Young Adult Alcohol and Cannabis Impaired Driving After the Opening of Cannabis Retail Stores in Washington State.

Motor vehicle crashes are a leading cause of death for young adults (YA) in the USA, and driving under the influence of alcohol (DUIA), cannabis (DUIC), and simultaneous use of both substances (DUIAC) are prominent risk factors. Trends in YA impaired driving behaviors after opening of cannabis retail stores have been understudied. We examined YA trends in DUIA, DUIC, and DUIAC from immediately prior through 5 years following the opening of cannabis retail outlets in Washington State (2014-2019). Differences in trends were assessed across age, sex, and urbanicity. Weighted logistic regressions assessed yearly change in prevalence of DUIA, DUIC, and DUIAC from 2014 to 2019, using annual statewide data from the Washington Young Adult Health Survey (n = 12,963; ages 18-25). Moderation of trends by age, sex, and urbanicity was assessed. Prevalence of DUIA decreased overall (AOR = 0.93, 95% CI 0.90, 0.97) and among drinkers (AOR = 0.95, 95% CI 0.91, 0.99) but remained at concerning levels in 2019 (10% overall; 16% among drinkers). Overall DUIC did not change significantly (AOR = 0.99, 95% CI 0.96, 1.03; 11% by 2019) but decreased among those who used cannabis (AOR = 0.91, 95% CI 0.86, 0.96; 33% by 2019). DUIAC decreased but not significantly (overall: AOR = 0.89, 95% CI 0.78, 1.01; those who used alcohol and cannabis: AOR = 0.84, 95% CI 0.74, 1.04). Prevalence of YA DUI remained concerning. Trends may reflect some success in reducing DUI, but additional detection and prevention are needed.

Experiencing violence and other predictors of within-person same-day use of multiple substances in youth: a longitudinal study in emergency settings.

Background: Although experiencing violence is a risk factor for substance use among youth, its association with same-day use of multiple substances (a form of polysubstance use) and mitigating factors is less well understood.Objectives: To identify whether prosocial factors modified the effect of experiencing violence on the frequency of same-day use, and examine gender-specific risk/protective factors for same-day use.Methods: We analyzed longitudinal data from a cohort of youth who use drugs aged 14-24 (n = 599; 58% male) presenting to an urban emergency department between 2009-2011 and assessed biannually for two years. Using Poisson-generalized linear models with person-level fixed effects, we estimated within-person associations between self-reported experiencing violence and same-day use and analyzed gender and peer/parent support as effect modifiers. We adjusted for negative peer influence, parental drug and alcohol use, family conflict, anxiety and depression, and age.Results: Overall, positive parental support corresponded to lower rates of same-day use (rate ratio [RR]:0.93, 95% CI:0.87-0.99) and experiencing violence was associated with higher rates of same-day use (RR:1.25, 95% CI:1.10-1.41). Violence exposure was a risk factor among males (RR:1.42, 95% CI:1.21-1.66), while negative peer influences and parental substance use were risk factors among females (RR:1.63, 95% CI:1.36-1.97 and RR:1.58, 95% CI:1.35-1.83, respectively). Positive peer support reduced the association between violence exposure and same-day use among males (RR:0.69, 95% CI:0.57-0.84, p < .05).Conclusions: Tailored interventions may address gender differences in coping with experiencing violence - including interventions that promote parental support among males and reduce influence from parental substance use among females.

Anxiety, depression, and suicidal ideation among early adolescents during the COVID-19 pandemic.

BACKGROUND: Anxiety and depression are among the most common and debilitating psychiatric disorders affecting youth, with both related to increased suicide risk. While rates of youth anxiety and depression were increasing before the COVID-19 pandemic, the pandemic further negatively impacted adolescent mental health. Unfortunately, few studies have examined prevalence of these concerns among early adolescents (ages 10-13) longitudinally during the pandemic. METHOD: The current study examined self-reported anxiety and depression symptoms, and suicidal ideation amongst a general pediatrics population of 11- to 13-year-olds (n = 623) from March through September 2020 (early-pandemic) and approximately 7 months later (September 2020 through May 2021; mid-pandemic). Paired samples proportions were used to examine changes in prevalence of moderate to severe anxiety, depression, and suicidal ideation from early- to mid-pandemic. RESULTS: Results highlight high initial rates and stability in anxiety and suicidal ideation, as well as a significant increase in depression (42.9% increase; p < .05) among the full sample during the COVID-19 pandemic. Prevalance of concerns were greatest for females and Hispanic youth during the early-pandemic, and generally highest for females and Medicaid insured youth at mid-pandemic. DISCUSSION: Results extend recent research and underscore the need for continued monitoring of mental health concerns across development for youth who grew up during the COVID-19 pandemic; highlighting the need for sustainable, effective, and accessible early detection, prevention, and intervention strategies. Improving these services is critical to support youth who experienced pandemic-related stressors, and to prepare for supporting youth during future disruptive and isolating events.

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.

Lessons Learned From Integrating Anti-Oppression Pedagogy in a Graduate-Level Course in Epidemiology.

Despite the high burden of injury and violence globally and disproportionate burden on marginalized communities, few US schools of public health and departments of epidemiology offer classes focused on injury and violence, and even fewer are taught with an antiracist or anti-oppression framework. Recent years have brought renewed focus to incorporating antiracist and anti-oppression principles to pedagogy. Public health professionals have increasingly grappled with how we teach, conduct research, and advocate for just policies, which are shaped by interlocking systems of oppression. Although all areas of epidemiology are shaped by these structures, motivations for those who study injury and violence ought to be especially keen. In this commentary, we illustrate how anti-oppression can be integrated into course development and delivery with a case study of a graduate-level course at the University of Washington School of Public Health on injury and violence epidemiology. We include feedback from an epidemiology faculty reviewer, as well as narratives from students describing what worked and what did not. We offer our reflections and lessons learned, hoping to encourage others within public health and epidemiology to adopt an anti-oppression framework in developing classes and programs, particularly those related to injury and violence.

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.

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.

Race, structural racism and racial disparities in firearm homicide victimisation.

OBJECTIVES: To identify an approach in measuring the association between structural racism and racial disparities in firearm homicide victimisation focusing on racism, rather than race. METHODS: We examined associations of six measures of structural racism (Black/white disparity ratios in poverty, education, labour force participation, rental housing, single-parent households and index crime arrests) with state-level Black-white disparities in US age-adjusted firearm homicide victimisation rates 2010-2019. We regressed firearm homicide victimisation disparities on four specifications of independent variables: (1) absolute measure only; (2) absolute measure and per cent Black; (3) absolute measure and Black-white disparity ratio and (4) absolute measure, per cent Black and disparity ratio. RESULTS: For all six measures of structural racism the optimal specification included the absolute measure and Black-white disparity ratio and did not include per cent Black. Coefficients for the Black-white disparity were statistically significant, while per cent Black was not. CONCLUSIONS: In the presence of structural racism measures, the inclusion of per cent Black did not contribute to the explanation of firearm homicide disparities in this study. Findings provide empiric evidence for the preferred use of structural racism measures instead of race.

Analysis of Daily Ambient Temperature and Firearm Violence in 100 US Cities.

Importance: Firearm violence is a leading public health crisis in the US. Understanding whether and how ambient temperature is associated with firearm violence may identify new avenues for prevention and intervention. Objective: To estimate the overall and regional association between hotter temperatures and higher risk of firearm violence in the US. Design, Setting, and Participants: This cross-sectional study used distributed lag nonlinear models, controlling for seasonality and long-term time trends by city and pooled results overall and by climate region. The most populous cities in the US with the highest number of assault-related firearm incidence (ie, shootings) from 2015 to 2020 were analyzed. Data analysis was performed from October 2021 to June 2022. Exposures: Maximum daily temperature by city. Main Outcomes and Measures: The primary outcome was the number of assault-related firearm shootings by city. Results: A total of 116 511 shootings in 100 cities were included in this analysis. The pooled analysis estimated that 6.85% (95% CI, 6.09%-7.46%) of all shootings were attributable to days hotter than city-specific median temperatures. This equates to 7973 total shootings (95% CI, 7092-8688 total shootings) across the 100 cities over the 6-year study period, although the number of total persons injured or killed would be higher. Estimated risk of firearm incidents increased almost monotonically with higher temperatures, with a local peak at the 84th percentile of the temperature range corresponding to a relative risk of 1.17 (95% CI, 1.12-1.21) compared with the median temperature. However, even moderately hot temperatures were associated with higher risk of shootings. Although significant, there was low heterogeneity between cities (I2 = 11.7%; Cochran Q test, P = .02), indicating regional or climate-specific variation in the daily temperature and incident shootings relationship. Conclusions and Relevance: These findings underscore the importance of heat adaptation strategies broadly throughout the year to reduce shootings, rather than focusing on only the hottest days.

Neighborhood segregation, tree cover and firearm violence in 6 U.S. cities, 2015-2020.

Neighborhood segregation by race and income is a structural determinant of firearm violence. Addressing green space deficits in segregated neighborhoods is a promising prevention strategy. This study assessed the potential for reducing firearm violence disparities by increasing access to tree cover. Units of analysis were census tracts in six U.S. cities (Baltimore, MD; Philadelphia, PA; Richmond, VA; Syracuse, NY; Washington, DC; Wilmington, DE). We measured segregation using the index of concentration at the extremes (ICE) for race-income. We calculated proportion tree cover based on 2013-2014 imagery. Outcomes were 2015-2020 fatal and non-fatal shootings from the Gun Violence Archive. We modeled firearm violence as a function of ICE, tree cover, and covariates representing the social and built environment. Next, we simulated possible effects of "tree equity" programs, i.e., raising tract-level tree cover to a specified baseline level. In our fully-adjusted model, higher privilege on the ICE measure (1 standard deviation, SD) was associated with a 42% reduction in shootings (incidence rate ratio (IRR) = 0.58, 95% CI [0.54 0.62], p < 0.001). A 1-SD increase in tree cover was associated with a 9% reduction (IRR = 0.91, 95% CI [0.86, 0.97], p < 0.01). Simulated achievement of 40% baseline tree cover was associated with reductions in firearm violence, with the largest reductions in highly-deprived neighborhoods. Advancing tree equity would not disrupt the fundamental causes of racial disparities in firearm violence exposure, but may have the potential to help mitigate those disparities.

Long-Term Prescription Opioid Use After Injury in Washington State 2015-2018.

BACKGROUND: Patients with injury may be at high risk of long-term opioid use due to the specific features of injury (e.g., injury severity), as well as patient, treatment, and provider characteristics that may influence their injury-related pain management. OBJECTIVES: Inform prescribing practices and identify high-risk populations through studying chronic prescription opioid use in the trauma population. METHODS: Using the Washington State All-Payer Claims Database (WA-APCD) data, we included adults aged 18-65 years with an incident injury from October 1, 2015-December 31, 2017. We compared patient, injury, treatment, and provider characteristics by whether or not the patients had long-term (≥ 90 days continuous prescription opioid use), or no opioid use after injury. RESULTS: We identified 191,130 patients who met eligibility criteria and were included in our cohort; 5822 met criteria for long-term use. Most had minor injuries, with a median Injury Severity Score = 1, with no difference between groups. Almost all patients with long-term opioid use had filled an opioid prescription in the year prior to their injury (95.3%), vs. 31.3% in the no-use group (p < 0.001). Comorbidities associated with chronic pain, mental health, and substance use conditions were more common in the long-term than the no-use group. CONCLUSION: Across this large cohort of multiple, mostly minor, injury types, long-term opioid use was relatively uncommon, but almost all patients with chronic use post injury had preinjury opioid use. Long-term opioid use after injury may be more closely tied to preinjury chronic pain and pain management than acute care pain management.

Prevalence of a loaded firearm in the home among birth parents experiencing symptoms of postpartum depression.

Firearm access increases the risk of suicide among all household members. The prevalence of loaded firearms in the home among those experiencing symptoms of postpartum depression (PPD) is unknown. We conducted a cross-sectional study using Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2019. We included participants from the nine jurisdictions that asked about loaded firearms in the home and who screened positive for PPD. We excluded participants whose infants were not alive at time of survey completion and who did not respond to the firearm question, resulting in an analytic sample of 4986 participants. Using PRAMS analytic weights, we estimated the prevalence of a loaded firearm in the home and the prevalence of screening for PPD based on having a loaded firearm in the home. Among PRAMS participants experiencing symptoms of PPD, 8.8% (95% CI: 7.6%, 10.1%) reported there was a loaded firearm in their home. Participants with a loaded firearm in their home were more likely to be White (81.3% vs. 60.6%) and live in a rural area (57.9% vs. 27.5%) than those without. Among participants who reported attending a postpartum checkup, 78.6% (95% CI: 67.0%, 90.2%) of those with a loaded firearm in their home reported having been asked by a provider if they were feeling depressed, compared to 88.7% (95% CI: 85.3%, 92.0%) of those without. About 1 in 11 birth parents experiencing symptoms of PPD report a loaded firearm in their home. Further screening for firearm access in this population may need to be considered.

A Clinician's Guide to Conducting Research on Causal Effects.

Surgeons are uniquely poised to conduct research to improve patient care, yet a gap often exists between the clinician's desire to guide patient care with causal evidence and having adequate training necessary to produce causal evidence. This guide aims to address this gap by providing clinically relevant examples to illustrate necessary assumptions required for clinical research to produce causal estimates.

Assault-related injuries reported to police and treated by healthcare providers in the United States.

Research suggests that assault-related injuries known by the police significantly differ from those known by healthcare providers, but the magnitude and nature of these differences are poorly understood. To address this gap, our study examined the empirical differences between assault-related injuries reported to police and treated by healthcare providers. In June of 2021, we analyzed the National Crime Victimization Survey (1993-2019) to estimate the prevalence of police reporting and healthcare use among 5093 nonfatal victimizations that caused injury and were either reported to the police or treated by healthcare in the United States. Quasi-Poisson models identified the factors associated with whether people who sustained the injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare). Among victimizations that caused only minor injuries, 43% involved only a police report, 11% involved only healthcare, and 46% involved both services. Among victimizations that caused serious injuries, 14% involved only a police report, 13% involved only healthcare, and 73% involved both services. Whether people with violent injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare) was significantly associated with 13 different person- and incident-level factors. The number and nature of assault-related injuries reported to law enforcement significantly differ from those treated by healthcare providers. Therefore, public health efforts to link police and healthcare data are warranted and recommended.

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.

Domestic Violence Alleged in California Child Maltreatment Reports During the COVID-19 Pandemic.

During the COVID-19 pandemic, reports to child abuse and neglect hotlines have dropped significantly across the United States. Yet, during this same period, calls to domestic violence hotlines have increased. The purpose of this study was to examine if there have been measurable changes in domestic violence-related reports to child abuse and neglect hotlines. Using administrative child protection records from California, we plotted counts and proportions of child maltreatment reports with and without domestic violence allegations before and through the onset of school closures associated with the COVID-19 pandemic. We used an interrupted time series analysis to evaluate whether or not there was a change in domestic violence allegations in child protection reports corresponding to the COVID-19 pandemic. We document that during the first two quarters of 2020 there was a 14.3% drop in the overall number of child protection reports. Despite a decline in maltreatment reporting overall, there was a 25% increase in the proportion of reports with allegations of domestic violence. Our findings suggest both the count and composition of reports to child protection agencies were affected by the COVID-19 pandemic. The current analyses also showcase the seasonality of CPS reports generally, and reports with DV allegations, specifically.

Firearms and protective orders in intimate partner homicides.

PURPOSE: To determine differences among intimate partner homicides (IPH) by whether or not a firearm was used in and whether a protective order (PO) was filed prior to IPH. METHOD: We identified all incidents of IPH recorded in the National Violent Death Reporting System from 2003-2018, based on the relationship between victim and perpetrator. We characterized incidents, perpetrators and victims in IPH cases by whether or not a firearm was used, and whether a PO had been sought or issued prior to the IPH. RESULTS: We identified 8,375 IPH incidents with a total of 9,130 victims. Overall 306 (3.3%) victims were killed in a firearm IPH with PO, 4,519 (53.9%) in a firearm IPH without PO, 176 (2.1%) in a non-firearm IPH with PO and 3,416 (40.7%) in a non-firearm IPH without PO. Based on review of incident narratives, 5.4% (n=451) of incidents involved a previously-granted or sought PO, and none of which had explicitly mentioned firearm removal as a part of the PO. CONCLUSIONS: The majority of victims were killed with a firearm. Prior literature suggests that POs with firearm removal may be effective strategies for reducing risk of IPH, but we found no documentation in the narratives that firearm removal was a condition in the POs identified. As very few IPH narratives included documentation of a PO, it is likely that ascertainment of PO status is incomplete and could be an area for improvement in NVDRS data collection efforts.

Barriers to recruitment, retention and intervention delivery in a randomized trial among patients with firearm injuries.

BACKGROUND: We discuss barriers to recruitment, retention, and intervention delivery in a randomized controlled trial (RCT) of patients presenting with firearm injuries to a Level 1 trauma center. The intervention was adapted from the Critical Time Intervention and included a six-month period of support in the community after hospital discharge to address recovery goals. This study was one of the first RCTs of a hospital- and community-based intervention provided solely among patients with firearm injuries. MAIN TEXT: Barriers to recruitment included limited staffing, coupled with wide variability in length of stay and admission times, which made it difficult to predict the best time to recruit. At the same time, more acutely affected patients needed more time to stabilize in order to determine whether eligibility criteria were met. Barriers to retention included insufficient patient resources for stable housing, communication and transportation, as well as limited time for patients to meet with study staff to respond to follow-up surveys. These barriers similarly affected intervention delivery as patients who were recruited, but had fewer resources to help with recovery, had lower intervention engagement. These barriers fall within the broader context of system avoidance (e.g., avoiding institutions that keep formal records). Since the patient sample was racially diverse with the majority of patients having prior criminal justice system involvement, this may have precluded active participation from some patients, especially those from communities that have been subject to long and sustained history of trauma and racism. We discuss approaches to overcoming these barriers and the importance of such efforts to further implement and evaluate hospital-based violence intervention programs in the future. CONCLUSION: Developing strategies to overcome barriers to data collection and ongoing participant contact are essential to gathering robust information to understand how well violence prevention programs work and providing the best care possible for people recovering from injuries. TRIAL REGISTRATION: ClinicalTrials.gov NCT02630225 . Registered 12/15/2015.