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.

Suicide-related behavior and firearm access among perpetrators of domestic violence subject to domestic violence protection orders.

Perpetrators of domestic violence (DV) may be a population at elevated risk of suicide. Domestic violence protection orders (DVPOs) can include the removal of firearms from the individual subjected to the order (i.e., the respondent) to protect the victim-survivor. While removal of firearms in a DVPO is designed to protect the victim-survivor; it may also prevent suicide of the respondent by reducing access to lethal means. Therefore, we examined the association of respondent suicide-related behaviors with firearm possession and weapon use in DV among a sample of granted DVPO petitions in King County, Washington (WA), United States from 2014 to 2020 (n = 2,537). We compared prevalence ratios (PR) of respondent firearm possession and use of firearms or weapons to threaten or harm by suicide-related behavior. Overall, respondent suicide-related behavior was commonly reported by petitioners (46 %). Approximately 30 % of respondents possessed firearms. This was similar between respondents with and without a history of suicide-related behavior (PR: 1.03; 95 % CI: 0.91-1.17). Respondents with a history of suicide-related behavior were 1.33 times more likely to have used firearms or weapons to threaten/harm in DV compared to those without a history of suicide-related behavior (44.1 % vs. 33.8 %; 95 % CI: 1.20-1.47). In conclusion, both firearm possession and suicide-related behaviors were common among DVPO respondents. History of suicide-related behavior may be a marker for firearm-related harm to the victim-survivor. Evaluations of DVPO firearm dispossession should consider both firearm-related injury of the victim-survivor and suicide of the respondent.

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.

Use of immigration status for coercive control in domestic violence protection orders.

In the context of domestic violence (DV), immigration-related circumstances can be exploited by an abuser to coerce and manipulate their partner. Using an intersectional structural framework, we examine how social structures overlaid with immigration-specific experiences operate to further enhance opportunities for abuse against immigrant women. We conducted a textual analysis to identify how socially constructed systems interact with a victim-survivor's immigration status to introduce more tools for abusers to engage in coercive control and/or acts of violence in a random sample of petitioners (i.e., victim-survivors) who were granted a Domestic Violence Protection Order (DVPO) in King County, WA (n = 3,579) from 2014-2016 and 2018-2020. We hand-reviewed textual petitioner narratives and identified n = 39 cases that discussed immigration-related circumstances and related acts of violence and coercion. These narratives included threats to contact authorities to interfere with an ongoing immigration process, deportation threats, and threats that would separate families. In many cases, petitioners indicated that immigration-related threats prevented them from leaving the violent partner, seeking help, or reporting the abuse. We also found mention of barriers for victims to receive protection and gain autonomy from further abuse including a lack of familiarity with US protections and laws, and restrictions on authorizations to work. These findings demonstrate that structurally created immigration-specific circumstances provide opportunities for threats and retaliation against victim-survivors by abusers and create barriers to seeking help initially. Policy should respond to anticipate these threats in the immigrant community and engage early responders (e.g., healthcare providers, law enforcement) to support victim-survivors from immigrant communities.

Effect of the Communities That Care Prevention System on Adolescent Handgun Carrying: A Cluster-Randomized Clinical Trial.

Importance: There is little information on upstream community-based interventions that reduce the prevalence of handgun carrying among adolescents, especially those growing up in rural areas. Objective: To test whether Communities That Care (CTC), a community-based prevention system focusing on risk and protective factors for behavioral problems early in life, reduces handgun carrying prevalence among adolescents growing up in rural areas. Design, Setting, and Participants: Community-randomized trial of 24 small towns in 7 states assigned randomly to the CTC or control group with outcomes assessed from 2003 to 2011. Participants were youths attending public schools in grade 5 who received consent from their parents to participate (77% of the eligible population) and were repeatedly surveyed through grade 12 with 92% retention. Analyses were conducted from June to November 2022. Interventions: A coalition of community stakeholders received training and technical assistance to install CTC, used local epidemiologic data to identify elevated risk factors and low protective factors for adolescent behavioral problems, and implemented tested preventive interventions for youth, their families, and schools. Main Outcomes and Measures: Handgun carrying (never vs at least once) operationalized in 2 ways: (1) prevalence of past-year handgun carrying, and (2) cumulative prevalence of handgun carrying from grade 6 through grade 12. Results: Overall, the 4407 study participants' mean (SD) age was 12 (.4) years in both CTC (2405 participants) and control (2002 participants) communities in grade 6; about one-half of participants in each group were female (1220 [50.7 %] in the CTC group and 962 [48.1%] in the control group). From grade 6 through grade 12, 15.5% of participants in CTC communities and 20.7% of those in control communities reported carrying a handgun at least once. Youths in CTC communities were significantly less likely to report handgun carrying at a given grade than those in control communities (odds ratio [OR], 0.73; 95% CI, 0.65-0.82). The most pronounced effects were observed in grade 7 (OR, 0.70; 95% CI, 0.42-0.99), grade 8 (OR, 0.58; 95% CI, 0.41-0.74), and grade 9 (OR, 0.65; 95% CI, 0.39-0.91). Cumulatively from grade 6 through grade 12, youths in CTC communities were significantly less likely to report handgun carrying at least once than those in control communities (OR, 0.76; 95% CI, 0.70-0.84). Overall, CTC reduced the prevalence of past-year handgun carrying by 27% at a given grade and by 24% cumulatively through grade 12. Conclusions and Relevance: In this study, CTC reduced the prevalence of adolescent handgun carrying in participating communities. Trial Registration: ClinicalTrials.gov Identifier: NCT01088542.

Rural-Urban Variation in the Association of Adolescent Violence and Handgun Carrying in the United States, 2002-2019.

Importance: Adolescent handgun carrying is associated with increased risk of firearm-related violence. Most evidence on adolescent handgun carrying is from urban areas, but these findings may not generalize to rural areas. Objective: To examine differences in associations of adolescent interpersonal violence with handgun carrying across the rural-urban continuum. Design, Setting, and Participants: This cross-sectional study used nationally representative data from the US National Survey on Drug Use and Health among adolescents aged 12 to 17 years from 2002 to 2019 to estimate time-varying prevalence ratios (PRs) and prevalence differences (PDs) between interpersonal violence and handgun carrying across the rural-urban continuum. Analyses were conducted in April to July 2022. Exposures: Any past-year serious fighting, group fighting, and attacking with intent to harm. Main Outcomes and Measures: Any past-year handgun carrying. Associations were estimated within county rural-urban strata using the US Department of Agriculture's Rural-Urban Continuum Codes. Results: In each year, the sample included a weighted count of almost 25 million adolescents, with 50.9% (95% CI, 50.2%-51.6%) males and 24.7% (95% CI, 23.8%-25.6%) Hispanic adolescents, 13.5% (95% CI, 12.8%-14.2%) non-Hispanic Black adolescents, and 51.8% (95% CI, 50.8%-52.8%) non-Hispanic White adolescents in 2019. More rural counties had less racial and ethnic diversity. For example, 81.1% (95% CI, 75.9%-85.4%) of adolescents were non-Hispanic White in the most rural counties vs 43.1% (95% CI, 41.7%-44.6%) of adolescents were non-Hispanic White in the most urban counties in 2019. Adolescent handgun carrying increased over time, with the largest increases in the most rural counties, where the prevalence of adolescent handgun carrying increased from 5.2% (95% CI, 3.8%-7.0%) in 2003 to 12.4% (95% CI, 8.9%-16.9%) in 2019. PRs for the association of violence and handgun carrying were greater in more urban counties. For example, in the most urban counties in 2019, adolescents involved in a group fight had 3.7 (95% CI, 2.9-4.8) times the prevalence of handgun carrying vs those not involved in a group fight; this PR was 3.1 (95% CI, 1.6-5.6) in the most rural counties. PDs were similar and, in some cases, larger in rural areas. For example, in the most urban counties in 2019, handgun carrying prevalence was 7.5% (95% CI, 5.7%-9.5%) higher among adolescents who were involved in a group fight compared with those who were not; this PD was 21.8% (95% CI, 8.2%-37.8%) in the most rural counties, where handgun carrying was more common. Conclusions and Relevance: This cross-sectional study found that associations of interpersonal violence with handgun carrying were stronger in relative terms in urban areas than in rural areas; however, a higher percentage of rural than urban adolescents carried handguns, resulting in a greater absolute prevalence of handgun carrying associated with violence in rural areas than in urban areas. These findings suggest opportunities for preventing handgun carrying-related harms may differ between rural and urban communities.

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.

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.

Cumulative Payments Through the Earned Income Tax Credit Program in Childhood and Criminal Conviction During Adolescence in the US.

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

Earned Income Tax Credit and Youth Violence: Findings from the Youth Risk Behavior Surveillance System.

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

Firearm ownership and access to healthcare in the U.S.: A cross-sectional analysis of six states.

Provider-led firearm storage counseling is a form of firearm suicide prevention intervention. Little research examines whether barriers to healthcare access for at-risk individuals limit this intervention's impact. This study explores the relationship between household firearm presence/storage practices and healthcare access/utilization using a cross-sectional analysis of the 2017 Behavioral Risk Factor Surveillance System (BRFSS), which included state-representative data from six states that completed the Firearm Safety and Healthcare Access Modules: California, Idaho, Kansas, Oregon, Texas, and Utah. Exposures were household firearm presence and firearm storage practices. Outcomes were lacking health insurance, not having a healthcare provider, inability to afford care, and no recent routine checkup. Logistic regression models adjusted for age, sex, education, employment, children in the household, and state of residency. Our analysis included 31,888 individuals; 31.1% reported a household firearm. Compared to those in firearm-owning households, those in non-firearm-owning households had higher odds of being uninsured (aOR 1.99, 95%CI 1.60-2.48), not having a provider (aOR 1.40, 95%CI 1.18-1.67), and reporting cost as a barrier to care (aOR 1.37, 95%CI 1.13-1.67). Among firearm-owning households, those with firearms stored loaded and unlocked had higher odds of lacking a personal healthcare provider (aOR 1.52, 95%CI 1.07-2.15) compared to individuals in homes where firearms were stored unloaded. Results indicate that while individuals in firearm-owning households are more likely than non-firearm owning households to have healthcare access, those in homes with the riskiest firearm storage practices had less access. Provider-led counseling may have limited reach for individuals in homes with risky firearm storage practices.

Neighborhood disadvantage and firearm injury: does shooting location matter?

BACKGROUND: Firearm violence is a public health problem that disparately impacts areas of economic and social deprivation. Despite a growing literature on neighborhood characteristics and injury, few studies have examined the association between neighborhood disadvantage and fatal and nonfatal firearm assault using data on injury location. We conducted an ecological Bayesian spatial analysis examining neighborhood disadvantage as a social determinant of firearm injury in Seattle, Washington. METHODS: Neighborhood disadvantage was measured using the National Neighborhood Data Archive disadvantage index. The index includes proportion of female-headed households with children, proportion of households with public assistance income, proportion of people with income below poverty in the past 12 months, and proportion of the civilian labor force aged 16 and older that are unemployed at the census tract level. Firearm injury counts included individuals with a documented assault-related gunshot wound identified from medical records and supplemented with the Gun Violence Archive between March 20, 2016 and December 31, 2018. Available addresses were geocoded to identify their point locations and then aggregated to the census tract level. Besag-York-Mollie (BYM2) Bayesian Poisson models were fit to the data to estimate the association between the index of neighborhood disadvantage and firearm injury count with a population offset within each census tract. RESULTS: Neighborhood disadvantage was significantly associated with the count of firearm injury in both non-spatial and spatial models. For two census tracts that differed by 1 decile of neighborhood disadvantage, the number of firearm injuries was higher by 21.0% (95% credible interval: 10.5, 32.8%) in the group with higher neighborhood disadvantage. After accounting for spatial structure, there was still considerable residual spatial dependence with 53.3% (95% credible interval: 17.0, 87.3%) of the model variance being spatial. Additionally, we observed census tracts with higher disadvantage and lower count of firearm injury in communities with proximity to employment opportunities and targeted redevelopment, suggesting other contextual protective factors. CONCLUSIONS: Even after adjusting for socioeconomic factors, firearm injury research should investigate spatial clustering as independence cannot be able to be assumed. Future research should continue to examine potential contextual and environmental neighborhood determinants that could impact firearm injuries in urban communities.