Income inequality and firearm homicide in the US: a county-level cohort study.

OBJECTIVE: Income inequality has been rising in the US and thought to be associated with violence especially homicide. About 75% of homicides involve firearms. We quantified the association between county-level income inequality and all-race/ethnicity and race/ethnicity-specific firearm homicide rates among individuals aged 14-39 years. METHODS: We conducted a cohort study of US counties to examine the association of Gini Index (ranging from 0 [perfect income equality] to 1.0 [perfect income inequality]) separately measured in 1990 and 2000 with all-race/ethnicity and race/ethnicity-specific firearm homicide rates in 2005-2015. Generalised linear mixed models with Poisson distribution including a random intercept for state provided IRRs and 95% CIs. Bayesian Poisson-lognormal hierarchical modelling with integrated nested Laplace approximations was used in exploratory spatial analyses. Models accounted for county-level age, sex and race/ethnicity composition, crime rate, deprivation, social capital, urbanicity, and firearm ownership. FINDINGS: The Gini Index was associated with firearm homicide rates among all races/ethnicities. After accounting for contextual determinants of firearm homicide, the association persisted among African-Americans. In this group, a 1 SD greater Gini Index in 1990 (IRR=1.09; 95% CI 1.02 to 1.16) and 2000 (IRR=1.09; 95% CI 1.01 to 1.17) was associated with greater firearm homicide rates in 2005-2015. Exploratory spatial analyses did not materially change the results. CONCLUSION: Policies addressing the gap between the rich and the poor deserve further considerations for reducing firearm homicide rates. Incorporating income inequality to refine measures of socioeconomic position may advance public health and clinical research and practice for firearm violence prevention.

Spatial analysis of intentional homicides in João Pessoa, Paraíba, Brazil, 2011-2016. / Análise espacial dos homicídios intencionais em João Pessoa, Paraíba, 2011-2016.

OBJECTIVE: to describe spatial patterns of intentional homicides in João Pessoa, Paraíba, Brazil, 2011-2016. METHODS: this was an ecological study using census tracts as units of analysis; the study used data on intentional homicides of victims living in João Pessoa obtained by cross-checking Mortality Information System SIM information with Public Security information; mortality coefficients were calculated for the whole period and its triennia and were later smoothed using the local empirical Bayesian method; spatial autocorrelation techniques were applied to the smoothed coefficients which were using Moran's spatial statistics. RESULTS: significant spatial autocorrelation was detected for the period as a whole I=0.679, p=0.01, the 1st triennium I=0.508, p=0.01, and the 2nd triennium I=0.572, p=0.01; areas of greater risk were identified distributed among the western, northwestern, southeastern, and far south zones of the city, mainly in regions with low socioeconomic conditions; census tracts with low coefficients were located in areas of medium/high socioeconomic status. CONCLUSION: homicides in João Pessoa were high in poor districts and these are priority areas for intervention.

The Impact of Designated Behavioral Health Services on Resource Utilization and Quality of Care in Patients Requiring Constant Observation in a General Hospital Setting: A Quality Improvement Project.

Constant observation (CO) is a common economic burden on general hospitals. A quality improvement (QI) project focusing on behavioral health (BH) management of this population was piloted using a novel BH protocol for the proactive assessment and management of all patients requiring CO. The impact on CO-cost and length of stay (LOS) was assessed. Data on demographics, diagnoses, psychopharmacologic treatment, complications and clinical setting were collected and analyzed for all CO-patients over a 6-month period. Cost and LOS data were compared with a similar sequential group prior to project implementation. Out of the 533 patients requiring CO during the study period, 491 underwent the protocol. This QI-project resulted in a significant reduction in the average monthly CO-cost by 33.06% and a 15% reduction in LOS without any increase in complications.

And the survey said.... evaluating rationale for participation in gun buybacks as a tool to encourage higher yields.

BACKGROUND: Gun buyback programs represent one arm of a multipronged approach to raise awareness and education about gun safety. METHODS: The city of Worcester, MA has conducted an annual gun buyback at the Police Department Headquarters since 2002. We analyzed survey responses from a voluntary, 18-question, face-to-face structured interview from December 2009 to June 2015 using descriptive statistics to determine participant demographics and motivations for participation. RESULTS: A total of 943 guns were collected, and 273 individuals completed surveys. The majority of participants were white males older than 55years (42.4%). Participants represented 61 zip codes across Worcester County, with 68% having prior gun safety training and 61% with weapons remaining in the home (27% of which children could potentially access). The top reasons for turning in guns were "no longer needed" (48%) and "fear of children accessing the gun" (14%). About 1 in 3 respondents knew someone injured/killed by gun violence. Almost all (96%) respondents claimed the program raised community awareness of firearm risk. CONCLUSION: The Worcester Goods for Guns Buyback has collected more than 900 guns between 2009 and 2015. The buyback removes unwanted guns from homes and raises community awareness about firearm safety.

The Welfare Cost of Homicides in Brazil: Accounting for Heterogeneity in the Willingness to Pay for Mortality Reductions.

This paper estimates the health dimension of the welfare cost of homicides in Brazil incorporating age, gender, educational, and regional heterogeneities. We use a marginal willingness to pay approach to assign monetary values to the welfare cost of increased mortality due to violence. Results indicate that the present discounted value of the welfare cost of homicides in Brazil corresponds to roughly 78% of the GDP or, in terms of yearly flow, 2.3%. The analysis also shows that reliance on aggregate data to perform such calculations can lead to biases of around 20% in the estimated social cost of violence.

Early intervention for first-episode psychosis: broadening the scope of economic estimates.

AIM: To explore the economic impacts of early intervention in England on outcomes and costs for people with first-episode psychosis. METHODS: Three decision analytical models were constructed to compare treatment by early intervention for first-episode psychosis with standard care in relation to employment, education, homicide and suicide. Data on effectiveness and costs were taken from previous studies and expert opinion. Sensitivity analyses tested the robustness of assumptions. RESULTS: Our models indicate that early intervention demonstrates savings of £2087 per person over 3 years from improved employment and education outcomes. In addition, the annual costs over 10 years related to homicide after early intervention were £80 lower than for standard care. There were also annual savings of £957 per person for early intervention over 4 years compared to standard care as a result of suicides averted. CONCLUSIONS: Not only can investment in early intervention help reduce some of the long-term costs and consequences of mental disorders to the health-care system. In addition, there are broader economic benefits that strengthen the potential cost savings to society.

Injuries and violence in the Eastern Mediterranean Region: a review of the health, economic and social burden.

We review current literature and data on the burden of injury and violence in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), with a special focus on the health, economic and social burden they impose on individuals, families and society. Injury-associated mortality and disability is on the rise in EMR, especially among economically productive adults, young males and vulnerable road users. In particular, road traffic injuries, the leading cause of injuries, account for 27% of the total injury and violence mortality in EMR according to WHO. Violence including suicide, homicide and war-related injury has also been increasing over the past two decades for both females and males. There is need for greater interest and efforts in slowing and ultimately halting the trend through interventions, legislative actions, and research that examine the special needs and challenges in the Region.

Income inequality, poverty and crime across nations.

We examine the relationship between income inequality, poverty, and different types of crime. Our results are consistent with recent research in showing that inequality is unrelated to homicide rates when poverty is controlled. In our multi-level analyses of the International Crime Victimization Survey we find that inequality is unrelated to assault, robbery, burglary, and theft when poverty is controlled. We argue that there are also theoretical reasons to doubt that the level of income inequality of a country affects the likelihood of criminal behaviour.

Social welfare support and homicide: longitudinal analyses of European countries from 1994 to 2010.

The purpose of this research is to explore the extent to which retrenchment in welfare support is related to homicide trends across European countries between 1994 and 2010. Using a longitudinal decomposition design that allows for stronger causal inferences compared to typical cross-sectional designs, we examine these potential linkages between social support spending and homicide with data collected from a heterogeneous sample of European nations, including twenty Western nations and nine less frequently analyzed East-Central nations, during recent years in which European nations generally witnessed substantial changes in homicide rates as well as both economic prosperity and fiscal crisis. Results suggest that even incremental, short-term changes in welfare support spending are associated with short-term reductions in homicide-specifically, impacting homicide rates within two to three years for this sample of European nations.

Socioeconomic inequalities in premature mortality in Colombia, 1998-2007: the double burden of non-communicable diseases and injuries.

OBJECTIVES: Non-communicable diseases have become the leading cause of death in middle-income countries, but mortality from injuries and infections remains high. We examined the contribution of specific causes to disparities in adult premature mortality (ages 25-64) by educational level from 1998 to 2007 in Colombia. METHODS: Data from mortality registries were linked to population censuses to obtain mortality rates by educational attainment. We used Poisson regression to model trends in mortality by educational attainment and estimated the contribution of specific causes to the Slope Index of Inequality. RESULTS: Men and women with only primary education had higher premature mortality than men and women with post-secondary education (RRmen=2.60, 95% confidence interval [CI]: 2.56, 2.64; RRwomen=2.36, CI: 2.31, 2.42). Mortality declined in all educational groups, but declines were significantly larger for higher-educated men and women. Homicide explained 55.1% of male inequalities while non-communicable diseases explained 62.5% of female inequalities and 27.1% of male inequalities. Infections explained a small proportion of inequalities in mortality. CONCLUSION: Injuries and non-communicable diseases contribute considerably to disparities in premature mortality in Colombia. Multi-sector policies to reduce both interpersonal violence and non-communicable disease risk factors are required to curb mortality disparities.

"God must have been sleeping": faith as an obstacle and a resource for Rwandan genocide survivors in the United States.

In 1994, 1 million Rwandans were violently killed in only 100 days. Devastating for some Rwandan survivors was the significant role that some Catholic parishes and leaders took in ignoring, facilitating, and even perpetuating the genocide. This article seeks to understand how Rwandan genocide survivors draw on religion as they negotiate their postgenocide identities in the United States and comprehend their current faiths, beliefs, and practices. Based on qualitative interviews with Rwandan survivors now located within the United States, I argue that the experiences of religiosity postgenocide serve as both an obstacle and a resource in postgenocide life, creating significant individual and local ramifications for community engagement, reconciliation, and trauma recovery.

Homicide as a medical outcome: racial disparity in deaths from assault in US Level I and II trauma centers.

BACKGROUND: Since 1900, thousands of medical journal articles have been published on the topic of racial disparities in health and medical outcomes in the United States, including overlapping disparities based on health insurance status. But research on the question of such disparities in the medical treatment of injury from assault-matters of public safety, considerable public expense, and policy debate-is lacking. METHODS: To determine differences by race and insurance status on death from intentional injury by others on and after trauma center arrival, propensity score matching is used to estimate adjusted mortality risk ratios by race and medical insurance controlling for facility, case, and injury characteristics. Analysis is based on a nationally representative sample of 100 Level I and II US trauma centers (National Trauma Data Bank 2005-2008) and includes 137,618 black and white assault cases aged 15 years and older: 35% white, and 65% black, with 46% of the whites and 60% of the blacks coded as uninsured. RESULTS: Black patients showed higher overall raw mortality rates from assault than whites (8.9% vs. 5.1%), but after propensity score matching, the black to white adjusted risk ratio for death from assault (homicide) dropped significantly across firearm, cutting/piercing, and blunt injuries. After adjustment, estimated black deaths were 29% in excess of white deaths for firearm injuries, 36% in excess for cutting/piercing injuries, and 61% in excess for blunt injuries. Uninsured blacks comprised 76% of all excess trauma center deaths from assault. CONCLUSIONS: Along with insurance status, and after excluding on-scene deaths, among patients brought to the Level I and II trauma centers, race is a substantial independent predictor of who dies from assault. Blacks, especially the uninsured, have significantly worse outcomes overall, but there is some evidence that this pattern is minimized at higher levels of injury severity. LEVEL OF EVIDENCE: I, prognostic study.

A Lipskian analysis of child protection failures from Victoria Climbié to "Baby P": a street-level re-evaluation of joined-up governance.

This paper explores the issue of joined-up governance by considering child protection failures, firstly, the case of Victoria Climbié who was killed by her guardians despite being known as an at risk child by various public agencies. The seeming inability of the child protection system to prevent Victoria Climbié's death resulted in a public inquiry under the chairmanship of Lord Laming. The Laming report of 2003 looked, in part, to the lack of joined-up working between agencies to explain this failure to intervene and made a number of recommendations to improve joined-up governance. Using evidence from detailed testimonies given by key personnel during the Laming Inquiry, the argument of this paper is that we cannot focus exclusively on formal structures or decision-making processes but must also consider the normal, daily and informal routines of professional workers. These very same routines may inadvertently culminate in the sort of systemic failures that lead to child protection tragedies. Analysis of the micro-world inhabited by professional workers would benefit most, it is argued here, from the policy-based concept of street-level bureaucracy developed by Michael Lipsky some 30 years ago. The latter half of the paper considers child protection failures that emerged after the Laming-inspired reforms. In particular, the case of 'Baby P' highlights, once again, how the working practices of street-level professionals, rather than a lack of joined-up systems, may possibly complement an analysis of, and help us to explain, failures in the child protection system. A Lipskian analysis generally offers, although there are some caveats, only pessimistic conclusions about the prospects of governing authorities being able to avoid future child protection disasters. These conclusions are not wholeheartedly accepted. There exists a glimmer of optimism because street-level bureaucrats still remain accountable, but not necessarily in terms of top-down relations of authority rather, in terms of interpersonal forms of accountability ­ accountability to professionals and citizen consumers of services.

The limits of oral history: ethics and methodology amid highly politicized research settings.

In recent years, oral history has been celebrated by its practitioners for its humanizing potential, and its ability to democratize history by bringing the narratives of people and communities typically absent in the archives into conversation with that of the political and intellectual elites who generally write history. And when dealing with the narratives of ordinary people living in conditions of social and political stability, the value of oral history is unquestionable. However, in recent years, oral historians have increasingly expanded their gaze to consider intimate accounts of extreme human experiences, such as narratives of survival and flight in response to mass atrocities. This shift in academic and practical interests begs the questions: Are there limits to oral historical methods and theory? And if so, what are these limits? This paper begins to address these questions by drawing upon fourteen months of fieldwork in Rwanda and Bosnia-Hercegovina, during which I conducted multiple life history interviews with approximately one hundred survivors, ex-combatants, and perpetrators of genocide and related mass atrocities. I argue that there are limits to the application of oral history, particularly when working amid highly politicized research settings.

We fall down: the African American experience of coping with the homicide of a loved one.

Rates of homicide among African Americans are much higher than those of other racial or ethnic groups. Research has demonstrated that homicide can be psychologically debilitating for surviving family members. Yet, exploring the experiences of homicide victims' surviving loved ones has received little attention. This study examined the coping strategies of African American survivors of homicide. Qualitative interviews were conducted with 8 African American family members (ages 18-82) of homicide victims. Survivors were recruited from the Massachusetts Office of Victim Services and from homicide survivor support, school, and community groups throughout the New England area. Interviews were conducted using open-ended questions derived from coping, support network, grief, and bereavement literatures. Results indicate that the primary coping strategies utilized by African American survivors of homicide victims are spiritual coping and meaning making, maintaining a connection to the deceased, collective coping and caring for others, and concealment. Implications for research and practice are discussed.