Self-harm is a leading cause of morbidity and mortality in the United States (US), accounting for over 44,000 deaths and 500,000 injuries in 2015. 1 Rates of self-harm are also increasing, 1 for some groups rapidly, 2 but the reasons for these increases are not well-understood. The influence of social environments on self-harm has been recognized for over a century, 3 but research to identify which features of the social environment are most influential is limited.Community violence-defined as experiencing, witnessing, or hearing about violence in one's community-is one potentially modifiable feature of the social environment that may influence selfharm. However, few studies have examined the association of community violence with self-harm, [4][5][6][7][8][9][10][11] and to our knowledge, no research has examined short-term, within-community variation in violence, as opposed to chronic or overall levels of violence.Within-community variation in violence is directly relevant to common models of self-harm. The stressdiathesis model and its variants posit that incidents of self-harm are the confluence of long-term predisposition to self-harm (e.g., due to early life adversity) with stressful life events (e.g., loss of a loved one or psychosocial crisis) that trigger brief periods of elevated risk. 12 Increases in community violencefor example, having neighbors who were victims of a recent shooting-may trigger self-harm in a vulnerable individual. The effects of community violence on self-harm may also vary for different demographic subgroups, because self-harm is a heterogeneous condition with different drivers and manifestations. 1,13,14 Existing models of self-harm support the hypothesis that within-variation in violence may be associated with self-harm for some groups but not others, due to differences in vulnerability to stressors or in levels of predisposing risk factors.We examined whether within-community variation in community violence is associated with fatal and nonfatal self-harm. To maximize control of individual and community confounders, we utilized a casecrossover approach with community-matched controls drawn in close time proximity to cases. We leveraged data from statewide population-based registries, surveys, and healthcare utilization data from California, a large and heterogeneous state with self-harm trends similar to those seen nationwide.
Extended methods
Overall study designs and data sourcesWe conducted a case-crossover study, 17 comparing cases' exposure at a time relevant to case occurrence to exposure at referent non-case times. We compiled data on self-harm and community violence for 2005-2013 from mortality, emergency department, and inpatient hospitalization discharge records from the California Office of Vital Records and the Office Statewide Health Planning and Development. Records included all deaths and hospital visits statewide, excluding active duty military hospitals, and captured medical information including external cause of death or injury, demographic characteristics, and...