Bystander Program Effectiveness to Reduce Violence Acceptance: RCT in High Schools

Bystander-based violence prevention interventions have shown efficacy to reduce dating violence and sexual violence acceptance at the individual level yet no large randomized controlled trial (RCT) has evaluated this effect at the high-school level and over time. This rigorous cluster-randomized controlled trial addresses this gap by evaluating intervention effectiveness at both school and individual levels. Kentucky high schools were randomized to intervention or control conditions. In intervention schools educators provided school-wide ‘Green Dot’ presentations and bystander training with student popular opinion leaders. Each spring from 2010 to 2014; 73,044 students completed anonymous surveys with no missing data on relevant outcomes. Dating violence and sexual violence acceptance were the primary outcomes for this analysis. At the school level, slopes from linear mixed models using averaged school-level dating violence acceptance (condition–time, p \u3c 0.001) and sexual violence acceptance (condition–time interaction, p \u3c 0.001) differed indicating a significant reduction in the violence acceptance in the intervention relative to control schools over time and specifically in years 3 and 4 when ‘Green Dot’ was fully implemented. Analyses based on student’s self-reported receipt of ‘Green Dot’ training by condition confirmed the school level finding of significant reductions in both dating violence and sexual violence acceptance in years 3 and 4 for both males and females. In this RCT we find evidence that the bystander-based violence prevention intervention ‘Green Dot’ works, as hypothesized and as implemented, to reduce acceptance of dating violence and sexual violence at the school and individual levels

Trends in Drug Overdose Mortality Rates in Kentucky, 2019-2020

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Direct Effects of the Home, School, and Consumer Food Environments on the Association between Food Purchasing Patterns and Dietary Intake among Rural Adolescents in Kentucky and North Carolina, 2017

Background: Obesity rates are higher among rural versus urban adolescents. To examine possible mechanisms for the rural-urban adolescent obesity disparity, we examined the direct and indirect effects of food purchasing patterns, and the home, school, and consumer food environments on dietary intake among rural adolescents. Methods: A baseline survey was conducted among adolescents in eight rural high schools (four in Eastern Kentucky, and four in Eastern North Carolina). Participants answered questions about food purchasing patterns, dietary intake, home food availability, and demographics. The school and consumer food environments were assessed using validated measures from the School Meals Cost Study (United States Department of Agriculture-Mathematica) and the Nutrition Environment Measurement Survey for Stores, Restaurants, and Corner Stores. Results: Of 432 adolescents, 55% were normal weight, 24% were overweight, and 21% were obese. There was a direct association between unhealthy food purchasing patterns (shopping frequently at gas stations, fast food, and dollar stores) and consuming more added sugars, when compared to those with a healthy shopping pattern (shopping less frequently at gas stations, fast food, and dollar stores) [Odds Ratio = 2.41 (95% CI (confidence interval) 0.99, 3.82)]. Those who reported always having fruits and vegetables in the home consumed more servings of fruits and vegetables [OR = 0.31 cups (95% CI 0.22, 0.44)] compared to those who reported never having fruits and vegetables in the home. Adolescents attending a school with a low healthy food availability score consumed fewer servings of fruits and vegetables [−0.001 (95% CI −0.001, 0.0001)] compared to those attending a school with a high healthy food availability score. Conclusions: There are direct associations between food purchasing patterns, the home and school food environments, and dietary intake among rural adolescents. These cross-sectional results informed the development of the “Go Big and Bring it Home� program, a text messaging intervention to improve adolescents’ fruit, vegetable, and healthy beverage intake

RCT Testing Bystander Effectiveness to Reduce Violence

Introduction: Bystander-based programs have shown promise to reduce interpersonal violence at colleges, yet limited rigorous evaluations have addressed bystander intervention effectiveness in high schools. This study evaluated the Green Dot bystander intervention to reduce sexual violence and related forms of interpersonal violence in 26 high schools over 5 years. Design: A cluster RCT was conducted. Setting/participants: Kentucky high schools were randomized to intervention or control (wait list) conditions. Intervention: Green Dot−trained educators conducted schoolwide presentations and recruited student popular opinion leaders to receive bystander training in intervention schools beginning in Year 1. Main outcome measures: The primary outcome was sexual violence perpetration, and related forms of interpersonal violence victimization and perpetration were also measured using anonymous student surveys collected at baseline and annually from 2010 to 2014. Because the school was the unit of analysis, violence measures were aggregated by school and year and school-level counts were provided. Results: A total of 89,707 students completed surveys. The primary, as randomized, analyses conducted in 2014–2016 included linear mixed models and generalized estimating equations to examine the condition−time interaction on violence outcomes. Slopes of school-level totals of sexual violence perpetration (condition−time, p \u3c 0.001) and victimization (condition−time, p \u3c 0.001) were different over time. During Years 3–4, when Green Dot was fully implemented, the mean number of sexual violent events prevented by the intervention was 120 in Intervention Year 3 and 88 in Year 4. For Year 3, prevalence rate ratios for sexual violence perpetration in the intervention relative to control schools were 0.83 (95% CI=0.70, 0.99) in Year 3 and 0.79 (95% CI=0.67, 0.94) in Year 4. Similar patterns were observed for sexual violence victimization, sexual harassment, stalking, and dating violence perpetration and victimization. Conclusions: Implementation of Green Dot in Kentucky high schools significantly decreased not only sexual violence perpetration but also other forms of interpersonal violence perpetration and victimization

Analytical Enhancements in Kentucky’s Drug Overdose Mortality Surveillance: Rapid Monitoring of Trends and Decedents’ Recent Controlled Substance Prescription History

Background: Timely drug overdose mortality surveillance is key to informing public health action to reduce overdose-related fatalities. States are increasingly using linked data sources to enhance surveillance activities, yet approaches to their effective utilization and analyses are needed. Objectives: The objective of this study is to describe the development and utilization of analytical tools for rapid, ongoing monitoring of drug overdose trends in Kentucky (KY) and decedents’ exposure to prescribed controlled substances (CS). Methods: KY established a monthly process of linking all-cause death certificate (DC) with prescription drug monitoring program (DC-PDMP) data to enhance mortality surveillance. Using provisional 2018-2020 DC-PDMP data we developed scheduled quarterly analytical reports. Drug overdose deaths are identified based on underlying cause of death (ICD-10 X40-X44, X60-X64, X85, or Y10-Y14); involved drugs/drug classes are identified from multiple cause of death codes (T36 – T50). Common contributing substances are identified from DC cause of death section text fields. Drugs listed on DCs are compared with decedents’ past 90 days CS prescriptions. Results: KY resident drug overdose deaths accounted for 2.8% of all-cause mortality, but among age group 26-40 years, 28.6% of all-cause deaths were due to drug overdose. Drug overdose decedents were disproportionally male (65.4% vs. 51.8% among all-cause deaths). From 2018 to 2020, the number of drug overdose deaths increased 42%. Deaths involving synthetic opioids and psychostimulants increased (56.2%vs 71.7% and 27.3% vs 35.1%, respectively) and deaths involving heroin (10.4% vs 6.0%), benzodiazepines (24.1% vs 15.3%), cocaine (9.6% vs 8.4%) and natural/semi-synthetic opioids (22.7% vs 21.3%) declined. The five substances most frequently listed in the DC in 2020 were fentanyl, methamphetamine, 4-ANPP, gabapentin, and acetyl fentanyl. Sixty-three percent of deaths involving natural/semi- synthetic opioids and 76% of cases involving benzodiazepines had no dispensed prescriptions for those drug classes in the previous 90 days, suggesting possible diversion. A historically high level of drug overdose deaths was observed in the first months of COVID-19 pandemic, with April-June 2020 overdose deaths (n=557), 80%higher than the same period in 2019. Conclusions: The analytical enhancement of KY’s drug overdose surveillance supports rapid assessment to inform public health action and provides a rich dataset for pharmacoepidemiologic studies

Changing Trends in Drug Overdose Mortality in Kentucky: An Examination of Race and Ethnicity, Age, and Contributing Drugs, 2016-2020

Objectives: Increased drug overdose mortality among non-Hispanic Black people in the United States in the past 5 years highlights the need for better tailored programs and services. We evaluated (1) changes in drug overdose mortality for various racial and ethnic groups and (2) drug involvement to inform drug overdose prevention efforts in Kentucky. Methods: We used Kentucky death certificates and postmortem toxicology reports from 2016-2020 (provisional data) to estimate changes in age-adjusted drug overdose death rates per 100 000 standard population. Results: The age-adjusted drug overdose death rate per 100 000 standard population among non-Hispanic Black residents doubled from 2016 (21.2) to 2020 (46.0), reaching the rate among non-Hispanic White residents in 2020 (48.7; P = .48). From 2016 to 2020, about 80% of these drug overdose deaths involved opioids; heroin involvement declined about 20 percentage points; fentanyl involvement increased about 30 percentage points. The number of psychostimulant-involved drug overdose deaths increased 513% among non-Hispanic Black residents and 191% among non-Hispanic White residents. Cocaine-involved drug overdose deaths increased among non-Hispanic Black residents but declined among non-Hispanic White residents. Drug overdose death rates were significantly lower among Hispanic residents than among non-Hispanic White residents. Conclusions: Increased opioid-involved overdose deaths among non-Hispanic Black residents in Kentucky in combination with rapidly expanding concomitant psychostimulant involvement require increased understanding of the social, cultural, and illicit market circumstances driving these rapid trend changes. Our findings underscore the urgent need to expand treatment and harm reduction services to non-Hispanic Black residents with substance use disorder

Total and Marginal Cost Analysis for a High School Based Bystander Intervention

Costs of providing the Green Dot bystander-based intervention, shown to be effective in the reduction of sexual violence among Kentucky high school students, were estimated based on data from a large cluster-randomized clinical trial. Rape Crisis Center Educators were trained to provide Green Dot curriculum to students. Implementing Green Dot in schools (N = 13) randomized to the intervention, over five years, cost $1.6 M and included start-up ($58 K) and ongoing implementation ($1.55 M). Costs for adding a school ($25,510) were calculated based on the final year, where no start-up costs were incurred. Knowing the $25,510 cost estimate for adding Green Dot may be particularly useful for high school administrators or school boards when they were making economic decisions based on strong evidence of program effectiveness to reduce violence