and 23 waves. Marginal structural modeling was used to account for multiple time-varying and time-fixed covariates through use of inverse probability weights. RESULTS: In final weighted models, a greater number of time points (i.e., study waves) showing elevated depressive symptoms was associated with an increased likelihood of CUD at age 26 (Prevalence Ratio = 1.46; 95% CI: 1.20, 1.77). There was no strong evidence for moderation of this association by perceived ease of access or perceived risk for harms due to regular cannabis use. CONCLUSIONS: Persistent experience of elevated depressive symptoms may place young adults at risk for cannabis use disorder. Strategies to reduce the burden of depressive symptoms among young adults may lead to downstream effects such as reducing the prevalence of cannabis-related problems.

The association of alcohol use and heavy drinking with subsequent handgun carrying among youth from rural areas.

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.

Young adults with a history of substance use disorder experienced more negative mental health, social and economic outcomes during the COVID-19 pandemic period.

BACKGROUND AND AIMS: For young adults, the disruptions brought by the COVID-19 pandemic to work, social relationships and health-care probably impacted normative life stage transitions. Disaster research shows that negative effects of these events can persist for years after the acute crisis ends. Pandemic-related disruptions may have been especially consequential for young adults with a history of substance use disorder (SUD). The current work aimed to measure the broad impact of the COVID-19 pandemic on young adults with and without a history of SUD. DESIGN, SETTING AND PARTICIPANTS: Data were from a longitudinal panel of n = 4407 young adults across the United States surveyed repeatedly from 2014 to 2019 (aged 19-26 years, pre-pandemic) and again in 2021 (aged 28 years, mid-pandemic). MEASUREMENTS: We fitted multi-level models to understand the association between SUD history and pandemic outcomes, controlling for potential confounders (socio-demographic and health measures). Outcomes included overall life disruption; mental health, social and economic impacts; substance use; and physical health. FINDINGS: Young adults with a history of SUD reported greater life disruption (standardized ß = 0.13-0.15, Ps < 0.015) and negative mental health impacts (standardized ß = 0.12-0.14, Ps < 0.012), experienced approximately 20% more work-related stressors (relative risks = 1.18-1.22, Ps < 0.002) and 50% more home-related stressors (relative risks = 1.40-1.51, Ps < 0.001), and had two to three times the odds of increased substance use during the pandemic (odds ratios = 2.07-3.23, Ps < 0.001). Findings generally did not differ between those with a recent SUD diagnosis and those in recovery from SUD before the pandemic began. CONCLUSIONS: United States young adults with a history of substance use disorder (SUD) reported more life disruption and greater negative physical and mental health, social and economic impacts during the COVID mid-pandemic period than young adults with no history of SUD.

How has the economic downturn affected communities and implementation of science-based prevention in the randomized trial of communities that care?

This study examined implications of the economic downturn that began in December 2007 for the Community Youth Development Study (CYDS), a longitudinal randomized controlled trial of the Communities That Care (CTC) prevention system. The downturn had the potential to affect the internal validity of the CYDS research design and implementation of science-based prevention in study communities. We used archival economic indicators and community key leader reports of economic conditions to assess the extent of the economic downturn in CYDS communities and potential internal validity threats. We also examined whether stronger economic downturn effects were associated with a decline in science-based prevention implementation. Economic indicators suggested the downturn affected CYDS communities to different degrees. We found no evidence of systematic differences in downturn effects in CTC compared to control communities that would threaten internal validity of the randomized trial. The Community Economic Problems scale was a reliable measure of community economic conditions, and it showed criterion validity in relation to several objective economic indicators. CTC coalitions continued to implement science-based prevention to a significantly greater degree than control coalitions 2 years after the downturn began. However, CTC implementation levels declined to some extent as unemployment, the percentage of students qualifying for free lunch, and community economic problems worsened. Control coalition implementation levels were not related to economic conditions before or after the downturn, but mean implementation levels of science-based prevention were also relatively low in both periods.

School Handgun Carrying Among Youth Growing Up in Rural Communities.

PURPOSE: To characterize school handgun carrying and violence risk factors among rural youth. METHODS: Using a sample of rural youth (n = 1995), we quantified the proportion who carried a handgun to school, carried but not to school, and did not carry across grades 7-12 and endorsed risk factors for violence in individual, peer, school, and community domains. RESULTS: Overall, 3% (95% confidence interval [CI]: 2%-4%) of youth ever carried to school; 15% (95% CI: 14%-16%) carried but not to school; and 82% (95% CI: 80%-84%) never carried. Violence risk factors (e.g., attacking someone) were more commonly endorsed by youth who carried to school (84%; 95% CI: 73%-95%) than those who carried but not to school (51%; 95% CI: 44%-58%) and did not carry (23%; 95% CI: 20%-26%). DISCUSSION: Carrying a handgun to school in rural areas is not common; however, it is associated with risk factors for violence. Understanding violence risk factors among youth who carry handguns to school could inform violence prevention programs in rural areas.