Gun-free zones and active shootings in the United States: a matched case-control study.

Background: Most Americans believe that gun-free zones make locations more vulnerable to violent crimes, particularly active shootings. However, there is no empirical evidence regarding the impact of gun-free zones on protecting locations from violence. The objective of this study was to estimate the association between gun-free zones and active shootings. Methods: We used a pair-matched case-control study where cases were all US establishments where active shootings occurred between 2014 and 2020, and controls were randomly selected US establishments where active shootings could have but did not occur, pair-matched by establishment type, year, and county. Gun-free status of included establishments was determined via local laws, company policy, news reporting, Google Maps and posted signage, and calling establishments. Findings: Of 150 active shooting cases, 72 (48.0%) were determined to have occurred in a gun-free zone. Of 150 controls where no active shooting occurred, 92 (61.3%) were determined to be gun-free. After accounting for matched pairs, the conditional odds of an active shooting in gun-free establishments were 0.38 times those in non-gun-free establishments, with a 95% confidence interval of 0.19-0.73 (p-value = 0.0038). Several robustness analyses affirmed these findings. Interpretation: It is unlikely that gun-free zones attract active shooters; gun-free zones may be protective against active shootings. This study challenges the proposition of repealing gun-free zones based on safety concerns. Funding: This work was funded in part by the National Collaborative on Gun Violence Research and the Arnold Foundation.

Protocol for a nationwide case-control study of firearm violence prevention tactics and policies in K-12 schools.

BACKGROUND: Most U.S. K-12 schools have adopted safety tactics and policies like arming teachers and installing metal detectors, to address intentional school gun violence. However, there is minimal research on their effectiveness. Furthermore, sociodemographic factors may influence their implementation. Controlled studies are necessary to investigate their impact on gun violence and related disciplinary outcomes. OBJECTIVE: The paper outlines the protocol for a case-control study examining gun violence prevention policies in U.S. K-12 schools. The study aims to investigate if there is an association between the total number and type of specific safety tactics and policies and the occurrence of intentional shootings in K-12 public schools, student disciplinary outcomes, and if urbanicity, economic, and racial factors modify these associations. METHODS: We will create a nationally representative dataset for this study and ascertain a full census of case schools (schools that experienced intentional gunfire on the campus during school hours since 2015) through national school shooting databases. Matched control schools will be randomly selected from U.S. Department of Education's national database of all public schools. We will analyze 27 school safety strategies organized into seven key exposure groupings. RESULTS: Supported by the National Institutes for Child Health and Development (R01HD108027-01) and having received Institutional Review Board approval, our study is currently in the data collection phase. Our analytical plan will determine the association between the number and type of school safety tactics and policies with the occurrence of intentional shootings and suspensions and expulsions in a national sample of approximately 650 K-12 public schools. Additional analyses will investigate the effect modification of specific covariates. CONCLUSION: As the first national, controlled study, its results will provide novel and needed data on the effectiveness of school safety tactics and policies in preventing intentional shootings at K-12 public schools.

Gun violence in K-12 schools in the United States: Moving towards a preventive (versus reactive) framework.

Intentional shootings in K-12 schools in the U.S. persist as a public health problem. The number of shootings in K-12 schools has increased precipitously since 2017. And with approximately 100,000 K-12 public schools nationally serving 51 million children, investing in a comprehensive gun violence prevention strategy is critical. Unfortunately, our current school gun violence prevention approach almost exclusively centers reactive strategies that are in place to respond to acts of gun violence in the moment, rather than preventive strategies that would prevent them from occurring at all. Reliance on these strategies alone, however, is not sufficient. In line with the core tenets of public health prevention and the Whole School, Whole Child, Whole Community model, we present a more expansive school gun violence prevention framework that broadens the spectrum of what constitutes "school gun violence prevention." Our work highlights how enhancing basic neighborhood and school structures-including investments in public libraries, affordable housing, and universal school-based violence prevention programs-are key to both preventing gun violence and promoting well-being. We also highlight the role of stricter gun laws, reasonable school security efforts, bystander interventions, building awareness within school communities, and meaningful investments in early interventions and mental health services. Children, who have been tragically exposed to any number of adverse experiences in the wake of the COVID-19 pandemic, deserve more reasoned choices and large-scale investments in understanding and cutting off the root causes of school gun violence; not just a reliance on strategies that focus on what to do in the moment of a violent act. As gun violence in K-12 schools persists, we must reframe the discourse about school gun violence around prevention, not reaction.

Clusters of Adversity Types Among U.S. Youth: Associations With Mental Health.

INTRODUCTION: Childhood adversities are risk factors for subsequent mental health problems. Research commonly focuses on adverse childhood experiences, despite evidence that other exposures, such as neighborhood violence or peer victimization, co-occur with adverse childhood experiences and are associated with similar mental health outcomes. This study explored the clustering of these exposures and examined the associations with mental health. METHODS: Data were a nationally representative sample of U.S. children aged 10-17 years (N=1,959), collected in 2013-2014. Latent class analysis was conducted on 22 types of childhood adversity. Regression models examined associations with mental health and substance use. These secondary analyses were conducted in 2021. RESULTS: A total of 5 classes were identified: Low all (59% of the sample), Abuse (29%), High multiple adversities (5%), Peer adversity (4%), and Neighborhood violence (4%). All classes had poorer mental health and a higher prevalence of substance use than Low all, with particularly harmful levels in High multiple adversities. Neighborhood violence was not significantly different from High multiple adversities on mental health symptoms and showed a greater proportion of past-year substance use than all other classes except High multiple adversities. Peer adversity and Abuse classes did not differ significantly in any outcomes. CONCLUSIONS: Findings highlight the particularly deleterious impact of neighborhood violence and highly co-occurring adversity types on mental health and substance use. It is important to extend our conceptualization of adverse childhood experiences to include peer adversity and neighborhood violence and shift from a siloed approach to examining all these exposures.

State firearm laws, gun ownership, and K-12 school shootings: Implications for school safety.

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.

Racial Disparities in Child Exposure to Firearm Violence Before and During COVID-19.

INTRODUCTION: Childhood exposure to neighborhood firearm violence adversely affects mental and physical health across the life course. Study objectives were to (1) quantify racial disparities in these exposures across the U.S. and (2) assess changes during the COVID-19 pandemic, when firearm violence increased. METHODS: The study used counts of children aged 5-17 years, disaggregated by U.S. Census racial category, for every census tract (N=73,056). Neighborhood firearm violence was the number of fatal shootings per census tract, based on 2015-2021 Gun Violence Archive data. Quasi-Poisson regressions were used to estimate baseline disparities and COVID-19‒related changes and examined differences across geographic regions. RESULTS: Prepandemic exposure was lowest among White children and highest among Black children, who experienced 4.44 times more neighborhood firearm violence exposure (95% CI=4.33, 4.56, p<0.001) than White children. The pandemic increased exposure by 27% in the lowest risk group (i.e., White children; 95% CI=20%, 34%, p<0.001), but pandemic effects were even greater for children in nearly all non-White categories. Baseline violence levels and racial disparities varied considerably by region, with the highest levels in the South and the largest magnitude disparities observed in the Northeast and Midwest. CONCLUSIONS: Large-scale racial disparities exist in child exposure to neighborhood firearm violence, and these disparities grew during the pandemic. Equitable access to trauma-informed programs, community-based prevention, and structural reforms are urgently needed.

Evaluation of an Experimental Web-based Educational Module on Opioid-related Occupational Safety Among Police Officers: Protocol for a Randomized Pragmatic Trial to Minimize Barriers to Overdose Response.

BACKGROUND: As drug-related morbidity and mortality continue to surge, police officers are on the front lines of the North American overdose (OD) crisis. Drug law enforcement shapes health risks among people who use drugs (PWUD), while also impacting the occupational health and wellness of officers. Effective interventions to align law enforcement practices with public health and occupational safety goals remain underresearched. OBJECTIVE: The Opioids and Police Safety Study (OPS) aims to shift police practices relating to PWUD. It adapts and evaluates the relative effectiveness of a curriculum that bundles content on public health promotion with occupational risk reduction (ORR) to supplement a web-based OD response and naloxone training platform (GetNaloxoneNow.org, or GNN). This novel approach has the potential to improve public health and occupational safety practices, including using naloxone to reverse ODs, referring PWUD to treatment and other supportive services, and avoiding syringe confiscation. METHODS: This longitudinal study uses a randomized pragmatic trial design. A sample of 300 active-duty police officers from select counties in Pennsylvania, Vermont, and New Hampshire with high OD fatality rates will be randomized (n=150 each) to either the experimental arm (GNN + OPS) or the control arm (GNN + COVID-19 ORR). A pre- and posttraining survey will be administered to all 300 officers, after which they will be administered quarterly surveys for 12 months. A subsample of police officers will also be qualitatively followed in a simultaneous embedded mixed-methods approach. Research ethics approval was obtained from the New York University Institutional Review Board. RESULTS: Results will provide an understanding of the experiences, knowledge, and perceptions of this sample of law enforcement personnel. Generalized linear models will be used to analyze differences in key behavioral outcomes between the participants in each of the 2 study arms and across multiple time points (anticipated minimum effect size to be detected, d=0.50). Findings will be disseminated widely, and the training products will be available nationally once the study is completed. CONCLUSIONS: The OPS is the first study to longitudinally assess the impact of a web-based opioid-related ORR intervention for law enforcement in the U.S. Our randomized pragmatic clinical trial aims to remove barriers to life-saving police engagement with PWUD/people who inject drugs by focusing both on the safety of law enforcement and evidence-based and best practices for working with persons at risk of an opioid OD. Our simultaneous embedded mixed-methods approach will provide empirical evaluation of the diffusion of the naloxone-based response among law enforcement. TRIAL REGISTRATION: ClinicalTrail.gov NCT05008523; https://clinicaltrials.gov/show/NCT05008523. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33451.

Experiences of Online Bullying and Offline Violence-Related Behaviors Among a Nationally Representative Sample of US Adolescents, 2011 to 2019.

BACKGROUND: Being bullied online is associated with being bullied in school. However, links between online bullying and violence-related experiences are minimally understood. We evaluated potential disparities in these associations to illuminate opportunities to reduce school-based violence. METHODS: We used five cohorts of Youth Risk Behavior Survey national cross-sectional data (2011-2019, Ntotal  = 73 074). We used survey-weighted logistic and multinomial models to examine links between online bullying and five school-based violence-related experiences: offline bullying, weapon carrying, avoiding school due to feeling unsafe, being threatened/injured with a weapon, and physical fighting. We examined interactions by sex, race/ethnicity, and sexual identity. RESULTS: Being bullied online was positively associated with all offline violence-related behaviors. Groups with stronger associations between online bullying and physical fighting, including boys, adolescents whose sexual identity was gay/lesbian or unsure, and many adolescents of color (Black, Hispanic/Latino, and Asian/Pacific Islander adolescents), had stronger associations between online bullying and either weapon carrying or avoiding school. CONCLUSIONS: Online bullying is not an isolated harmful experience; many marginalized adolescents who experience online bullying are more likely to be targeted in school, feel unsafe, get in fights, and carry weapons. Reduction of online bullying should be prioritized as part of a comprehensive school-based violence prevention strategy.

Automated Substance Use/Sexual Risk Reporting and HIV Test Acceptance Among Emergency Department Patients Aged 13-24 Years.

Despite federal guidelines, many adolescents and emerging adults are not offered HIV testing by their healthcare providers. As such, many-including those who may be at high-risk for contracting HIV given their sexual and/or substance use risk-are not routinely tested. The current study examines sexual risk and substance use among emergency department patients aged 13-24 years (n = 147), who completed an automated screening as part of a tablet-based intervention designed to increase HIV testing. Twenty seven percent (n = 39) of participants chose to test for HIV after completing the tablet-based intervention. Among this sample, sexual risk was a significant independent predictor of HIV testing (χ2 = 16.50, p < 0.001). Problem substance use (e.g. trying but failing to quit) also predicted testing (χ2 = 7.43, p < 0.01). When considering these behaviors together, analyses indicated that the effect of problem substance use (ß = 0.648, p = 0.154) on testing is explained by sexual risk behavior (ß = 1.425, p < 0.01). The study's findings underscore the value of using routine automated risk screenings to collect sensitive data from emergency department patients, followed by computer-based HIV test offers for adolescent youth. Our research indicates tablet-based interventions can facilitate more accurate reporting of sexual behavior and substance use, and can also potentially increase HIV test uptake among those at risk.

Mobile Augmented Screening to Increase HIV Testing Among Emergency Department Patients as Young as 13 Years.

Because adolescents and emerging adults are frequently not offered HIV testing, and often decline tests when offered, we developed and tested a tablet-based intervention to increase HIV test rates among emergency department (ED) patients aged 13-24 years. Pediatric and adult ED patients in a high volume New York City hospital (N = 295) were randomized to receive a face-to-face HIV test offer, or to complete a tablet-based intervention that contained an HIV test offer delivered via computer. Test rates in both conditions were then compared to historic test rates in the same ED during the previous six months. Among participants aged 19 years and younger who were offered HIV testing and declined before enrollment in the study, participants in the tablet-based condition were 1.7 times more likely to test for HIV compared to participants in the face-to-face condition. Participants aged 19 years and younger were three times as likely to test for HIV compared to patients the same age who were treated in the previous six months (26.39%, n = 71 study participants vs. 10.29%, n = 189 prior patients, OR = 3.13, [Formula: see text]2 = 54.76, p < 0.001). Protocols designed to offer HIV testing to all eligible patients can significantly increase adolescent test rates compared to standard practice. Because tablets are equally effective compared to face-to-face offers, and in some cases more so, EDs may consider tablet-based interventions that require fewer staff resources and may integrate more easily into high-volume workflows.

K-12 School Shootings: Implications for Policy, Prevention, and Child Well-Being.

Schools should be considered safe spaces for children; children need to feel secure in order to grow and learn. This article argues that when a school shooting occurs, the harm goes beyond those who are injured or killed, because the presumption of security is shattered, and the mental and emotional health of the students is threatened. There are many interventions for preventing these attacks at the school, state, and federal levels. This article explores evidence behind some of these interventions and describes the delicate balance in implementing interventions without introducing undue stress and anxiety into a child's everyday life.

Drug Transaction Experiences in American High Schools 2001-2015.

BACKGROUND: Among adolescents, the pathway from being offered drugs to engaging in drug use has been established. The prevalence of drug transactions specifically in schools is less understood. The purpose of this study was to identify the prevalence of adolescents who have reported drug transaction experiences (being offered, sold, or given an illegal drug) on school property and subsequently identify behavioral correlates associated with these experiences. METHODS: This study analyzed YRBS data from 2001 to 2015 (N = 117,815). We used 95% confidence intervals to evaluate differences in prevalence across years and demographic subgroups. Odds ratios determined the likelihood of engaging in risk behaviors among those youth also experiencing drug transactions on school property. RESULTS: Every survey year, at least 1 in 5 youth reported having drug transaction experiences at school. Boys consistently reported significantly higher rates of drug transaction experiences in comparison to girls, with Hispanic boys representing the highest rates. Youth reporting these experiences with drug transactions were also more likely to carry a weapon to school and to be bullied at school. CONCLUSIONS: Implications for the reduction of drug transactions in high schools are discussed and recommendations for prevention efforts addressing youth engagement in multiple risk behaviors are identified.

The importance of content and choice in a technology-based intervention to increase HIV testing.

Although the Centers for Disease Control and Prevention recommends routine HIV testing in emergency departments and other facilities, many patients are never offered testing, and those who are offered testing frequently decline. In response, our team developed and evaluated a series of differently configured technology-based interventions to explore how we can most effectively increase HIV testing among reluctant patients. The current study examines how different videos (onscreen physician vs. onscreen community member), and different intervention configurations (enabling some participants to select a video while others are assigned to watch a video or to view bullet-point text), could potentially increase self-efficacy to test for HIV among patients who had never tested. Analyses of data from 285 emergency department patients in New York City who declined HIV testing offered by hospital staff indicated that participants reported highly significant differences in self-efficacy depending on their history of previous testing, whether they were enabled to select a video or were assigned a video, and which video they watched. Participants who reported no previous testing reported significantly lower pre-test self-efficacy compared to those who had tested at least once before. Among those who had not previously tested, the greatest pre-post increases in self-efficacy were reported by participants who were randomly enabled to select an intervention video and chose to watch video depicting a physician. Our findings highlight the importance, not only of intervention content, but how that content is delivered to specific participants. These findings may inform more effective technology-based behavioral health interventions.

Youth exposure to violence involving a gun: evidence for adverse childhood experience classification.

Adverse childhood experiences (ACEs) have historically included child maltreatment, household dysfunction, and other critical issues known to impact children negatively. Although youth experiences with violence are broadly captured in some ACE measures, youth exposure to violence involving a gun has not been included specifically in the operationalizing, and therefore scientific study, of ACEs. There are numerous implications of this omission, including limiting access to ACE interventions that are currently available and resources for individuals who have been exposed to gun violence. Thus, and given the persistent prevalence of gun violence in the US, we conducted a systematic review of the literature over the past two decades on the assessment of and response to ACEs and gun violence. Eighty-one journal articles across four search engines met our inclusion criteria. Our findings provide evidence that youth gun violence exposure should be classified as an ACE. In addition to increasing access to resources for youth affected by gun violence, these findings may improve the likelihood of funding and research into gun violence, with direct implications for prevention and intervention efforts.

Maternal Self-Efficacy Is Protective for Child (but Not Mother) Body Mass Index Among Mexican-Origin Children with Negative Temperament.

OBJECTIVE: Childhood obesity persists as a serious public health concern, particularly among Mexican-origin youth. Teen mothers are also at heightened obesity risk. Multiple factors may exacerbate this risk, including stressors associated with parenting. Indeed, difficult child temperaments pose unique parenting challenges, which may also be linked to physical health outcomes in mothers. The purpose of this study was to examine whether the interaction between negative child temperament and parenting self-efficacy is related to the body mass index (BMI) of young children and their adolescent mothers while controlling for important contextual factors. We also examined which pathways differed for girls versus boys. METHODS: Data were from a longitudinal study spanning 5 years that included 204 Mexican-origin young mothers and their children (with data collected at birth, age 4 years, and age 5 years). A multigroup structural equation modeling framework was used. RESULTS: The rate of early childhood obesity was low in comparison with national averages, whereas the rate of adolescent mother obesity was notably higher than the national average. Negative child temperament was associated with higher child BMI among those adolescent mothers with low parenting self-efficacy. Among the children with a negative temperament, their mothers' high parenting self-efficacy may have served as a protective factor against unhealthy child BMI. This significant interaction held for both boys and girls. CONCLUSION: Research evaluating the potential effectiveness of interventions that promote parenting self-efficacy during early childhood as a means to reduce the rate of obesity among children of adolescent mothers should be conducted.

The Implementation of Mental Health Policies and Practices in Schools: An Examination of School and State Factors.

BACKGROUND: Poor mental health outcomes persist among adolescent youth. Secondary schools play a critical role in fostering positive mental health by implementing policies and practices grounded in evidence. The factors associated with implementation, however, are unclear. This study examines which school- and state-level factors are associated with improved implementation of mental health policies and practices at secondary schools across the United States. METHODS: US Centers for Disease Control and Prevention data stemming from 3 datasets (School Health Policies and Practices, School Health Profiles, and Youth Risk Behavior Surveillance System) surveys were integrated and analyzed. RESULTS: Health educator certification, school use of data during school improvement planning, presence of a health/safety coordinator, presence of a health council and state-provided health educator professional development in mental health and suicide prevention were each significantly positively associated with schools' implementation of mental health policies and practices. CONCLUSIONS: To promote improved implementation of mental health policies and practices in schools and provide better support for youth mental health outcomes, the use of certified health educators and health-related supports should be considered. State health and education agencies should undertake evaluations of its mental health practices to ensure the assistance they offer to schools is evidence based.

Implementation of Online Opioid Prevention, Recognition and Response Trainings for Laypeople: Year 1 Survey Results.

BACKGROUND: This article reports on the first implementation of an online opioid-overdose prevention, recognition and response training for laypeople. The training was disseminated nationally in November 2014. Between 2000 and 2014, U.S. opioid deaths increased by 200%. The importance of complementary approaches to reduce opioid overdose deaths, such as online training, cannot be overstated. OBJECTIVES: A retrospective evaluation was conducted to assess perceived knowledge, skills to intervene in an overdose, confidence to intervene, and satisfaction with the training. MEASUREMENTS: Descriptive statistics were used to report sample characteristics, compare experiences with overdose and/or naloxone between subgroups, and describe participants' satisfaction with the trainings. Z-ratios were used to compare independent proportions, and paired t-tests were used to compare participant responses to items pre- and posttraining, including perceived confidence to intervene and perceived knowledge and skills to intervene successfully. RESULTS: Between January and October 2015, 2,450 laypeople took the online training; 1,464 (59.8%) agreed to be contacted. Of these, 311 (21.2% of those contacted) completed the survey. Over 80% reported high satisfaction with content, format and mode of delivery and high satisfaction with items related to confidence and overdose reversal preparedness. Notably, 89.0% of participants felt they had the knowledge and skills to intervene successfully posttraining compared to 20.3% pretraining (z = -17.2, p <.001). Similarly, posttraining, 87.8% of participants felt confident they could successfully intervene compared to 24.4% pretraining (z = -15.9, p <.001). CONCLUSIONS: This study demonstrates the effectiveness of the GetNaloxoneNow.org online training for laypeople.

Heroin Use and Drug Injection among Youth Also Misusing Prescription Drugs.

OBJECTIVES: We identified the prevalence of nonmedical prescription drug use and its relationship to heroin and injection drug use in 4 nationally representative samples of adolescents. METHODS: We used the most recent data (2009-2015) from the Youth Risk Behavior Surveillance System (Ntotal= 61,132). Prevalence rates and 95% confidence intervals for prescription drug misuse, heroin use, and injection drug use were calculated across time points, sex, and race/ethnicity subgroups. Using odds ratios, we determined the likelihood of youth reporting nonmedical prescription drug use also reporting heroin and drug injection. RESULTS: In 2015, one in 6 adolescents reported recent prescription drug misuse. High rates of nonmedical prescription drug use persisted or increased among Hispanic boys, black boys, and "other" youth, while declining among white youth. Youth who used prescription drugs nonmedically at least once were 17.5 times more likely to have used heroin (CI: 13.7, 22.4) and 14.6 times more likely to have injected drugs (CI: 11.2, 19.2) in their lifetime. CONCLUSIONS: Public health programming focused on reducing prescription drug misuse also may reduce youth engagement in heroin and/or injection drug use. Preventive efforts to support communities of color in reducing rates of prescription drug misuse are crucial.