Studying "exposure" to firearms: household ownership v access.

BACKGROUND: Firearm ownership has often been used to measure access to weapons. However, persons who own a firearm may not have access to it and conversely, persons who do not own a firearm may be able to access one quickly. OBJECTIVES: To examine whether using firearm ownership is a reasonable proxy for access by describing the demographic characteristics associated with ownership and access. METHODS: Data are from the 1994 Injury Control and Risk Survey, a national, random digit dial survey. Information about household firearm ownership and ready access to a loaded firearm were collected and weighted to provide national estimates. Adjusted odds ratios for three separate models were calculated using logistic regression. RESULTS: A total of 1353 (27.9%) respondents reported both having a firearm in the household and ready access to one. An additional 313 respondents (8.1%) reported having a firearm, but were not able to access these weapons. Another 421 respondents (7.2%) did not have a firearm in or around their home, yet reported being able to retrieve and fire one within 10 minutes. Based on the logistic regression findings, the demographic characteristics of this latter group are quite different from those who report ownership. Those who do not have a firearm, but report ready access to one, are more likely to be ethnic minorities, single, and living in attached homes. CONCLUSIONS: Asking only about the presence of a firearm in a household may miss some respondents with ready access to a loaded firearm. More importantly, those who do not own a firearm, but report ready access to one, appear to be qualitatively different from those who report ownership. Caution should be exercised when using measures of ownership as a proxy for access.

Youth violence. Developmental pathways and prevention challenges.

Youth violence is an important public health problem. During the latter half of the 1980s and early 1990s, the United States witnessed unprecedented levels of violence among the nation's youths. Homicide remains one of the leading causes of death for young people aged 10 to 24 years. This paper reviews the major trends in homicide victimization and perpetration among youths during the past decade, the developmental pathways of delinquent and violent behavior and the context in which these behaviors occur, and some of the challenges associated with disrupting these pathways and preventing violence. Previous research reveals that multiple pathways lead toward violence and delinquency. Predicting which pathway a youth will follow, or if one will be followed at all, depends to some extent on a host of other biological, psychosocial, and environmental factors present as young people transition from early childhood to adolescence to early adulthood. Preventing violence requires a comprehensive approach that takes into account developmental needs, tasks, and supports.

Predictors of injury from fighting among adolescent males.

OBJECTIVES: To identify violence related behaviors associated with injuries among adolescent males involved in fights. METHODS: Data from the National Longitudinal Study of Adolescent Health were used to develop weighted estimates of injury prevalence and associations between injury and violence related behaviors. RESULTS: Forty seven per cent injured others and 18% were themselves injured in a fight among adolescent males in the preceding 12 months. Group fighting, fighting with strangers, and weapon use were predictive of injury in this sample. CONCLUSIONS: These findings suggest that injuries associated with fighting are a health risk among adolescent males. Certain behaviors, such as fighting in groups and fighting with strangers, increase the likelihood of injuries requiring medical attention.

Partner violence, partner notification, and women's decisions to have an HIV test.

OBJECTIVES: Reports of partner violence against HIV-positive women after they have disclosed their serostatus have led some to reassess partner notification strategies and to speculate that fear of partner violence following partner notification may influence women's HIV testing decisions. We studied whether associations exist between women's declining to have an HIV test and history of partner violence, fear of partner violence, previous experience with partner notification, or beliefs about partner notification. METHODS: In this cross-sectional study, we interviewed women seen at Newark and Miami sexually transmitted disease clinics. The women were at least 18 years old, not known to be HIV positive, not tested for HIV in the previous 3 months, and offered HIV testing during the clinic visit. Women who declined testing were compared with women who accepted. RESULTS: Of 490 participants (89% of eligible women), 16% reported partner violence in the past year, and 28% declined HIV testing. Declining the test was not significantly (p >.05) associated with history or fear of partner violence, previous experience with partner notification, or beliefs about partner notification. When specifically asked, only 2 women responded that their declining the test was related to fear that their partner or partners might harm them if the women tested positive. CONCLUSIONS: Among women seen at these clinics, we did not find evidence that declining the HIV test was strongly influenced by partner violence, previous experience with partner notification, or beliefs about partner notification. However, many women reported partner violence. Therefore, providers should assess the potential for partner violence and be prepared to make appropriate referrals.

Students who carry weapons to high school: comparison with other weapon-carriers.

PURPOSE: To determine if those who have recently carried a weapon on school grounds differ from those who carry weapons elsewhere. We hypothesized that involvement in other problem behaviors and exposure to school crime and violence would be associated with risk for weapon carrying on school grounds. METHODS: The data for this study were from the 1995 Youth Risk Behavior Survey of 10,904 high school students. Logistic regression analysis was used to examine risk for weapon carrying on school grounds. RESULTS: Among the students who carried a weapon, 48% carried a weapon on school grounds. Female gender, lower parental education levels, substance use on school grounds, involvement in physical fights, exposure to school crime and violence, frequency of weapon-carrying, and gun carrying distinguished students who carried weapons on school grounds from those who carried weapons off school grounds. CONCLUSIONS: The results suggest that weapon-carrying on school grounds is associated with individual and school-related characteristics. Efforts to reduce weapon-carrying on school grounds might focus on reduction of students' actual and perceived vulnerability to victimization, as well as by helping students understand that other problem behaviors increase their risk for violence.

Youth violence in the United States. Major trends, risk factors, and prevention approaches.

Violence among youths is an important public health problem. Between 1985 and 1991, homicide rates among youths 15-19 years of age increased 154% and remain, today, at historically high levels. This paper reviews the major trends in homicide victimization and perpetration among youths over the last decade, the key risk factors associated with violence, and summarizes the many primary prevention efforts under way to reduce violence. Previous research points to a number of factors that increase the probability of violence during adolescence and young adulthood. Some of these factors include the early onset of aggressive behavior in childhood, social problem-solving skill deficits, exposure to violence, poor parenting practices and family functioning, negative peer influences, access to firearms, and neighborhoods characterized by high rates of poverty, transiency, family disruption, and social isolation. Efforts to address some of the primary risk factors for violence are under way across the United States, but evaluations to confirm program effectiveness are needed.

Firearm-related deaths in the United States and 35 other high- and upper-middle-income countries.

BACKGROUND: The Forty-Ninth World Health Assembly recently declared violence a worldwide public health problem. Improved understanding of cross-national differences is useful for identifying risk factors and may facilitate prevention efforts. Few cross-national studies, however, have explored firearm-related deaths. We compared the incidence of firearm-related deaths among 36 countries. METHODS: Health officials in high-income (HI) and upper-middle-income countries (UMI) with populations greater than one million were asked to provide data using ICD-9 codes on firearm-related homicides, suicides, unintentional deaths and deaths of undetermined intent, as well as homicides and suicides for all methods combined. Thirty-six (78%) of the 46 countries provided complete data. We compared age-adjusted rates per 100,000 for each country and pooled rates by income group and geographical location. RESULTS: During the one-year study period, 88,649 firearm deaths were reported. Overall firearm mortality rates are five to six times higher in HI and UMI countries in the Americas (12.72) than in Europe (2.17), or Oceania (2.57) and 95 times higher than in Asia (0.13). The rate of firearm deaths in the United States (14.24 per 100,000) exceeds that of its economic counterparts (1.76) eightfold and that of UMI countries (9.69) by a factor of 1.5. Suicide and homicide contribute equally to total firearm deaths in the US, but most firearm deaths are suicides (71%) in HI countries and homicides (72%) in UMI countries. CONCLUSIONS: Firearm death rates vary markedly throughout the industrialized world. Further research to identify risk factors associated with these variations may help improve prevention efforts.

Suicide after natural disasters.

BACKGROUND: Among the victims of floods, earthquakes, and hurricanes, there is an increased prevalence of post-traumatic stress disorder and depression, which are risk factors for suicidal thinking. We conducted this study to determine whether natural disasters affect suicide rates. METHODS: From a list of all the events declared by the U.S. government to be federal disasters between 1982 and 1989, we selected the 377 counties that had each been affected by a single natural disaster during that period. We collected data on suicides during the 36 months before and the 48 months after the disaster and aligned the data around the month of the disaster. Pooled rates were calculated according to the type of disaster. Comparisons were made between the suicide rates before and those after disasters in the affected counties and in the entire United States. RESULTS: Suicide rates increased in the four years after floods by 13.8 percent, from 12.1 to 13.8 per 100,000 (P<0.001), in the two years after hurricanes by 31.0 percent, from 12.0 to 15.7 per 100,000 (P<0.001), and in the first year after earthquakes by 62.9 percent, from 19.2 to 31.3 per 100,000 (P<0.001). The four-year increase of 19.7 percent after earthquakes was not statistically significant. Rates computed in a similar manner for the entire United States were stable. The increases in suicide rates were found for both sexes and for all age groups. The suicide rates did not change significantly after tornadoes or severe storms. CONCLUSIONS: Our study shows that suicide rates increase after severe earthquakes, floods, and hurricanes and confirms the need for mental health support after severe disasters.

Nurses' logs as an evaluation tool for school-based violence prevention programs.

Programs for preventing violence among youth should be evaluated to determine if they are effective. Nurses' logs appear to be a useful tool for evaluating school-based violence prevention programs. The logs provide a record of students' visits to the school nurse that can be used to determine if a violence prevention program is associated with a reduction in fighting- and other injury-related nurse visits. This method has many strengths: it is simple and inexpensive, it does not interrupt the school routine, it permits school-level rather than student-level data collection, it provides a ready "baseline," and it allows continuous data collection. However, potential limitations do exist. For example, the method may provide insufficient information and may be affected by factors unrelated to the intervention. School officials can increase the usefulness of the logs by encouraging standardization and providing training in their use.

Estimating intruder-related firearm retrievals in U.S. households, 1994.

To estimate the frequency of firearm retrieval because of a known or presumed intruder, the authors analyzed data from a 1994 national random digit dialing telephone survey (n = 5,238 interviews). Three mutually exclusive definitions of firearm retrieval were constructed: (1) retrieved a firearm because there might be an intruder, (2) retrieved a firearm and saw an intruder, and (3) retrieved a firearm, saw an intruder, and believed the intruder was frightened away by the gun. Of 1,678 (34%) households with firearms, 105 (6%) retrieved a firearm in the previous 12 months because of an intruder. National projections based on these self-reports reveal an estimated 1,896,842 (95% CI [confidence interval] = 1,480,647-2,313,035) incidents in which a firearm was retrieved, but no intruder was seen; 503,481 (95% CI = 305,093-701,870) incidents occurred in which an intruder was seen, and 497,646 (95% CI = 266,060-729,231) incidents occurred in which the intruder was seen and reportedly scared away by the firearm. Estimates of the protective use of firearms are sensitive to the definitions used. Researchers should carefully consider both how these events are defined and the study methods used.

The impact of an elementary school-based violence prevention program on visits to the school nurse.

INTRODUCTION: In Tucson, Arizona, an elementary school-based violence prevention program (PeaceBuilders) was implemented during the 1994-1995 school year. Anecdotal evidence from school nurses suggested that children were visiting the nurse less often following the implementation of the program. We examined nurses' logs to assess whether the program had an impact on visits to the school nurse. METHODS: For the school years 1993-1994 and 1994-1995, the weekly number of nurse visits for all reasons, all injuries, and injuries caused by fights in each of the four PeaceBuilders schools were compared with those for three control schools. As part of a planned evaluation, schools had been matched on demographic factors and randomly assigned as intervention or control schools. RESULTS: Between 1993-1994 and 1994-1995, the rate of visits/1,000 student days decreased 12.6% in the intervention schools while remaining unchanged in the comparison schools. The same trend was detected for injury-related visits. Rates of fighting-related injuries changed little in the intervention schools but increased 56.0% in the control schools. An analysis of covariance confirmed that injuries and visits to nurses decreased in intervention schools relative to control schools. CONCLUSIONS: These data indicate that in the intervention schools, injuries and visits to the school nurse decreased over the two-year period and that the intervention may have contributed to this change. They also suggest that visits to the school nurses' office may be a useful tool to evaluate some types of elementary school-based violence prevention programs.

Prevention of youth violence: rationale and characteristics of 15 evaluation projects.

Interpersonal violence is a major cause of injury, disability, and death, especially among youth. Evaluations of 15 youth violence-prevention projects are under way. Public health is concerned about health problems that need to be addressed via collective action. Public health involvement in addressing interpersonal violence among youths brings an emphasis on primary prevention, a systematic and scientific process, and integrative leadership. Few quantitative evaluations of violence-prevention projects have been done. The interventions are scientifically based and use a spectrum of strategies. Individually oriented strategies are more common than those directed toward peers, families, schools, or communities. Each project has a rigorous evaluation design. Twelve are randomized. Sample sizes range from 180 to 10,000. Participants range in age from 5 to 18 years, although most are in the middle-school years (11-14 years). At baseline, intervention and comparison groups are similar. Baseline data demonstrate high frequency of violent behavior, weapon carrying, and exposure to violence among the youthful participants. Field intervention and evaluation research is difficult and expensive. Difficulties encompass organizational programatic, and scientific issues; these difficulties reduce scientific interest and financial support for projects such as these. Public health has an important role to play in reducing violence. These projects will make important contributions to that task.

Using multimedia to teach conflict-resolution skills to young adolescents.

SMART Talk is a multimedia, computer-based violence-prevention intervention that employs games, simulations, graphics, cartoons, and interactive interviews to engage young adolescents in learning new skills to resolve conflicts without violence. Eight modules cover anger management, dispute resolution, and perspective taking. SMART Talk was pilot-tested in a small-city middle school during a three-week period. After the pilot testing, SMART Talk was implemented in a middle school (sixth, seventh, and eighth grades) with a diverse socioeconomic population, located within 10 miles of a major Midwestern metropolis. The 16-week intervention began in January. Students had access to SMART Talk during the school day and could use the computer alone or with a partner. Subjects for whom parental permission (n = 558) was granted were given a preintervention and postintervention survey. The survey measured demographic, psychosocial, and environmental factors as well as aggressive and other violence-related behaviors. After the pretest, two teams from each grade were randomly assigned to the intervention group and one team to the control group. Only students in the intervention group had access to SMART Talk during the 16-week intervention period. After the posttest, control subjects had access to SMART Talk. Additional data for the evaluation were collected through archival records of grades and school disciplinary actions. All variables indicated comparability between intervention and control groups. As a population, 84% of the students were Caucasian and 9% were African American. Psychosocial variables indicated 30-day frequently angry (64%), 30-day depression (15%), and impulsivity (28%). Environmental variables indicated that 68% reported they could get a gun easily, 59% feel unsafe in their neighborhood, and 24% were personally affected by violence. Violence-related variables indicated 30-day threatened to hit (45%), 30-day hit someone (56%), bullying behavior (29%), and fighting (38%). Overall, a significant percentage of the sixth-, seventh-, and eighth-graders in this study have engaged in aggressive or risky behaviors such as fighting and bullying other students. Because many of these students frequently are angry, feel unsafe in their neighborhood, and have been personally affected by violence, violence-prevention programs are warranted in this school. SMART Talk gave the students an avenue to explore anger-management strategies and conflict-resolution and perspective-taking skills.

Richmond youth against violence: a school-based program for urban adolescents.

The Richmond Youth Against Violence Project teaches middle school students in the Richmond Public Schools knowledge, attitudes, and skills for reducing their involvement in violence. These students are primarily African Americans, many of whom come from low-income, single-parent households in neighborhoods with high rates of crime and drug use. The program, "Responding in Peaceful and Positive Ways," employs a developmentally anchored health promotion model. Its goal is to promote peaceful and positive alternatives to interpersonal and situational violence, by creating environments that teach and encourage health-enhancing behaviors and intrapersonal attributes and weakening supports for health-compromising behaviors and intrapersonal attributes. The 16-session school-based program was implemented by prevention specialists with sixth graders during the 1994-1995 school year. Students are taught a seven-step problem-solving model. Program implementation was staggered to allow an intervention group to participate during the fall semester and a control group to participate during the spring semester. Outcome measures include school data and measures completed by students. There were few significant baseline differences between the intervention and control groups. A high percentage of students, particularly boys, reported exposure to community violence; more than 92% had heard gunshots. Many have also engaged in risk behaviors; 70% of the boys and 44% of the girls reported being in a fight in the preceding 30 days. The impact of the curriculum is being examined. The program has provided valuable lessons about conducting community-based research, particularly designing, implementing, and evaluating prevention programs.

Evaluation of a hospital-based youth violence intervention.

To decrease adolescent morbidity and mortality and improve the quality of life, a violence-prevention consultation is offered to hospitalized victims of nondomestic violence. The context is a violence-prevention team approach to patient assessment, treatment, and follow-up. Psychoeducational counseling emphasizes the individual through a cognitive behavioral approach and also recognizes the individual in the proximal social setting through referrals to community resources. The in-hospital component draws on the health beliefs model, self-efficacy, the theory of reasoned action and their synergy with cognitive mediation theory as expressed in developmental psychology. The target group for the intervention is adolescents (12-17 years of age) who have been victims of violent assaults severe enough to warrant treatment at a Level One trauma center. The six steps in the intervention are to (1) review and assess the incident, (2) review the patient's conflict-resolution strategies and introduce nonviolent alternatives, (3) provide information on the prevalence of violence/homicide and determine the patient's risk status, (4) explore the patient's coping skills and support system, (5) develop a plan to stay safe, and (6) refer patient to services for follow-up activities. Approximately 15 study participants are identified each month, half of whom are randomly assigned to receive the intervention. Over the 12-month recruitment interval, approximately 180 adolescent patients will be identified. Baseline data are collected through hospital intake procedures and chart reviews. A battery of standardized measures supplemented by a brief structured, closed-ended interview is collected four months after the youths leave the hospital. Preliminary baseline data for 39 youths are reported. The "typical" youth is a 16-year-old African-American male. Even though nearly one third of victims had been shot, the typical patient was injured in a fight during which he was kicked, bitten, or beaten with or without a blunt instrument. The majority of incidents involved only one attacker who was known to the victim. Nearly half the injuries were precipitated by an argument or fight. No statistically significant differences between intervention subjects and nonintervention controls in terms of baseline variables have been observed. For inner-city adolescent victims of violent assaults, a hospital-based intervention offers a unique opportunity for reduction of the incidence of reinjury. We describe the elements of the intervention, including the theoretical basis and implementation; detail the overall evaluation design including modifications; and present preliminary analyses of baseline data.

Evaluating a cognitive/ecological program for the prevention of aggression among urban children.

The Metropolitan Area Child Study (MACS) is a multifaceted school- and family-based intervention and evaluation study designed to prevent and understand the development of aggressive behavior. The multifaceted interventions are grounded in combined social-cognitive and ecologic theories. Social-cognitive theories contend that cognitive scripts, attributions, and beliefs acquired early in life mediate the effects of ecological factors that influence the development of antisocial behavior. Prevention programs aimed at these cognitions must address multiple dimensions of the child's environment including family, peer, school, and community. The program has three levels of intervention delivered in two-year segments: (1) Level 1: a general enhancement classroom intervention that stresses culturally sensitive student and teacher interaction involving instructional and classroom management strategies and a social-cognitive curriculum that mitigates aggressive development; (2) Level 2: intensive small-group sessions designed to change children's cognitions and enhance peer relationship skills for at-risk children added to the general classroom enhancement program; and (3) Level 3: a one-year family relationship intervention that stresses parenting skill building and emotional responsiveness in family interactions added to the general enhancement and small-group training conditions. Sixteen Chicago-area schools are randomly assigned (four each) to a control group or one of the three intervention levels. Individual child assessment, peer assessments, classroom behavioral observations, and archival data are collected before the interventions begin, during the interventions, at the end of each intervention, and at a follow-up point. The pretests indicate that the children on average have higher levels of aggression than found nationally and elevated clinical levels of other psychopathologies. Across the four intervention levels there are no significant differences in ethnic composition, socio-economic status (SES), aggressive behavior, and normative beliefs about aggression.

Childhood homicide, suicide, and firearm deaths: an international comparison.

This article is intended to provide a better understanding of the incidence of violent deaths among children under 15 years of age in highly industrialized countries/areas. We found that rates of violent childhood deaths are not uniform in the industrialized world and that rates in the United States greatly exceed those in the other countries and areas. In fact, total firearm deaths among children are 12 times higher in the United States than in all of the other countries or areas combined; childhood homicide rates are 5 times higher; and childhood suicide rates are twice as high. Five countries or areas, 3 of which are in Asia, reported no firearm deaths among children under 15 years old. These findings suggest the value of conducting further research to explore these cross-national differences.