BACKGROUND: Children aged 0-4 years have the highest rate of emergency department (ED) visits for traumatic brain injury (TBI); falls are the leading cause. Infants younger than 2 years are more likely to sustain a fractured skull after a fall. OBJECTIVE: This study examined caregiver actions and products associated with ED visits for fall-related fractured skulls in infants aged 0-4 months. METHODS: Data were analyzed from the 2001-2017 National Electronic Injury Surveillance System-All Injury Program. Case narratives of infants aged 0-4 months who visited an ED for a fall-related skull fracture were examined to code caregiver actions preceding the fall. Product codes determined fall location and product type involved (e.g., flooring, bed, or stairs). All national estimates were weighted. RESULTS: There were more than 27,000 ED visits (weighted estimate) of infants aged 0-4 months for a nonfatal fall-related fractured skull between 2001 and 2017. Most were younger than 2 months (46.7%) and male (54.4%). Falls occurred primarily in the home (69.9%) and required hospitalization (76.4%). Primary caregiver actions coded involved placing (58.6%), dropping (22.7%), and carrying an infant (16.6%). Floor surfaces were the most common product (mentioned in 24.0% of the cases). CONCLUSIONS: Fall-related fractured skulls are a health and developmental concern for infants, highlighting the importance of a comprehensive assessment at the time of the injury to better understand adult actions. Findings indicated the need to develop prevention messages that include safe carrying and placement of infants.

Hepatitis B virus (HBV) causes acute and chronic infection of the liver leading to substantial morbidity and mortality. In the United States, since 1996, a total of 29 outbreaks of HBV infection in one or multiple long-term-care (LTC) facilities, including nursing homes and assisted-living facilities, were reported to CDC; of these, 25 involved adults with diabetes receiving assisted blood glucose monitoring. These outbreaks prompted the Hepatitis Vaccines Work Group of the Advisory Committee on Immunization Practices (ACIP) to evaluate the risk for HBV infection among all adults with diagnosed diabetes. The Work Group reviewed HBV infection-related morbidity and mortality and the effectiveness of implementing infection prevention and control measures. The strength of scientific evidence regarding protection was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology,* and safety, values, and cost-effectiveness were incorporated into a recommendation using the GRADE system. Based on the Work Group findings, on October 25, 2011, ACIP recommended that all previously unvaccinated adults aged 19 through 59 years with diabetes mellitus (type 1 and type 2) be vaccinated against hepatitis B as soon as possible after a diagnosis of diabetes is made (recommendation category A). Data on the risk for hepatitis B among adults aged ≥60 years are less robust. Therefore, ACIP recommended that unvaccinated adults aged ≥60 years with diabetes may be vaccinated at the discretion of the treating clinician after assessing their risk and the likelihood of an adequate immune response to vaccination (recommendation category B). This report summarizes these recommendations and provides the rationale used by ACIP to inform their decision making.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of homicide-related death in the United States. Penetrating TBI associated with firearms is a unique injury with an exceptionally high mortality rate that requires specialized neurocritical trauma care. OBJECTIVE: To report incidence patterns of firearm-related and nonfirearm-related TBI homicides in the United States between 2000 and 2019 by demographic characteristics to provide foundational data for prevention and treatment strategies. METHODS: Data were obtained from multiple cause of death records from the National Vital Statistics System using Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for the years 2000 to 2019. Number, age-adjusted rates, and percent of firearm and nonfirearm-related TBI homicides by demographic characteristics were calculated. Temporal trends were also evaluated. RESULTS: During the study period, there were 77 602 firearm-related TBI homicides. Firearms were involved in the majority (68%) of all TBI homicides. Overall, men, people living in metro areas, and non-Hispanic Black persons had higher rates of firearm-related TBI homicides. The rate of nonfirearm-related TBI homicides declined by 40%, whereas the rate of firearm-related TBI homicides only declined by 3% during the study period. There was a notable increase in the rate of firearm-related TBI homicides from 2012/2013 through 2019 for women (20%) and nonmetro residents (39%). CONCLUSION: Firearm-related violence is an important public health problem and is associated with the majority of TBI homicide deaths in the United States. The findings from this study may be used to inform prevention and guide further research to improve treatment strategies directed at reducing TBI homicides involving firearms.

Purpose: Despite evidence showing the importance of structural determinants for child well-being and the existence of policies that can promote child well-being, many communities are not adopting these policies. Limited awareness of structural determinants may explain this gap. This study establishes the public's recognition of structural determinants and their associations with support for policies that promote child well-being. Methods: Secondary analyses of survey data collected in 2019 from a random sample of 2496 adults in the United States. This survey asked why some children “struggle” (e.g., do poorly in school, use drugs, or get involved in crime). Respondents could select individual (e.g., lack of effort) and structural (e.g., low wages) explanations. Respondents were also asked about their support for policies that are supportive of children and families. Results: Stronger beliefs of structural explanations were associated with greater support for policies that strengthen family economics, family-friendly work, and afford access to high-quality early childcare and education. Beliefs in individual explanations were inversely associated with support for these policies. Conclusions: These findings suggest increasing recognition of the structural determinants that hinder child development may help increase support for policies that are effective in improving children's outcomes. © 2021 Society for the Psychological Study of Social Issues. This article has been contributed to by US Government employees and their work is in the public domain in the USA.

OBJECTIVES: Widespread SARS-CoV-2 testing is critical to identify infected people and implement public health action to interrupt transmission. With SARS-CoV-2 testing supplies and laboratory capacity now widely available in the United States, understanding the spatial heterogeneity of associations between social determinants and the use of SARS-CoV-2 testing is essential to improve testing availability in populations disproportionately affected by SARS-CoV-2. METHODS: We assessed positive and negative results of SARS-CoV-2 molecular tests conducted from February 1 through June 17, 2020, from the Massachusetts Virtual Epidemiologic Network, an integrated web-based surveillance and case management system in Massachusetts. Using geographically weighted regression and Moran's I spatial autocorrelation tests, we quantified the associations between SARS-CoV-2 testing rates and 11 metrics of the Social Vulnerability Index in all 351 towns in Massachusetts. RESULTS: Median SARS-CoV-2 testing rates decreased with increasing percentages of residents with limited English proficiency (median relative risk [interquartile range] = 0.96 [0.95-0.99]), residents aged ≥65 (0.97 [0.87-0.98]), residents without health insurance (0.96 [0.95-1.04], and people residing in crowded housing conditions (0.89 [0.80-0.94]). These associations differed spatially across Massachusetts, and localized models improved the explainable variation in SARS-CoV-2 testing rates by 8% to 12%. CONCLUSION: Indicators of social vulnerability are associated with variations in SARS-CoV-2 testing rates. Accounting for the spatial heterogeneity in these associations may improve the ability to explain and address the SARS-CoV-2 pandemic at substate levels.

BACKGROUND: People who inject drugs (PWID) lag behind other key populations in HIV care continuum outcomes. The impacts of criminal justice reform and increasing drug treatment access on HIV have been underexplored. METHODS: We developed agent-based models (ABM) of sexual partnerships among PWID and non-PWID, and injection equipment-sharing partnerships among PWID in five US cities (Baltimore, Boston, Miami, New York City, San Francisco) over 3 years. The first set of ABM projected changes in partnership discordance among PWID as a function of decreasing ZIP code-level incarceration rates. The second set projected discordance as a function of increasing ZIP code-level drug treatment access. ABM were parameterized and validated overall, and by city and PWID race/ethnicity (Black, Latino, White) using National HIV Behavioral Surveillance data, administrative ZIP code-level data, surveillance reports and prior literature. Informed by research on prisoner release and community-level HIV prevalence, reductions in incarceration rates were fixed at 5% and 30% and respectively projected to increase ZIP code-level HIV prevalence by 2% and 12%. Increases in drug treatment access were fixed at 30% and 58%. RESULTS: In each city, a 30% reduction in ZIP code-level incarceration rates and 12% increase in ZIP code-level HIV prevalence significantly increased sero-discordance among at least one racial/ethnic group of PWID by 1-3 percentage points. A 5% reduction in incarceration rates, and 30% and 58% increases in drug treatment access, led to isolated significant changes in sero-discordance among Black and White PWID that were less than 1 percentage point. CONCLUSION: Reductions in incarceration rates may lead to short-term increases in sero-discordant partnerships among some PWID by increasing community-level HIV prevalence. Efforts to increase HIV testing, engagement in care and community reintegration post release, should be strengthened in the wake of incarceration reform. Additional research should confirm these findings and explore the lack of widespread impacts of drug treatment in this study.

Child corporal punishment is a prevalent public health problem in the US. Although corporal punishment is sustained through parents' perceptions of social norms supporting this discipline behavior, little research has investigated where these normative perceptions come from. To fill this gap, we conducted 13 focus groups including 75 low-income Black, Latino, and White parents across five states in the US. Results revealed that one influential source of Black and White parents' perceived norms was their positive framing of corporal punishment experiences during childhood. Furthermore, Black parents formed normative perceptions based on identification with parents in their racial/ethnic group, while White parents did so with parents sharing the same generation. Results are interpreted in light of the false consensus effect and self-categorization theory. In contrast, Latino parents viewed their childhood experience of corporal punishment as negative and distanced their parenting practices from those practiced in their countries of origin, suggesting an influence of acculturation. Their perceived norms were likely transmitted through interpersonal communication within their social networks. These findings shed light on how social norms are formed and in turn guide parents' use of corporal punishment as a tool to discipline children.

Corporal punishment (CP) leads to detrimental mental and physical consequences for a child. One way to prevent CP is to encourage parents to apply alternative discipline strategies that do not involve violence. Based on the knowledge-behavior gap framework in public health education, this study analyzed the focus group data of 75 low-income Black, Latino and White parents to uncover commonalties and differences in their knowledge, self-efficacy and response efficacy of alternative discipline strategies. Findings revealed that parents knew several alternative discipline strategies and had confidence in their ability to conduct these strategies. However, parents reported that some strategies were hard to implement because they lacked the relevant resources. Moreover, parents did not perceive that alternative discipline strategies were effective without using some forms of CP. Knowledge, self-efficacy and response efficacy of alternative discipline strategies are risk factors for child physical abuse and addressing them will help prevent injury and health impacts on children, while providing safe, stable, nurturing relationships and environments for child development.

Children who grow up in poverty are at risk for various poor outcomes. Socioeconomic policies can shape the conditions in which families are raising children and may be effective at reducing financial strain and helping families obtain economic sufficiency, thereby reducing risk for poor health outcomes. This study used data from two surveys conducted in the US, the National Longitudinal Survey of Youth 1979 (NLSY79) and the NLSY79 Young Adult survey to determine whether the U.S. Federal Child Tax Credit (CTC), a socioeconomic policy that provides tax relief to low- and middle-income families to offset the costs of raising children, is associated with child well-being, as indicated by whether the child had injuries requiring medical attention and behavioral problems. Fixed-effects models, accounting for year and state of residence, detected a lower likelihood of injuries requiring medical attention (OR = 0.58, 95% CI [0.40, 0.86]) and significantly fewer behavior problems (b = -2.07, 95% CI [-4.06, -0.08]) among children with mothers eligible to receive a CTC, but only when it was partially refundable (i.e., mothers could receive a tax refund for a portion of the CTC that exceeds their tax liability) for families making as little as $3000 a year. Tax credits like the CTC have the potential to alleviate financial strain among families, and consequently, may have impacts on injury and behavior problems.

Homicide is the 13th leading cause of death among infants (i.e., children aged <1 year) in the United States (1). Infant homicides occurring within the first 24 hours of life (i.e., neonaticide) are primarily perpetrated by the mother, who might be of young age, unmarried, have lower educational attainment, and is most likely associated with concealment of an unintended pregnancy and nonhospital birthing (2). After the first day of life, infant homicides might be associated with other factors (e.g., child abuse and neglect or caregiver frustration) (2). A 2002 study of the age variation in homicide risk in U.S. infants during 1989-1998 found that the overall infant homicide rate was 8.3 per 100,000 person-years, and on the first day of life was 222.2 per 100,000 person-years, a homicide rate at least 10 times greater than that for any other time of life (3). Because of this period of heightened risk, by 2008 all 50 states* and Puerto Rico had enacted Safe Haven Laws. These laws allow a parent(†) to legally surrender an infant who might otherwise be abandoned or endangered (4). CDC analyzed infant homicides in the United States during 2008-2017 to determine whether rates changed after nationwide implementation of Safe Haven Laws, and to examine the association between infant homicide rates and state-specific Safe Haven age limits. During 2008-2017, the overall infant homicide rate was 7.2 per 100,000 person-years, and on the first day of life was 74.0 per 100,000 person-years, representing a 66.7% decrease from 1989-1998. However, the homicide rate on first day of life was still 5.4 times higher than that for any other time in life. No obvious association was found between infant homicide rates and Safe Haven age limits. States are encouraged to evaluate the effectiveness of their Safe Haven Laws and other prevention strategies to ensure they are achieving the intended benefits of preventing infant homicides. Programs and policies that strengthen economic supports, provide affordable childcare, and enhance and improve skills for young parents might contribute to the prevention of infant homicides.

Despite advances in the sexual violence (SV) prevention field, practitioners still face challenges with identifying indicators to measure the impact of their prevention strategies. Public data, such as existing administrative and surveillance system data, may be a good option for organizations to examine trends in indicators for the purpose of program evaluation. In this article, we describe a framework and a process for identifying indicators with public data. Specifically, we present the SV Indicator Framework and a five-step indicator review process, which we used to identify indicators for a national SV prevention program. We present the findings of the indicator review and explain how the process could be used by evaluators and program planners within other developing topic areas. Tracking indicators with public data, in conjunction with other evaluation methods, may be a viable option for state-level program evaluations. We discuss limitations and implications for practice and research.

Public health addresses child maltreatment and other adverse childhood experiences by focusing primarily on preventing them from happening in the first place; understanding and addressing their individual, relational, community, and societal causes using the best available scientific evidence; and engaging in large-scale, multi-sector partnerships. Such large scale efforts require bringing together a compelling narrative, relationships, and strategy. This article describes how the Centers for Disease Control and Prevention used a public health approach to develop a narrative, relationships, and strategy to prevent child maltreatment.

Foster care caseloads, an indicator of child maltreatment, are increasing. Children living in poverty are significantly more likely to be reported to the child welfare system and are overrepresented in foster care. Thus, it is critical to identify prevention strategies that can stem the flow of foster care entries, particularly among populations at higher risk. We used variations in the adoption and refund status of state-level Earned Income Tax Credit (EITC), a socioeconomic policy intended to reduce poverty, to examine their effect on foster care entry rates. Fixed-effects models, accounting for year- and state-fixed effects, demonstrated that a refundable EITC was associated with an 11% decrease in foster care entries compared to states without a state-level EITC after controlling for child poverty rate, racial/ethnic composition, education, and unemployment. Policies that strengthen economic supports for families may prevent child maltreatment and reduce foster care entries and associated costs.

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID).Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors.Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses.Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response.Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative. (Am J Public Health. Published online ahead of print November 14, 2019: e1-e8. doi:10.2105/AJPH.2019.305366).

INTRODUCTION: Adverse childhood experiences, such as violence victimization, substance misuse in the household, or witnessing intimate partner violence, have been linked to leading causes of adult morbidity and mortality. Therefore, reducing adverse childhood experiences is critical to avoiding multiple negative health and socioeconomic outcomes in adulthood. METHODS: Behavioral Risk Factor Surveillance System data were collected from 25 states that included state-added adverse childhood experience items during 2015-2017. Outcomes were self-reported status for coronary heart disease, stroke, asthma, chronic obstructive pulmonary disease, cancer (excluding skin cancer), kidney disease, diabetes, depression, overweight or obesity, current smoking, heavy drinking, less than high school completion, unemployment, and lack of health insurance. Logistic regression modeling adjusting for age group, race/ethnicity, and sex was used to calculate population attributable fractions representing the potential reduction in outcomes associated with preventing adverse childhood experiences. RESULTS: Nearly one in six adults in the study population (15.6%) reported four or more types of adverse childhood experiences. Adverse childhood experiences were significantly associated with poorer health outcomes, health risk behaviors, and socioeconomic challenges. Potential percentage reductions in the number of observed cases as indicated by population attributable fractions ranged from 1.7% for overweight or obesity to 23.9% for heavy drinking, 27.0% for chronic obstructive pulmonary disease, and 44.1% for depression. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Efforts that prevent adverse childhood experiences could also potentially prevent adult chronic conditions, depression, health risk behaviors, and negative socioeconomic outcomes. States can use comprehensive public health approaches derived from the best available evidence to prevent childhood adversity before it begins. By creating the conditions for healthy communities and focusing on primary prevention, it is possible to reduce risk for adverse childhood experiences while also mitigating consequences for those already affected by these experiences.

From 2000 to 2014, the number of annual diagnoses of human immunodeficiency virus (HIV) infection in Massachusetts declined 47% (1). In August 2016, however, the Massachusetts Department of Public Health (MDPH) received reports of five new HIV cases among persons who inject drugs from a single community health center in the City of Lawrence (2). On average, less than one case per month among persons who inject drugs had been reported in Lawrence during 2014–2015 from all providers. Surveillance identified additional cases of HIV infection among such persons linked to Lawrence and Lowell, in northeastern Massachusetts, during 2016–2017. In 2018, MDPH and CDC conducted an investigation to characterize the outbreak and recommend control measures.

To establish commonalities and differences in social norms related to corporal punishment among Black, Latino, and White parents, we first examine survey data from a random sample of a nationally representative opt-in internet panel (n = 2500) to establish the frequency of corporal punishment among parents of children under five (n = 540) and their perceptions of the frequency of use of corporal punishment in their community and whether they ought to use corporal punishment. We disaggregate by race/ethnicity and education to identify higher risk groups. To better understand the beliefs underlying these perceptions among the higher risk group (i.e., less educated), we used a grounded theory approach to analyze data from 13 focus groups (n = 75) segmented by race/ethnicity (i.e., Black, Latino, or White), gender (i.e., mothers or fathers), and population density (i.e., rural or urban). Survey findings revealed that 63% of parents spanked, albeit the majority seldom or sometimes. Spanking was most frequent among Latinos (73%) and lowest among White parents (59%). While all participants across racial/ethnic groups believed the majority of parents spanked, even more than the proportion that actually do, about half believed they ought to spank. Perceptions of the frequency and acceptability of corporal punishment were associated with use of corporal punishment. The qualitative findings highlight more similarities than differences across Black, Latino, and White communities. The findings suggest social norms change efforts might focus on parents with less education and influencing perceptions around whether they ought to spank.

Policies that improve the socioeconomic conditions of families have been identified as one of the most promising strategies to prevent child maltreatment, particularly neglect. In this study, we examined the impact of integrated Temporary Assistance for Needy Families (TANF) and child welfare (CW) systems on child maltreatment-related hospitalizations and Child Protective Services investigations and substantiations in nine counties in Colorado from 1996 to 2014. Regression analyses showed TANF-CW integration was associated with subsequent year, but not second-year, increases rates of substantiated child maltreatment overall and neglect specifically (that is, there was no longer a difference in the rate two years after the change in integration). Neither unemployment nor the one- or two-year lagged effect of integration were significant for investigations or child maltreatment-related hospitalizations. Increased opportunities to interact with a family in crisis using an integrated case management model may help explain these findings. Implications for future research are discussed.

Child maltreatment incurs a high lifetime cost per victim and creates a substantial US population economic burden. This study aimed to use the most recent data and recommended methods to update previous (2008) estimates of 1) the per-victim lifetime cost, and 2) the annual US population economic burden of child maltreatment. Three ways to update the previous estimates were identified: 1) apply value per statistical life methodology to value child maltreatment mortality, 2) apply monetized quality-adjusted life years methodology to value child maltreatment morbidity, and 3) apply updated estimates of the exposed population. As with the previous estimates, the updated estimates used the societal cost perspective and lifetime horizon, but also accounted for victim and community intangible costs. Updated methods increased the estimated nonfatal child maltreatment per-victim lifetime cost from $210,012 (2010 USD) to $830,928 (2015 USD) and increased the fatal per-victim cost from $1.3 to $16.6 million. The estimated US population economic burden of child maltreatment based on 2015 substantiated incident cases (482,000 nonfatal and 1670 fatal victims) was $428 billion, representing lifetime costs incurred annually. Using estimated incidence of investigated annual incident cases (2,368,000 nonfatal and 1670 fatal victims), the estimated economic burden was $2 trillion. Accounting for victim and community intangible costs increased the estimated cost of child maltreatment considerably compared to previous estimates. The economic burden of child maltreatment is substantial and might off-set the cost of evidence-based interventions that reduce child maltreatment incidence.

OBJECTIVES: To understand the role of the community environment on intergenerational continuity in adverse childhood experiences (ACEs) among a rural White sample. METHODS: Parents in 12 counties in rural Iowa reported retrospectively on their own ACEs in 1989. We measured their child's ACEs retrospectively and prospectively across adolescence (n = 451 families). We measured structural and social process-related measures of community environment (i.e., community socioeconomic status, parents' perception of community services, perceived community social cohesion, and neighborhood alcohol vendor density) on multiple occasions during the child's adolescence. RESULTS: The 4 measures of community environment were all correlated with the child's ACEs, but only alcohol vendor density predicted ACEs after inclusion of covariates. Intergenerational continuity in ACEs was moderated by both social cohesion (b = -0.11; SE = 0.04) and alcohol vendor density (b = -0.11; SE = 0.05). CONCLUSIONS: Efforts to increase community social cohesion and manage alcohol vendor density may assist families in breaking the cycle of maltreatment across generations.

The degree to which child maltreatment interacts with other household adversities to exacerbate risk for poor adult socioeconomic outcomes is uncertain. Moreover, the effects of residential, school, and caregiver transitions during childhood on adult outcomes are not well understood. This study examined the relation between household adversity and transitions in childhood with adult income problems, education, and unemployment in individuals with or without a childhood maltreatment history. The potential protective role of positive relationship quality in buffering these risk relationships was also tested. Data were from the Lehigh Longitudinal Study (n=457), where subjects were assessed at preschool, elementary, adolescent, and adult ages. Multiple group path analysis tested the relationships between childhood household adversity; residential, school, and caregiver transitions; and adult socioeconomic outcomes for each group. Caregiver relationship quality was included as a moderator, and gender as a covariate. Household adversity was negatively associated with education level and positively associated with income problems for non-maltreated children only. For both groups, residential transitions was negatively associated with education level and caregiver transitions was positively associated with unemployment problems. Relationship quality was positively associated with education level only for non-maltreated children. For children who did not experience maltreatment, reducing exposure to household adversity is an important goal for prevention. Reducing exposure to child maltreatment for all children remains an important public health priority. Results underscore the need for programs and policies that promote stable relationships and environments.

Background: Persons with prior sexually transmitted infections (STIs) are at high risk for re-infection. No recent studies have examined the frequency with which persons within a geographic area are diagnosed and reported with multiple bacterial STIs over time. Methods: We conducted a retrospective, population-based study of confirmed syphilis, gonorrhea, and chlamydial infections reported to the Massachusetts state surveillance system within a two-year period, July 28, 2014 - July 27, 2016. Results: Among the Massachusetts population 13-65 years old (4,847,510), 49,142 (1.0%) were reported with >/=1 STI; 6,999 (14.2% of those with one STI) had >/=2 STIs, accounting for 27.7% of STIs. Of cases with >/=5 STIs (high-volume repeaters), 118 (74%) were men and 42 (26%) women. Men spanned the age spectrum, were predominantly white, non-Hispanic, and 87% reported same-sex contacts. Women were younger, predominantly non-white, without known same-sex contacts. Women were re-infected with gonorrhea and chlamydia, or chlamydia alone; none had syphilis or HIV infection. All men with syphilis also had gonorrhea and/or chlamydia; 35% were diagnosed with HIV, before, during the study period, or within 10 months after. The majority (56%) of high-volume repeaters were seen at more than one care site/system. Conclusions: In Massachusetts, a large proportion of bacterial STIs are reported from a small sub-population, many of whom have been repeatedly infected and are likely to have a higher impact on STI/HIV rates. Public health can play a crucial role in reaching high-volume repeaters, whose STI history may be hidden from clinicians due to fragmented care.

Children around the world experience violence at the hands of their caregivers at alarming rates. A recent review estimates that a minimum of 50% of children in Asia, Africa, and North America experienced severe physical violence by caregivers in the past year, with large variations between countries. Identifying modifiable country-level factors driving these geographic variations has great potential for achieving population-level reductions in rates of child maltreatment. This study builds on previous research by focusing on caregiver-reported physical abuse and neglect victimisation, examining 22 societal factors representing 11 different constructs among 42 countries from 5 continents at different stages of development. Our findings suggest that gender inequity may be important for both child physical abuse and neglect. Indicators of literacy and development may also be important for child neglect. Given the limitations of the correlational findings and measurement issues, it is critical to continue to investigate societal-level factors of child maltreatment so that interventions and prevention efforts can incorporate strategies that have the greatest potential for population-level impact.

Gender inequity is proposed as a societal-level risk factor for child maltreatment. However, most cross-national research examining this association is limited to developing countries and has used limited measures of gender inequity and child homicides as a proxy for child maltreatment. To examine the relationship between gender inequity and child maltreatment, we used caregivers’ reported use of severe physical punishment (proxy for physical abuse) and children under 5 left alone or under the care of another child younger than 10 years of age (supervisory neglect) and three indices of gender inequity (the Social and Institutional Gender Index, the Gender Inequality Index, and the Gender Gap Index) from 57 countries, over half of which were developing countries. We found all three gender inequity indices to be significantly associated with physical abuse and two of the three to be significantly associated with neglect, after controlling for country-level development. Based on these findings, efforts to prevent child abuse and neglect might benefit from reducing gender inequity.

We assessed the US state-level budget and societal impact of implementing two child abuse and neglect (CAN) primary prevention programs. CAN cost estimates and data from two prevention programs (Child-Parent Centers and Nurse-Family Partnership) were combined with current population, cost, and CAN incidence data by US state. A cost-benefit mathematical model for each program by US state compared program costs with the future monetary value of benefits from reduced CAN. The models used a lifetime time horizon from government payer and societal perspectives. Both programs could potentially avert CAN among tens of thousands of children across the country. Lower costs from reduced CAN may substantially offset, but not always entirely eliminate, payers' program implementation cost. Results are sensitive to the rate of CAN in each US state. Given the considerable lifetime societal cost of CAN, including victims' lost work productivity, the programs were cost saving from the societal perspective in all US states using base case methods. This analysis represents an overall minimum return on payers' investment because averted CAN is just one of many positive health and educational outcomes associated with these programs and non-monetary benefits from reduced CAN were not included. Translating cost and effectiveness research on injury prevention programs for local conditions might increase decision makers' adoption of effective programs.

OBJECTIVES: Policies that increase household income, such as the earned income tax credit (EITC), have shown reductions on risk factors for child maltreatment (ie, poverty, maternal stress, depression), but evidence is lacking on whether the EITC actually reduces child maltreatment. We examined whether states' EITCs are associated with state rates of hospital admissions for abusive head trauma among children aged <2 years. METHODS: We conducted difference-in-difference analyses (ie, pre- and postdifferences in intervention vs control groups) of annual rates of states' hospital admissions attributed to abusive head trauma among children aged <2 years (ie, using aggregate data). We conducted analyses in 14 states with, and 13 states without, an EITC from 1995 to 2013, differentiating refundable EITCs (ie, tax filer gets money even if taxes are not owed) from nonrefundable EITCs (ie, tax filer gets credit only for any tax owed), controlling for state rates of child poverty, unemployment, high school graduation, and percentage of non-Latino white people. RESULTS: A refundable EITC was associated with a decrease of 3.1 abusive head trauma admissions per 100 000 population in children aged <2 years after controlling for confounders ( P = .08), but a nonrefundable EITC was not associated with a decrease ( P = .49). Tax refunds ranged from $108 to $1014 and $165 to $1648 for a single parent working full-time at minimum wage with 1 child or 2 children, respectively. CONCLUSIONS: Our findings with others suggest that policies such as the EITC that increase household income may prevent serious abusive head trauma.

INTRODUCTION: Previous research has consistently found that low SES is associated with higher levels of both intimate partner violence (IPV) and sexual violence (SV) victimization. Though associated with poverty, two indicators of economic insecurity, food and housing insecurity, have been identified as conceptually distinct social determinants of health. This study examined the relationship between food and housing insecurity experienced in the preceding 12 months and IPV and SV victimization experienced in the preceding 12 months, after controlling for SES and other demographic variables. METHODS: Data were from the 2010 National Intimate Partner and Sexual Violence Survey, a nationally representative telephone survey of U.S. adults. In 2016, multivariate logistic regression modeling was used to examine the association between food and housing insecurity and multiple forms of IPV and SV victimization. RESULTS: Robust associations were found between food and housing insecurity experienced in the preceding 12 months and IPV and SV experienced in the preceding 12 months, for women and men, even after controlling for age, family income, race/ethnicity, education, and marital status. CONCLUSIONS: Food and housing insecurity may be important considerations for the prevention of SV and IPV or the reductions of their consequences, although future research is needed to disentangle the direction of the association. Strategies aimed at buffering economic insecurity may reduce vulnerability to IPV and SV victimization.

Substantial research shows that early adversity, including child abuse and neglect, is associated with diminished health across the life course and across generations. Less well understood is the relationship between early adversity and adult socioeconomic status, including education, employment, and income. Collectively, these outcomes provide an indication of overall life opportunity. We analyzed data from 10 states and the District of Columbia that used the adverse childhood experiences (ACE) module in the 2010 Behavioral Risk Factor Surveillance System to examine the association between ACEs and adult education, employment, and income. Compared to participants with no ACEs, those with higher ACE scores were more likely to report high school non-completion, unemployment, and living in a household below the federal poverty level. This evidence suggests that preventing early adversity may impact health and life opportunities that reverberate across generations. Current efforts to prevent early adversity might be more successful if they broaden public and professional understanding (i.e., the narrative) of the links between early adversity and poverty. We discuss our findings within the context of structural policies and processes that may further contribute to the intergenerational continuity of child abuse and neglect and poverty.

Importance: Studies suggest that a postnatal parental intervention may reduce the incidence of abusive head trauma (AHT) of infants and young children. Objective: To assess the effect of statewide universal AHT education for parents on AHT hospitalization rates in Pennsylvania and on parents' self-reported knowledge gains and parenting behaviors. Design, Setting, and Participants: Changes in AHT hospitalization rates in Pennsylvania before and during the intervention were compared with those in 5 other states lacking universal parental AHT education during the same period. Data were collected from maternity units and birthing centers throughout Pennsylvania from the parents of 1593834 infants born on these units from January 1, 2003, to December 31, 2013. Parental behavior and knowledge were assessed through immediate (n = 16111) and 7-month postintervention (n = 146) parent surveys in a per protocol analysis of evaluable parents. Interventions: Parents read a brochure, viewed an 8-minute video about infant crying and AHT, asked questions of the nurse, and signed a commitment statement affirming their participation. Educational posters were displayed on each unit. Main Outcomes and Measures: Changes in AHT hospitalization rates before and during the intervention in Pennsylvania and 5 other states. Secondary outcomes included self-reported knowledge gains and changes in parenting practices. Results: A total of 1180291 parents (74.1%) of children ranging in age from 0 to 23 months signed a commitment statement. Incidence rate ratios for hospitalization for AHT increased in Pennsylvania from 24.1 (95% CI, 22.1-26.3) to 26.6 (95% CI, 24.9-28.4) per 100000 children aged 0 to 23 months during the intervention period; changes in Pennsylvania were not significantly different from aggregate changes in the 5 other states, from 22.4 (95% CI, 21.2-23.6) to 22.0 (95% CI, 21.2-22.8) per 100000 children aged 0 to 23 months. A total of 16111 parents (21.5% men, 78.5% women) completed the postnatal survey. Despite an overall 74.1% adherence with the intervention, only 20.6% of parents saw the brochure and video and only 5.7% were exposed to the entire intervention. Among the respondents answering individual questions on the postnatal surveys, 10958 mothers (91.0%) and 2950 fathers (88.6%) reported learning a lot about understanding infant crying as normal; 11023 mothers (92.2%) and 2923 fathers (88.9%), calming their infant, 11396 mothers (94.6%) and 3035 fathers (91.9%), calming themselves; 10060 mothers (85.1%) and 2688 fathers (83.4%), selecting other infant caregivers; and 11435 mothers (94.8%) and 3201 fathers (95.8%), that the information would decrease the likelihood of shaking an infant. Among the 143 respondents completing the 7-month survey, 109 (76.2%) reported remembering the information while their child was crying. Conclusions and Relevance: This intervention was not associated with a reduction in pediatric AHT hospitalization rates but was associated with self-reported gains in parental knowledge that were retained for 7 months.

Despite theoretical and empirical evidence suggesting that the family environment plays a central role in Latino youth development, relatively little is known about how family processes influence dating violence victimization among Latino adolescents. To address this gap in the literature, we used data from 210 Latino parents and their 13- to 15-year-old adolescents to examine associations between several different family processes, including both parenting practices (parent monitoring, parent–adolescent communication) and aspects of the family relational climate (family cohesion, family conflict, acculturation conflict) and psychological, physical, and sexual dating violence victimization. Consistent with expectations, lower levels of family cohesion and higher levels of family and acculturation conflict were associated with risk for dating violence victimization, although associations varied depending on victimization type. In contrast, neither parental monitoring nor parent–adolescent communication was significantly associated with any type of dating violence victimization. In addition, we found that parent, but not teen, Anglo-American acculturation was associated with higher dating violence victimization risk. Findings suggest that family-based dating abuse prevention programs for Latino youth should seek to increase family cohesion and decrease family conflict, including acculturation-based conflict.