Developing and implementing survivor-centred approaches for college student-athletes: perspectives from athletic department, Title IX, and campus advocacy personnel.

ABSTRACTBackground: Sexual violence (SV) is a persistent issue on US college campuses, particularly among college student-athletes. Strategies to address SV are urgently needed. Yet, prior research shows that many university practices can be more harmful than helpful to SV survivors and necessitates a reimagination of how institutions support SV survivors. Survivor-centred approaches may be one way to effectively address SV for students, including student-athletes, across college campuses.Objective: This qualitative study explored campus personnel experiences with and perceptions of survivor-centred SV prevention and intervention policies and practices on college campuses and examined how these approaches serve SV survivors, including college student-athletes.Methods: As part of a larger study on campus SV and student-athletes across four institutions, semi-structured interviews with 22 representatives from athletic departments, campus advocacy, and Title IX were conducted. Guided by phenomenology, a thematic analysis approach was used to identify key patterns in survivor-centred SV prevention and intervention policies and practices. Participant demographic data were analysed descriptively.Results: Most participants identified as white (72.2%), heterosexual (63.6%), women (68.2%), and were an average of 41.8 years old (SD = 10.2). The majority were in positions associated with athletic departments (63.6%), and they had been in their role for an average of 5.6 years (SD = 6.6). Through thematic analysis, three main themes were identified: (1) education & accessibility; (2) interpersonal relationships & individual well-being; and (3) campus and societal norms.Conclusions: The findings from this study highlight clear policy and practice recommendations for survivor-centred SV prevention and intervention on college campuses, such as accessible, applicable SV training and the implementation of survivor-centred approaches. Further research is needed to understand existing survivor-centred practices and the facilitators and barriers to their implementation across institutions and within athletic departments.

Sexual violence is a persistent issue on US college campuses, particularly among college student-athletes. Strategies to address SV are urgently needed. Survivor-centred approaches may offer solutions to better serve survivors of sexual violence, including student-athletes.Through interviews with athletic department, Title IX, and campus advocacy personnel, three themes were identified related to developing and implementing survivor-centred approaches: (1) education & accessibility; (2) interpersonal relationships & individual well-being; and (3) campus and societal norms.Further research is needed to understand existing survivor-centred practices and the facilitators and barriers to their implementation across institutions, particularly for college student-athletes.

State laws addressing teen dating violence in US high schools: A difference-in-differences study.

OBJECTIVE: Teen dating violence (TDV) is prevalent with lifelong adverse consequences, and strategies to reduce its burden are needed. Many U.S. states have enacted laws to address TDV in schools, but few studies have examined their effectiveness. This study aimed to assess whether state TDV laws were associated with changes in physical TDV victimization among high school students. METHODS: We used repeated cross-sectional data of high school students from the Youth Risk Behavior Survey across 41 states from 1999 to 2019. Using a difference-in-differences approach with an event study design, we compared changes in past-year physical TDV in states that enacted TDV laws (n = 21) compared to states with no required laws (n = 20). Analyses accounted for clustering at the state-level and state and year-fixed effects. We conducted sensitivity analyses to assess the robustness of our findings. RESULTS: In our sample of 1,240,211 students, the prevalence of past-year physical TDV was 9.2% across all state-years. In 1999, the prevalence of TDV at the state-level ranged from 7.5 to 13.0%; in 2019, the prevalence ranged from 3.7 to 10.5%. There was no significant association between TDV laws and past-year physical TDV. Six or more waves after enactment, we observed a non-significant 1.7% percentage point reduction in TDV in states with TDV laws (95% CI: -3.6 to 0.3 percentage points; p = 0.10). CONCLUSIONS: We found no significant association between enactment of TDV laws and physical TDV among high school students. Further research is needed to understand how TDV laws are implemented and components of TDV laws that may influence effectiveness.

An Introduction to Bayesian Spatial Smoothing Methods for Disease Mapping: Modeling County Firearm Suicide Mortality Rates.

This article introduces Bayesian spatial smoothing models for disease mapping, a specific application of small area estimation where the full universe of data is known, to a wider audience of public health professionals using firearm suicide as a motivating example. Besag, York and Mollié (BYM) Poisson spatial and space-time smoothing models were fit to firearm suicide counts for the years 2014-2018. County raw death rates in 2018 ranged from 0-24.81 deaths per 10,000 people. However, the highest mortality rate was highly unstable based on only 2 deaths in a population of approximately 800, and 82.4% of contiguous US counties experienced fewer than 10 firearm suicide deaths and were thus suppressed. Spatially smoothed county firearm suicide mortality estimates ranged from 0.06-4.05 deaths per 10,000 people and could be reported for all counties. The space-time smoothing model produced similar estimates with narrower credible intervals as it allowed counties to gained precision from adjacent neighbors and their own rates in adjacent years. Bayesian spatial smoothing methods are a useful tool for evaluating spatial health disparities in small geographies where small numbers can result in highly variable rate estimates, and new estimation techniques in R have made fitting these models more accessible to researchers.

Threats, Violence, and Weapon Use Against Children in Domestic Violence Protection Orders.

BACKGROUND AND OBJECTIVES: Childhood exposure to domestic violence is common, but the overlap between threats and violence against children and weapon/firearm use has not been well studied. The objectives of this study were to: assess differences in respondent firearm access and the use of weapons in granted domestic violence protection orders (DVPOs) with and without minors (individuals <18 years of age); and characterize the frequency and characteristics of threats and acts of violence against minors. METHODS: We conducted a cross-sectional study of a random sample of granted DVPOs from 2014-2020 in King County, Washington. We examined the use of threats, violence, and weapons by restrained individuals (ie, respondents) by reviewing and abstracting information from DVPO case files. RESULTS: Respondent weapon use and firearm possession were more common among DVPOs including minors than DVPOs not including minors (weapon use: 38.2% and 33.0%; firearm possession: 23.1% and 19.1%, respectively). Almost 2 in 3 DVPOs including minors (1338 of 2029) involved threats or violence directed at a minor perpetrated by the DVPO respondent. About 1 in 3 (32.5%) DVPOs documented explicit threats, and 1 in 2 (48.9%) documented violence. Over two-thirds (680 of 993, 68.5%) of acts of violence directed at minors included a weapon. CONCLUSIONS: We found higher lethality risk (weapon use and respondent firearm access/ownership) among DVPOs including minors. Many minors experienced threats and acts of violence involving weapons and firearms by DVPO respondents. Evidence-based safety planning strategies and training of judicial officers are needed.

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.

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.

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.

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.

Prevalence and Formal Reporting of Sexual Violence among Undergraduate Student-Athletes: A Multi-State Study.

Sexual violence (SV) is a serious problem on college campuses, and student-athletes are one group of college students at risk for experiencing SV. The administrative context and close-knit bonds of college teams introduce opportunities and structures for responding to SV and delivering uniquely tailored prevention programming, but there is limited research about formal reporting of SV among student-athletes. The current study examines the prevalence of SV and SV reporting history and perceptions among a multi-state sample of undergraduate student-athletes. Student-athletes at 10 National Collegiate Athletic Association (NCAA) Division I institutions across the US participated in an online survey about their experiences of SV victimization, formal reporting of SV, knowledge of resources, and perceptions of responses to SV at their institutions. Among 1004 student-athletes who completed the survey, 29% experienced some type of SV since enrolling at their university, with higher prevalence of SV among student-athletes on women's teams (36%) compared to men's teams (13%). About one fifth of student-athletes felt very or extremely knowledgeable about where to make a report of SV, and only about 10% felt very or extremely knowledgeable about what happens when a student reports SV. Only 9% of participants who experienced SV filed a formal report at their institution. Perceptions about whether campus officials would take the report seriously or would conduct a fair investigation were most positive for students who experienced and formally reported SV. Further research with student-athletes about their decision to formally report and barriers to reporting is needed to build a more comprehensive understanding of the unique experiences of SV among student-athletes. Our results highlight the importance of including and targeting student-athletes in campus SV prevention efforts to build knowledge and trust in hopes of ultimately decreasing the prevalence and adverse consequences of SV.

Institution of Higher Education Substance Use Amnesty Policies and Sexual Violence Reporting.

Sexual violence (SV) is common among college students, but the vast majority of these experiences are not formally reported to institutions of higher education (IHEs). While it is well known that alcohol and drug use is highly associated with SV, little is known about whether policies and procedures regarding substance use (SU) at IHEs may contribute to low rates of reporting. This study describes the association between SU violations and SV reporting at IHE campuses in the US and examines whether SU amnesty policies are associated with more SV reporting. Linear regression was used to estimate the association between SU violations and SV reporting and assess differences between IHE campuses by amnesty policy status. Around 50% of campuses between 2001 and 2018 document neither SV reports nor SU violations. IHE campuses with amnesty policies have more SV reports. On average, IHEs with amnesty policies have 2.7 SV reports per 1000 students and an additional 0.02 SV reports for each SU violation per 1000 students. Amnesty policies that reduce the potential costs of reporting like facing disciplinary action for alcohol or drug use are positively associated with both the level and rate of SV reporting. Institutions of higher education administrators interested in making reporting an option for more SV survivors should examine how their policies, especially those related to alcohol, may play in creating barriers to SV reporting.

Implicit Racial and Gender Bias About Handguns: A New Implicit Association Test.

This study measured implicit and explicit racial bias about women and handguns and addressed important perceptions and stereotypes about gun competence and victimization that vary based on race and gender. We administered a national survey to 1,000 US adults using a new Race-Women-Handguns Implicit Association Test (IAT). Survey weighting was used to generate nationally representative estimates on the prevalence of implicit racial bias about women with handguns. The majority of participants (62.5%) associated Black women with handguns and White women with smartphones (weighted-mean IAT = 0.252; 95% CI [0.227, 0.276]) reflecting an anti-Black bias among US adults that is stereotype consistent associating Black women with handguns and White women with smartphones. The proportion that indicated Black and White women were competent with handguns was low (21.6% and 22.4%, respectively), and the proportion of US adults who indicated Black women are more likely to experience intimate partner violence (range: 19.4%-22.9%) and sexual harassment/assault (range: 11.4%-20.4%) was low compared to the prevalence of both forms of violence US among Black women that may impact the decision to possess a handgun. These findings suggest there is an anti-Black implicit bias about women with handguns (associating Black women with handguns) among US adults and support the need for further research measuring racism in systems and structures that intersect with gun possession.

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.

Suicide, Firearms, and Terminal Illness: A Latent Class Analysis Using Data From the National Violent Death Reporting System.

OBJECTIVE: Firearms are highly lethal when used for suicide and are used more frequently as a suicide method by persons of older age. Individuals with terminal illness are at high risk for suicide, yet little research has explored how firearms may be used for self-harm in this population. The authors sought to understand the patterns of psychiatric diagnoses, substance use disorders diagnoses, and suicide mechanisms for individuals with terminal illness who died by suicide as well as their demographic and circumstantial characteristics. METHODS: A latent class analysis using data from the National Violent Death Reporting System was undertaken to better understand typologies of individuals with terminal illness who died by suicide in 2003-2018 (N=3,072). To develop the classes, the authors considered diagnoses of mental illness and of alcohol or substance use disorders, suicidal thoughts and behaviors, and mechanism of suicide (firearm or no firearm). Demographic and circumstantial variables were examined across classes. RESULTS: The analysis revealed four classes of persons with terminal illness who died from suicide: depression and nonfirearm methods (N=375, 12%), suicidal intent and firearm use (N=922, 30%), alcohol or substance use disorder and nonfirearm methods (N=70, 2%), and firearm use only (N=1,705, 56%). CONCLUSIONS: Firearm access is an important consideration for terminally ill persons at risk for suicide. Screening for psychiatric and substance use disorders may not identify terminally ill persons who are at increased suicide risk because of the presence of a firearm in the home. This population may benefit from tailored interventions in specialty care settings to address firearm safety.

Student-Athlete Preferences for Sexual Violence Reporting: A Discrete Choice Experiment.

BACKGROUND: Sexual violence (SV) is prevalent among US college athletes, but formal reports are rare. Little is known about adaptations to institution-level reporting policies and procedures that could facilitate reporting. METHODS: We conducted a discrete choice experiment (DCE) survey with 1004 student-athletes at ten Division I NCAA member institutions to examine how attributes of the reporting system influence the decision to formally report SV to their institution. Changes in utility values were estimated using multinomial logistic regression and mixed multinomial logistic regression. Importance scores were compared to understand student-athlete preferences. RESULTS: In order of relative importance, the two attributes most preferred by student-athletes were higher probabilities of students perpetrating SV being found in violation of code of conduct policies (relative importance score = 33), and the availability of substance use amnesty policies (relative importance score = 24). Student-athletes with prior SV experiences were more likely to opt out of formally reporting in the DCE paired choice, had lower estimated utility values for all attributes, and had less between-person heterogeneity. While anonymous reporting and survivor-initiated investigations were preferred by student-athletes on average, there was considerable valuation heterogeneity between student-athletes (sizeable deviations from mean estimated utilities). These two attributes also varied in relative importance; anonymous reporting had higher relative importance after interacting levels with prior SV experiences and competitive status, but lower relative importance after interacting levels with whether a student-athlete played on men's or women's sports teams. CONCLUSIONS: Changes to reporting policies and procedures (e.g., transparency about SV reporting outcomes, implementing substance use amnesty policies) may be promising institution-level interventions to increase formal reporting of SV among student-athletes. More research is needed to understand preference heterogeneity between students and generalize these findings to broader student populations.

Household food insecurity is associated with diabetic ketoacidosis but not severe hypoglycemia or glycemic control in youth and young adults with youth-onset type 2 diabetes.

OBJECTIVE: To examine the association between household food insecurity (HFI), glycemic control, severe hypoglycemia and diabetic ketoacidosis (DKA) among youth and young adults (YYA) with youth-onset type 2 diabetes. RESEARCH DESIGN AND METHODS: This cross-sectional study included 395 YYA with type 2 diabetes from the SEARCH for Diabetes in Youth Study (2015-2019). HFI was reported by young adult participants or parents of minor participants via the US Household Food Security Survey Module. Glycemic control was assessed by HbA1c and analyzed as a continuous and categorical variable (optimal: <7.0%, suboptimal: ≥7.0%-9.0%, poor: >9.0%). Acute complications included self-reported severe hypoglycemia or DKA in the last 12 months. Adjusted logistic and linear regression were used for binary and continuous outcomes, respectively. RESULTS: Approximately 31% reported HFI in the past 12 months. Mean HbA1c among those with HFI was 9.2% compared to 9.5% without HFI. Of those with HFI, 56% had an HbA1c >9.0% compared to 55% without HFI. Adjusted models showed no associations between HFI and glycemic control. Of those with HFI, 14.4% reported experiencing DKA and 4.7% reported severe hypoglycemia. YYA with HFI had 3.08 times (95% CI: 1.18-8.06) the odds of experiencing DKA as those without HFI. There was no association between HFI and severe hypoglycemia. CONCLUSIONS: HFI was associated with markedly increased odds of DKA but not with glycemic control or severe hypoglycemia. Future research among YYA with type 2 diabetes should evaluate longitudinally whether alleviating HFI reduces DKA.

Trajectories of Handgun Carrying in Rural Communities From Early Adolescence to Young Adulthood.

Importance: Characterizing patterns of handgun carrying among adolescents and young adults can inform programs to reduce firearm-related harm. Longitudinal patterns of handgun carrying among rural adolescents have not been identified. Objectives: To assess specific points of intervention by characterizing patterns of handgun carrying by youths in rural communities from early adolescence to young adulthood and to quantify how age at initiation, duration, and frequency of carrying differ across identified patterns. Design, Setting, and Participants: This cohort study uses the control group of the community-randomized trial of the Communities That Care prevention system, conducted among public school students in 12 rural communities across 7 states. Participants self-reported their handgun carrying at 10 data collection points from 12 to 26 years of age (2005-2019). Data were analyzed from January to July 2021. Main Outcomes and Measures: Handgun carrying in the past 12 months. Latent class growth analysis was used to estimate handgun carrying trajectories. Results: In this longitudinal rural sample of 2002 students, 1040 (51.9%) were male; 532 (26.6%) were Hispanic, Latino, Latina, or Latinx; 1310 (65.4%) were White; and the highest level of educational attainment of either parent was a high school degree or less for 649 students (32.4%). The prevalence of handgun carrying in the last 12 months ranged from 5.3% (95 of 1795) to 7.4% (146 of 1969) in adolescence and increased during the mid-20s (range, 8.9% [154 of 1722] to 10.9% [185 of 1704] from 23 to 26 years of age). Among the participants who reported handgun carrying at least once between 12 and 26 years of age (n = 601 [30.0%]), 320 (53.2%) reported carrying a handgun in only 1 wave. Latent class growth analysis indicated 6 longitudinal trajectories: never or low probability of carrying (1590 [79.4%]), emerging adulthood carrying (166 [8.3%]), steadily increasing carrying (163 [8.1%]), adolescent carrying (53 [2.6%]), declining carrying (24 [1.2%]), and high probability and persistent carrying (6 [0.3%]). The earliest mean (SD) age at initiation of handgun carrying occurred in both the adolescent and declining carrying groups at the ages of 12.6 (0.9) and 12.5 (0.7) years, respectively. More than 20% of some groups (emerging adulthood [age 26 years: 49 of 154 (31.8%)], steadily increasing [age 26 years: 37 of 131 (28.2%)], declining [age 13 years: 7 of 23 (30.4%)], and high probability and persistent carrying [age 15 years: 3 of 6 (50.0%)]) reported carrying 40 times or more in the past year by the age of 26 years. Conclusions and Relevance: This study found distinct patterns of handgun carrying from adolescence to young adulthood in rural settings. Findings suggest that promoting handgun safety in rural areas should start early. Potential high-risk trajectories, including carrying at high frequencies, should be the focus of future work to explore the antecedents and consequences of handgun carrying in rural areas.