Racial and ethnic differences in the effects of state firearm laws: a systematic review subgroup analysis.

BACKGROUND: Despite growing evidence about how state-level firearm regulations affect overall rates of injury and death, little is known about whether potential harms or benefits of firearm laws are evenly distributed across demographic subgroups. In this systematic review, we synthesized available evidence on the extent to which firearm policies produce differential effects by race and ethnicity on injury, recreational or defensive gun use, and gun ownership or purchasing behaviors. MAIN BODY: We searched 13 databases for English-language studies published between 1995 and February 28, 2023 that estimated a relationship between firearm policy in the USA and one of eight outcomes, included a comparison group, evaluated time series data, and provided estimated policy effects differentiated by race or ethnicity. We used pre-specified criteria to evaluate the quality of inference and causal effect identification. By policy and outcome, we compared policy effects across studies and across racial/ethnic groups using two different ways to express effect sizes: incidence rate ratios (IRRs) and rate differences. Of 182 studies that used quasi-experimental methods to evaluate firearm policy effects, only 15 estimated policy effects differentiated by race or ethnicity. These 15 eligible studies provided 57 separate policy effect comparisons across race/ethnicity, 51 of which evaluated interpersonal violence. In IRR terms, there was little consistent evidence that policies produced significantly different effects for different racial/ethnic groups. However, because of different baseline homicide rates, similar relative effects for some policies (e.g., universal background checks) translated into significantly greater absolute differences in homicide rates among Black compared to white victims. CONCLUSIONS: The current literature does not support strong conclusions about whether state firearm policies differentially benefit or harm particular racial/ethnic groups. This largely reflects limited attention to these questions in the literature and challenges with detecting such effects given existing data availability and statistical power. Findings also emphasize the need for additional rigorous research that adopts a more explicit focus on testing for racial differences in firearm policy effects and that assesses the quality of race/ethnicity information in firearm injury and crime datasets.

America's Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms.

Opioids play an outsized role in America's drug problems, but they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids (such as fentanyl) are involved in a majority of U.S. drug overdoses, but the problems are broader and deeper than drug fatalities. Depending on the drugs involved, there can be myriad physical and mental health consequences associated with having a substance use disorder. And it is not just those using drugs who suffer. Substance use and related behaviors can significantly affect individuals' families, friends, employers, and wider communities. Efforts to address problems related to opioids are insufficient and sometimes contradictory. Researchers provide a nuanced assessment of America's opioid ecosystem, highlighting how leveraging system interactions can reduce addiction, overdose, suffering, and other harms. At the core of the opioid ecosystem are the individuals who use opioids and their families. Researchers also include detail on ten major components of the opioid ecosystem: substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education. The primary audience for this study is policymakers, but it should also be useful for foundations looking for opportunities to create change that have often been overlooked. This study can help researchers better consider the full consequences of policy changes and help members of the media identify the dynamics of interactions that deserve more attention.

Diversity in U.S. Military Families: An Environmental Scan of the Peer-Reviewed Literature on Race and Ethnic Variation for Select Well-Being Outcomes.

Researchers explore the literature on race and ethnicity (R/E) in relation to U.S. military service member well-being in the areas of mental health, behavioral health, family violence, marital satisfaction, and financial stress to uncover whether past research has focused on R/E differences in outcomes as a driving research question; the variables used to capture R/E; and the quality of research in terms of design, data, and analysis. The Department of Defense (DoD) has expressed commitment to improving diversity and inclusion in the military. If leaders seek to do this based on existing evidence, they will find that information about how R/E intersects with the well-being of service members and their families is extremely limited. DoD should consider developing a deliberate, strategic, and comprehensive research agenda on R/E diversity in service member and family well-being outcomes. This will help DoD identify where differences exist and where policies and programs can address those gaps.

Availability and Accessibility of Mental Health Services in New York City.

Mental health services are critical components of public health infrastructure that provide essential supports to people living with psychiatric disorders. In a typical year, about 20 percent of people will have a psychiatric disorder, and about 5 percent will experience serious psychological distress, indicating a potentially serious mental illness. Nationally, the use of mental health services is low, and the use of care is not equitably distributed. In the United States as a whole and in New York City (NYC), non-Hispanic white individuals are more likely to use mental health services than non-Hispanic black individuals or Hispanic individuals. The challenges of ensuring the availability of mental health services for all groups in NYC are particularly acute, given the size of the population and its diversity in income, culture, ethnicity, and language. Adding to these underlying challenges, the coronavirus disease 2019 (COVID-19) pandemic has disrupted established patterns of care. To advance policy strategy for addressing gaps in the mental health services system, RAND researchers investigate the availability and accessibility of mental health services in NYC. The RAND team used two complementary approaches to address these issues. First, the team conducted interviews with a broad group of professionals and patients in the mental health system to identify barriers to care and potential strategies for improving access and availability. Second, the team investigated geographic variations in the availability of mental health services by compiling and mapping data on the locations and service characteristics of mental health treatment facilities in NYC.

Improving Outcomes for Children Exposed to Violence: Safe Start Promising Approaches.

Children's exposure to violence is common and can lead to mental health problems and delinquent behaviors. Because many interventions have focused on specific violence types or symptoms and been difficult to implement in real-world settings, the evidence base is still emerging. The Office of Juvenile Justice and Delinquency Prevention's Safe Start Promising Approaches (SSPA) initiative focused on preventing and reducing the impact of children's exposure to violence through interventions in ten diverse communities. The evaluation examined the effectiveness of the SSPA interventions to address issues for children and families exposed to violence. The ten sites were diverse in their intervention approaches, types of violence exposure targeted, and implementation settings. To evaluate each approach's effectiveness in reducing violence's harmful effects, RAND researchers partnered with the community-based sites to develop a rigorous controlled evaluation design for each intervention, with either a randomized control group or a comparison group selected on similar characteristics. The longitudinal analyses found that families in both the intervention and comparison groups had positive gains on many outcomes, but there was no evidence that the intervention groups improved more. Among those who received Safe Start services, one site produced large, significant improvements in posttraumatic stress disorder symptoms, and another site produced medium, significant effects on several outcomes (child self-control, posttraumatic stress disorder, and behavior; caregiver depression; and family conflict). Although the initiative added to knowledge about how to address the problem, there was no clear case for using a particular intervention to help these children and their families.

Characteristics and Proximal Outcomes of Calls Made to Suicide Crisis Hotlines in California.

BACKGROUND: Suicide hotlines are commonly used to prevent suicides, although centers vary with respect to their management and operations. AIMS: To describe variability across suicide prevention hotlines. METHOD: Live monitoring of 241 calls was conducted at 10 suicide prevention hotlines in California. RESULTS: Call centers are similar with respect to caller characteristics and the concerns callers raise during their calls. The proportion of callers at risk for suicide varied from 3 to 57%. Compliance with asking about current suicide risk, past ideation, and past attempts also ranged considerably. Callers to centers that were part of the National Suicide Prevention Lifeline (NSPL) were more likely to experience reduced distress than callers to centers that were not part of the NSPL. CONCLUSION: Because callers do not generally choose the center or responder that will take their call, it is critical to promote quality across call centers and minimize the variability that currently exists. Accrediting bodies, funders, and crisis centers should require that centers continuously monitor calls to ensure and improve call quality.

RAND's Silent Monitoring Protocol for Assessing Suicide Crisis Line Call Content and Quality.

This article describes the methods for developing and testing a silent monitoring protocol for California suicide crisis call centers to evaluate call content and quality, document staff strengths and weaknesses, and identify areas for further training.

Access to Behavioral Health Care for Geographically Remote Service Members and Dependents in the U.S.

With many service members now returning to the United States from the recent conflicts in Iraq and Afghanistan, concern over adequate access to behavioral health care (treatment for mental, behavioral, or addictive disorders) has risen. Yet data remain very sparse regarding how many service members (and their dependents) reside in locations remote from behavioral health providers, as well as the resulting effect on their access to and utilization of care. Little is also known about the effectiveness of existing policies and other efforts to improve access to services among this population. To help fill these gaps, a team of RAND researchers conducted a geospatial analysis using TRICARE and other data, finding that roughly 300,000 military service members and 1 million dependents are geographically distant from behavioral health care, and an analysis of claims data indicated that remoteness is associated with lower use of specialty behavioral health care. A review of existing policies and programs discovered guidelines for access to care, but no systematic monitoring of adherence to those guidelines, limiting their value. RAND researchers recommend implementing a geospatial data portal and monitoring system to track access to care in the military population and mark progress toward improvements in access to care. In addition, the RAND team highlighted two promising pathways for improving access to care among remote military populations: telehealth and collaborative care that integrates primary care with specialty behavioral care.

Care Transitions to and from the National Intrepid Center of Excellence (NICoE) for Service Members with Traumatic Brain Injury.

Improvised explosive devices (IEDs) have been one of the leading causes of death and injury among U.S. troops. Those who survive an IED blast or other injuries may be left with a traumatic brain injury (TBI) and attendant or co-occurring psychological symptoms. In response to the need for specialized services for these populations, the U.S. Department of Defense (DoD) established the National Intrepid Center of Excellence (NICoE) in Bethesda, Maryland, in 2010. The NICoE's success in fulfilling its mission is impacted by its relationships with home station providers, patients, and their families. The RAND Corporation was asked to evaluate these relationships and provide recommendations for strengthening the NICoE's efforts to communicate with these groups to improve patients' TBI care. Through surveys, site visits, and interviews with NICoE staff, home station providers, service members who have received care at the NICoE, and the families of these patients, RAND's evaluation examined the interactions between the NICoE and the providers responsible for referring patients and implementing treatment plans.

Suicide Postvention in the Department of Defense: Evidence, Policies and Procedures, and Perspectives of Loss Survivors.

The U.S. Department of Defense (DoD) has been struggling with increasing rates of suicide among military personnel for the past decade. As DoD continues to implement new programs and examine its policies in an effort to prevent military personnel from taking their own lives, it is important to assess its current responses to suicide and to identify opportunities to enhance these programs and policies. Unfortunately, there is little scientific evidence on how best to respond to suicides, how to ensure that surveillance activities are managed appropriately and that loss survivors are given sufficient support to grieve, how additional suicides can be prevented, and how to honor and respect the decedent and his or her loved ones. At the same time, there are many resource guides intended to provide recommendations for organizations (mostly schools) in responding to suicides. A review of the existing scientific evidence on postvention (responses to prevent additional suicides in the aftermath of a suicide) and guidance for other types of organizations provides potential insights for DoD, however. Complemented by the perspectives of those most intimately touched by military suicide-the family and friends of those who have died-these sources may help DoD formulate its guidance in a practical and sensitive way.

A Case Study Evaluating the Fidelity of Suicide Prevention Workshops in California.

Reports on an evaluation of California suicide intervention training workshops to provide evidence that training is delivered with fidelity and adherence to the workshop's design, as well as with high quality.

How much does "how much" matter? Assessing the relationship between children's lifetime exposure to violence and trauma symptoms, behavior problems, and parenting stress.

The study explores whether and how lifetime violence exposure is related to a set of negative symptoms: child internalizing and externalizing behavior problems, child trauma symptoms, and parenting stress. Using a large sample of violence-exposed children recruited to participate in intervention research, the study employs different methods of measuring that exposure. These include total frequency of all lifetime exposure, total frequency of lifetime exposure by broad category (i.e., assault, maltreatment, sexual abuse, and witnessing violence), and polyvictimization defined as exposure to multiple violence categories. The results indicate that only polyvictimization, constructed as a dichotomous variable indicating two or more categories of lifetime exposure, emerged as a consistent predictor of negative symptoms. The total lifetime frequency of all violence exposure was not associated with negative symptoms, after controlling for the influence of polyvictimization. Likewise, in the presence of a dichotomous polyvictimization indicator the total lifetime frequency of exposure to a particular violence category was unrelated to symptoms overall, with the exception of trauma symptoms and experiences of sexual abuse. Taken together, these findings suggest that total lifetime exposure is not particularly important to negative symptoms, nor is any particular category of exposure after controlling for polyvictimization, with the single exception of sexual abuse and trauma symptoms. Instead, it is the mix of exposure experiences that predict negative impacts on children in this sample. Further research is needed to continue to explore and test these issues.

An examination of measures related to children's exposure to violence for use by both practitioners and researchers.

Millions of children each year are exposed to violence in their homes, schools, and communities as both witnesses and victims. As a result, evidence-based programs for children and adolescents who have been exposed to traumatic events (CEV-EBPs) have been widely disseminated but rarely evaluated in their real-world applications. One crucial aspect of conducting such evaluations is finding appropriate measures that can be of use both to the practitioner and to the researcher. This review aims to provide guidance to the field by first identifying any gaps in the availability of psychometrically tested measures for certain outcome domains and age ranges and then recommending the measures that are most appropriate for use by both researchers and practitioners. Interviews with content experts in the measurement of trauma symptoms and parent-child relationships were conducted to identify the key outcome domains for measurement that are critical to the evaluation of CEV-EBPs and the criteria for dual-use measures, defined as measures that are useful to both researchers and practitioners. A database of 46 relevant measures was created by compiling measures from existing repositories and conducting a focused literature review. Our review of these measures found that existing repositories had few measures of depression, a major gap that should be addressed. Further, there were few measures for young children ages 0-3 years (n = 15) and only a handful of measures (n = 9) had both a child and parent version of the measure. Overall, although the different repositories that currently exist are helpful, researchers and practitioners would benefit from having a single reputable source (e.g., a centralized repository or item bank) to access when searching for measures to use in evaluating CEV-EBPs. Such a tool would hold promising to narrow the current gap between research and practice in the field of children's exposure to violence.

National Evaluation of Safe Start Promising Approaches: Assessing Program Implementation.

Children's exposure to violence (CEV)-including direct child maltreatment, witnessing domestic violence, and witnessing community and school violence-can have serious consequences, including a variety of psychiatric disorders and behavioral problems, such as posttraumatic stress disorder, depression, and anxiety. Fortunately, research has shown that interventions for CEV can substantially improve children's chances of future social and psychological well-being. Safe Start Promising Approaches (SSPA) was the second phase of a planned four-phase initiative focusing on preventing and reducing the impact of CEV, sponsored by the U.S. Department of Justice's Office of Juvenile Justice and Delinquency Prevention (OJJDP). OJJDP selected 15 program sites across the country that proposed a range of intervention approaches, focused on multiple types of violence, included variations in ages and age-appropriate practices, and would be implemented in different settings. Each site participated in a national evaluation, conducted by the RAND Corporation. The evaluation design involved three components: a process evaluation, an evaluation of training, and an outcomes evaluation. This article presents the results of the first two evaluations. It describes the program and community settings, interventions, and implementations of the 15 SSPA programs for the first two years of implementation (through March 2009), as well as the training evaluation results.

Toolkit for Adapting Cognitive Behavioral Intervention for Trauma in Schools (CBITS) or Supporting Students Exposed to Trauma (SSET) for Implementation with Youth in Foster Care.

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was developed for use by school-based mental health professionals for any student with symptoms of distress following exposure to trauma. Supporting Students Exposed to Trauma (SSET) was adapted from CBITS for use by any school personnel with the time and interest to work with students affected by trauma. The purpose of this toolkit is to assist school-based mental health professionals, school personnel, and child welfare social workers in adapting these interventions for use with youth aged 10-15 who are in foster care. The authors note that delivering a school-based mental health program to youth in foster care has many challenges, including collaboration between the child welfare and education systems, confidentiality and information sharing policies regarding youth in foster care, and identification of these youth. The toolkit was designed to help understand these challenges and provide strategies for addressing them.

National Evaluation of Safe Start Promising Approaches.

Safe Start Promising Approaches (SSPA) is the second phase of a community-based initiative focused on developing and fielding interventions to prevent and reduce the impact of children's exposure to violence (CEV). This article shares the results of SSPA, which was intended to implement and evaluate promising and evidence-based programs in community settings. Fifteen program sites across the country were selected to implement a range of interventions for helping children and families cope with the effects of CEV. The settings, populations served, intervention types, types of violence addressed, community partners, and program goals differed across the 15 sites.