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Studies have shown that poverty and income are powerful predictors of homicide and violent crime. We hypothesized that the effect of the growing gap between the rich and poor is mediated through an undermining of social cohesion, or social capital, and that decreased social capital is in turn associated with increased firearm homicide and violent crime. Social capital was measured by the weighted responses to two items from the U.S. General Social Survey: the per capita density of membership in voluntary groups in each state; and the level of social trust, as gauged by the proportion of residents in each state who believed that 'most people would take advantage of you if they got the chance'. Age-standardized firearm homicide rates for the years 1987-1991 and firearm robbery and assault incidence rates for years 1991-1994 were obtained for each of the 50 U.S. states. Income inequality was strongly correlated with firearm violent crime (firearm homicide, r = 0.76) as well as the measures of social capital: per capita group membership (r = -0.40) and lack of social trust (r = 0.73). In turn, both social trust (firearm homicide, r = 0.83) and group membership (firearm homicide, r = -0.49) were associated with firearm violent crime. These relationships held when controlling for poverty and a proxy variable for access to firearms. The profound effects of income inequality and social capital, when controlling for other factors such as poverty and firearm availability, on firearm violent crime indicate that policies that address these broader, macro-social forces warrant serious consideration. [ABSTRACT FROM AUTHOR]

We examined the status of women in the 50 American states in relation to women's and men's levels of health. The status of women in each state was assessed by four composite indices measuring women's political participation, economic autonomy, employment and earnings, and reproductive rights. The study design was cross-sectional and ecologic. Our main outcome measures were total female and male mortality rates, female cause-specific death rates and mean days of activity limitations reported by women during the previous month. Measures of women's status were strikingly correlated with each of these health outcomes at the state level. Higher political participation by women was correlated with lower female mortality rates (r = -0.51), as well as lower activity limitations (-0.47). A smaller wage gap between women and men was associated with lower female mortality rates (-0.30) and lower activity limitations (-0.31) (all correlations, P < 0.05). Indices of women's status were also strongly correlated with male mortality rates, suggesting that women's status may reflect more general underlying structural processes associated with material deprivation and income inequality. However, the indices of women's status persisted in predicting female mortality and morbidity rates after adjusting for income inequality, poverty rates and median household income. Associations were observed for specific causes of death, including stroke, cervical cancer and homicide. We conclude that women experience higher mortality and morbidity in states where they have lower levels of political participation and economic autonomy. Living in such states has detrimental consequences for the health of men as well. Gender inequality and truncated opportunities for women may be one of the pathways by which the maldistribution of income adversely affects the health of women. [ABSTRACT FROM AUTHOR]

Background: Exploring the perceptions of underrepresented in medicine (URiM) students about the medical education curriculum and learning environment could optimize their education outcomes. The current study delineated perceptions of URiM medical students about the unique elements and characteristics of an impactful medical education program that create a positive, supportive learning environment culture., Methods: We conducted in-depth interviews with 15 URiM students between January 2018 and April 2018. Interviewees were recruited from an accredited medical education program in Historically Black Colleges and Universities (HBCUs). The University is also a member of the Hispanic Association of Colleges and Universities in the U.S. The main question that guided the study was, "What do URiM students at a Historically Black Colleges and Universities (HBCU) medical school believe would make a medical education program (MEP) impactful?" We used the grounded theory analytical approach and performed content analysis via qualitative thematic evaluation., Results: Of 112 enrolled medical students (MS), 15 verbally consented to participation. We identified four general themes and several subthemes. The themes include 1) Grounding learning in the community; 2) Progressive system-based practice competency; 3) Social justice competency and 4) Trauma-informed medical education delivery. Theme 1 included the following subthemes (a) community engagement, and (b) student-run clinic, mobile clinic, and homeless clinic rotations. Theme 2 includes (a) interprofessional learning and (b) multidisciplinary medicine for cultivating a 'just' healthcare system. Theme 3 includes (a) longitudinal social justice curriculum, (b) advocacy, and (c) health disparity research. Theme 4 had the following subdomains (a) early and ongoing mentoring and (b) provision of supportive policies, services and practices to maximize learning and mental health., Conclusion: Our learners found that social justice, trauma-informed, community-based curricula are impactful for URiM learners. These findings highlight the need for further research to assess the impact of permeating the championship culture, community cultural wealth, and transformational education in all aspects of the MEP in providing a supporting and positive learning environment for URiM students., (© 2022. The Author(s).)

Local face-to-face provider training has the benefit of enabling participants to network with people in their communities who are working on similar issues, to engage in interactive discussions, and to learn from local experts and local program examples. However, face-to-face training has considerable costs (labor and expense) and provides limited exposure to national experts. In recent years, technology has allowed training methods to expand to include distance learning methods (satellite and web-based). The newer methods can decrease per-person training costs, provide exposure to national experts, and result in wide dissemination of information. Yet these distance learning methods often limit the ability of participants to interact and network with each other and substantially reduce opportunities to apply the learning objectives to local circumstances. To maximize the benefits of both models, the Harvard School of Public Health, the Prevention Institute, and the Education Development Center developed, implemented, and evaluated Partnerships for Preventing Violence (PPV), an innovative six-part satellite training series on the public health approach to preventing youth violence. Using a unique hybrid methodology that combines satellite training with local, face-to-face facilitation by trained experts, PPV trained over 13,000 people, generated youth violence prevention activities across the country, and created a national cadre of youth violence prevention leaders.

This study tests the hypothesis that disparities of hypertension risk in African Americans is related to lead exposure, perceptions of racism, and stress, among urban (Roxbury, MA) and rural (Gadsden, FL) communities. Analysis of preliminary data from Phase I reveal 60% in Gadsden and 39% in Roxbury respondents self-reported having hypertension. In Gadsden 80% people did not know if their residence contained lead paint, compared to 45% in Roxbury. In Gadsden County, 58% of respondents reported experiencing racial discrimination in different settings compared with 72% in Roxbury. In regression analyses high cholesterol emerged as a significant predictors of hypertension in Gadsden County (OR=8.29, CI=1.4-49.3), whereas monthly household income (OR=0.15, CI=0.04-0.7) and diabetes (OR=6.06, CI=1.4-26.17) were significant predictors of hypertension in Roxbury after adjusting for other covariates. These preliminary findings set the stage for initiating Phase II (Phase I continues recruitment), that entail biological marker measurements to rigorously test main hypothesis.

Eliminating racial and ethnic disparities in health status and health care, a major focus of Healthy People 2010, remains on the national agenda and among the priorities for the administration of President George W. Bush. Even though the elimination of racial and ethnic health disparities challenges the whole nation, individual states are on the front line of many initiatives and are often the focus of important policy efforts. In addition, it is important to focus on states because they are already responsible for much of the health and public health infrastructure, and several states have developed initiatives dating back to the release of Margaret Heckler's report on the gaps in health outcomes by race in 1985. This article makes the case for an outcome-oriented approach and provides a summary of lessons learned based upon preliminary investigations into constructing and applying two indices, the disparity reduction profile to measure effort and the disparity index to measure outcomes.

Approximately 16.4 million people in the United States have been affected by homicide. Five million adults have experienced the murder of an immediate family member; 6.6 million people have experienced the murder of a relative other than a family member, and 4.8 million have experienced the murder of a close friend. These homicide survivors experience a variety of difficulties, some similar to post-traumatic stress disorder (PTSD). The large incidence of homicide in the U.S. warrants an examination of the research on the impact of a murder on a victim's friends and family and the implications for healthcare providers. Homicide survivors experience negative psychological and physical effects that often result in an increase in the usage of primary care services. Provider training should include protocols to screen for, discuss, and make referrals for the family and friends of homicide victims. This article recommends the development of a training program to equip providers with the tools to recognize and serve this growing population of patients.

A state minority health policy report card may provide an important tool for evaluating and promoting state policies to reduce health disparities. This study develops criteria that can form the basis of such a state report card and assesses the performance of all fifty states on these measures. The results indicate wide variation among states, with geographic region being a significant predictor of performance on all four measures. Future research should be conducted on other predictors of state variation in minority health policy and connections between state policy and health outcomes for minorities.

Objectives: A growing number of studies have documented the deleterious health consequences of the experience of racial discrimination in African Americans. The present study examined the association of racial prejudice--measured at a collective level--to black and white mortality across the United States., Methods: Cross-sectional ecologic study, based on data from 39 states. Collective disrespect was measured by weighted responses to a question on a national survey, which asked: "On the average blacks have worse jobs, income, and housing than white people. Do you think the differences are: (A) Mainly due to discrimination? (yes/no); (b) Because most blacks have less in-born ability to learn? (yes/no); (c) Because most blacks don't have the chance for education that it takes to rise out of poverty? (yes/no); and (d) Because most blacks just don't have the motivation or will power to pull themselves up out of poverty? (yes/no)." For each state, we calculated the percentage of respondents who answered in the affirmative to the above statements. Age-standardized total and cause-specific mortality rates in 1990 were obtained for each state., Results: Both measures of collective disrespect were strongly correlated with black mortality (r = 0.53 to 0.56), as well as with white mortality (r = 0.48 to 0.54). A 1 percent increase in the prevalence of those who believed that blacks lacked innate ability was associated with an increase in age-adjusted black mortality rate of 359.8 per 100,000 (95% confidence interval: 187.5 to 532.1 deaths per 100,000)., Conclusions: These data suggest that racism, measured as an ecologic characteristic, is associated with higher mortality in both blacks and whites.

Objectives: Recent studies have demonstrated that income inequality is related to mortality rates. It was hypothesized, in this study, that income inequality is related to reduction in social cohesion and that disinvestment in social capital is in turn associated with increased mortality., Methods: In this cross-sectional ecologic study based on data from 39 states, social capital was measured by weighted responses to two items from the General Social Survey: per capita density of membership in voluntary groups in each state and level of social trust, as gauged by the proportion of residents in each state who believed that people could be trusted. Age-standardized total and cause-specific mortality rates in 1990 were obtained for each state., Results: Income inequality was strongly correlated with both per capita group membership (r = -.46) and lack of social trust (r = .76). In turn, both social trust and group membership were associated with total mortality, as well as rates of death from coronary heart disease, malignant neoplasms, and infant mortality., Conclusions: These data support the notion that income inequality leads to increased mortality via disinvestment in social capital.

Objective: To determine the effect of income inequality as measured by the Robin Hood index and the Gini coefficient on all cause and cause specific mortality in the United States., Design: Cross sectional ecological study., Setting: Households in the United States., Main Outcome Measures: Disease specific mortality, income, household size, poverty, and smoking rates for each state., Results: The Robin Hood index was positively correlated with total mortality adjusted for age (r = 0.54; P < 0.05). This association remained after adjustment for poverty (P < 0.007), where each percentage increase in the index was associated with' an increase in the total mortality of 21.68 deaths per 100,000. Effects of the index were also found for infant mortality (P = 0.013); coronary heart disease (P = 0.004); malignant neoplasms (P = 0.023); and homicide (P < 0.001). Strong associations were also found between the index and causes of death amenable to medical intervention. The Gini coefficient showed very little correlation with any of the causes of death., Conclusion: Variations between states in the inequality of income were associated with increased mortality from several causes. The size of the gap between the wealthy and less well off--as distinct from the absolute standard of living enjoyed by the poor--seems to matter in its own right. The findings suggest that policies that deal with the growing inequities in income distribution may have an important impact on the health of the population.

Purpose: To investigate the association of exposure to a community-based youth violence prevention project with adolescents' knowledge and attitudes about violence., Methods: Two samples of 400 teens each from Boston neighborhoods were surveyed by random-digit dialed telephone techniques: one at the start of the project and one after 1 year of implementation. Regression analyses were used to investigate associations between exposure to different educational formats and outcome measures., Results: Only self-reported exposure to the mass media campaign was significantly associated with higher scores in both knowledge and attitudes. An independent interaction between gender and exposure to the mass media campaign was found among males. Analyses using a historic control group support a program effect and not recall bias. Exposure to workshops or one-on-one discussions about violence prevention were not significantly associated with outcome scores., Conclusion: The measurable effect of the mass media may be somewhat related to the strength of that stimulus over the study period and suggests that 12 months is too short a time frame for evaluating community-based educational efforts.

Clinical settings provide excellent opportunities for educating adolescent patients about violence prevention. This paper reports on the experience of the Violence Prevention Project of Boston in implementing comprehensive violence prevention activities in different clinical settings. The project's evaluation revealed that staff training, specialized educational materials and staff commitment are required for both initial and sustained implementation of the education. Waiting room brochures and videos are inadequate to address the problem. Conversely, clinical settings can host a variety of educational experiences that generate significant response from patients, families and friends. Clinical settings can also be integrated into broader community-based efforts.

Violence is exacting an increasingly heavy toll on individuals across the country, causing a marked rise in fear and frustration. However, historical attempts to address violence have been both episodic and inconsistent. There has not been a comprehensive and coordinated, prevention-oriented approach. Many law enforcement experts now agree that violence must be met with solutions from disciplines other than law enforcement, those of public health included. These experts acknowledge that social conditions such as family stability, education, and other societal institutions directly affect the behavior of juveniles and thereby the safety of communities. No single strategy, institution, or discipline can create the changes needed to reduce violence in America. Preventing violence demands not only a long-term commitment but a comprehensive set of strategies and new partnerships. These combined efforts must focus on prevention and not solely on aggressive responses to violence.

Purpose: Educational interventions directed to the prevention of youth inter-personal violence make assumptions about the educational needs of adolescents for violence-prevention despite little available data. This paper provides new information on background levels of adolescents' knowledge of, attitudes about and experience with violence., Methods: Over 400 teens across Boston's neighborhoods were surveyed by rando-digit dialed telephone techniques., Results: Results show that while boys are more often involved in violence, almost one quarter of girls report fighting. Black teens witness more violence and are threatened more often than whites, but they do not fight more. Knowledge scores indicate a need for improvement in adolescents' understanding of risk factors. Attitude scores indicate that adolescents believe fighting can and should be avoided, but they lack knowledge of behavioral options. Regression analyses show a positive relationship between violence experience and knowledge and attitudes., Conclusion: These data suggest that preventive interventions should be directed to both improving adolescents' knowledge and understanding of personal risk and increasing their repertoire of conflict-resolution skills.

This paper describes the implementation of a community-based youth violence prevention project that utilized an educational curriculum and a mass media campaign. The extent of penetration of the intervention into target areas and the degree of contamination of control areas are assessed, and the most frequently contacted forms of educational outreach are identified. Two sources of data, provider interviews and a random digit dialed telephone survey, were used to track the source and extent of teens' exposure to the intervention. Agency provider data revealed that 40% of the 92 contacted agencies actually conducted violence prevention education, reaching 22% of the target area teens. Approximately one-half of the surveyed teens reported some exposure to the program, with 13% of the teens in target areas reporting participation in interactive educational activities associated with the project. The most common source of exposure was the media campaign. Most teens report a single exposure, usually to the media campaign, although 29% report contact with more than one form of violence prevention education. While the project did not achieve community saturation, the data show that the community-based model of intervention for violence prevention is feasible and effective in reaching teenagers. This research highlights some difficulties in evaluating prevention programs, including reconciling community ownership with project identification, the ethics of curtailing services for control purposes, and factors influencing recall of participation.

Some of the factors associated with such violence, notably racism and poverty, clearly demand societal solutions. Other factors, however, may respond to public health intervention strategies. Emergency room workers can practice secondary intervention, as they do with victims of child abuse, sexual assault, or attempted suicide. Family physicians can refer adolescents for appropriate help.

The Violence Prevention Project is a community-based outreach and education project directed toward reducing the negative social and medical outcomes of violence among adolescents. Community agency personnel are trained to work with youth on issues of anger and conflict resolution. A mass media campaign advertises the issue to the broader population. Interventions, such as the Violence Prevention Project, can use the public health strategies to increase awareness of the problem and associated risk factors, provide alternative conflict resolution techniques, and generate a new community ethos around violence. This approach holds great promise in an area in which after-the-fact legislative and punitive interventions have not worked.

Violence and its consequences are a major issue to be addressed by the health care community. The magnitude and characteristics of the problem cry out for new, creative approaches and provide for some insight into the direction that needs to be taken. Some of the components related to violence are societal in scope and will require long-term strategies well beyond the immediate realm of the health care system. Others provide direction that more clearly present a role for health providers and public health planners. Although there will be no easy answers or solutions to this problem, it is essential that support be developed for experimental efforts. The health community cannot ignore this problem and can in fact make a real contribution to its resolution through prevention, treatment, and research.