Community gun violence and functional disability: An ecological analysis among men in four U.S. cities

Gun violence exposure and population health inequality: a conceptual framework

This essay establishes a conceptual framework to understand how direct, secondar and community exposures to gun violence converge to influence population health. Our framework asserts that persistent gun violence in structurally disadvantaged communities enacts broad consequences for mental, physical and behavioural health, operating as a key driver of racial and socioeconomic health disparities. We discuss the applications of this framework for research and improved data collection with a focus on establishing timely and accurate measures of gun violence alongside individual and community health measures. We then address the policy implications of the framework, emphasising the need for long-term, institutional investment in gun violence prevention and intervention, survivor service provision and evidence-based policies at all levels of government.

Disability and Racial Justice Go Hand in Hand: A Commentary on Black Men and Firearm Violence

Black men in the United States face disproportionately high rates of firearm violence, leading to death and disability more often than males of other racial/ethnic groups. Managing life after such injuries involves significant challenges in daily activities, employment, and pain management. Despite the critical impacts of firearm-related disabilities on Black men, their experiences remain largely unexplored by disability scholars, public health researchers, and practitioners. This oversight is alarming, as Black men with firearm-acquired disabilities encounter considerable structural barriers to achieving health and social objectives. Our team focuses on: (a) the experiences of Black men with firearm-acquired disabilities, (b) the lack of literature on their lived realities, and (c) new pathways for disability and public health research. Recognizing and addressing the invisibility of violently injured Black men in research is crucial for advancing equity, social justice, and representation across society. We argue that disability justice is a vital starting point for acknowledging the social experiences of gunshot wound survivors. More research is needed to understand the experiences of these young Black men who have been largely ignored in public health and disability narratives. It is essential for clinicians and policymakers to grasp how this neglect affects conventional views on health, accessibility, and well-being, underscoring the need for a more inclusive and equitable approach.

Firearm Violence Exposure and Functional Disability among Black Men and Women in the United States

This study investigates the relationship between firearm violence exposure and functional health among Black adults in the United States (US). We examined associations between different forms of firearm violence exposure (direct, indirect, and community) and functional health with particular attention to differences across sex groups. We used survey data from a nationally representative sample of 3015 Black adult Americans to analyze associations between types of firearm violence exposure and four aspects of functional disability including: the ability to concentrate, walk/use stairs, dress/bathe, and run errands among males and females. The findings indicate notable disparities in exposure and health outcomes based on the exposure type and cumulative exposure to violence. Among males, functional disability was associated most closely with community violence exposure, while direct threats of firearm violence were most consequential for functional health among females. High cumulative exposure to firearm violence was linked to significant risks to functional health, particularly among females. The results shed light on sex differences in the repercussions of firearm violence exposure and emphasize its implications for daily functioning and health. This study contributes to the understanding of the multifaceted impacts of firearm violence on functional well-being and highlights the need for inclusive and culturally sensitive healing approaches based in community settings. There is a critical need for heightened awareness and strategies to enhance the well-being of those disproportionately affected by firearm violence in the US.

Local gun violence, mental health, and sleep: A neighborhood analysis in one hundred US Cities

RATIONALE

Community gun violence significantly shapes public health and collective well-being. Understanding how gun violence is associated with community health outcomes like mental health and sleep is crucial for developing interventions to mitigate disparities exacerbated by violence exposure.

OBJECTIVE

This study examines the associations between community gun violence , insufficient sleep, and poor mental health across neighborhoods in the United States.

METHODS

We utilized a novel database covering nearly 16,000 neighborhoods in 100 US cities from 2014 through 2019. Correlated trait fixed-effects models were employed to conduct all analyses while considering various neighborhood covariates such as concentrated disadvantage, demographic composition, population density, and proximity to trauma centers.

RESULTS

Our analysis revealed that greater gun violence is associated with both insufficient sleep and poor mental health in subsequent years. There is a reciprocal relationship between poor mental health and insufficient sleep, with each partially mediating the other's association with community gun violence. Notably, gun violence exhibits the strongest direct association with poor sleep rather than with poor mental health. We found a consistent reciprocal relationship between sleep and mental health at the community level.

CONCLUSIONS

The findings highlight a complex interplay between community violence, sleep, and mental health, underlining the importance of reducing community violence through numerous long-term interventions to address health disparities across the US.

AOA Critical Issues Symposium: Gun Violence as a Public Health Crisis

ABSTRACT

Gun violence is an epidemic throughout the United States and is increasing around the world-it is a public health crisis. The impact of gun violence is not limited to the victims (our patients); it also extends to the physicians and caregivers who are taking care of these patients every day. Even more broadly, gun violence affects those living and going to work in potentially dangerous environments. The "vicarious trauma" that is experienced in these situations can have long-term effects on physicians, nurses, and communities. Importantly, socioeconomic disparities and community deprivation strongly correlate with gun violence. Systemic factors that are deeply ingrained in our society can increase concerns for these underrepresented patient populations and cause increased stressors with substantial health consequences, including delayed fracture-healing and poorer overall health outcomes. It is incumbent on us as physicians to take an active role in speaking up for our patients. The importance of advocacy efforts to change policy (not politics) and continue to push for improvement in the increasingly challenging environments in which patients and physicians find themselves cannot be overstated. Multiple national organizations, including many orthopaedic and general surgery associations, have made statements advocating for change. The American College of Surgeons, in collaboration with many other medical organizations, has supported background checks, registration, licensure, firearm education and training, safe storage practices, red flag laws, addressing mental health issues, and more research to better inform an approach going forward and to address the root causes of violence. We encourage the orthopaedic surgery community to stand together to protect each other and our patients, both physically and mentally, with agreement on these principles.

Firearm Access and Gun Violence Exposure Among American Indian or Alaska Native and Black Adults

Importance

American Indian or Alaska Native and Black adults experience elevated rates of firearm injury and death, but both groups are severely underrepresented in research on firearm exposure and behaviors.

Objective

To explore geodemographic differences in firearm behaviors and violence exposure among American Indian or Alaska Native and Black adults in the US.

Design, Setting, and Participants

In this survey study, nationally representative samples of American Indian or Alaska Native and/or Black adults recruited from KnowledgePanel were surveyed cross-sectionally. Surveys were administered online between April 12 and May 4, 2023.

Main Outcomes and Measures

Firearm access, storage, and carrying behaviors and lifetime firearm violence exposure were the primary outcomes. Demographic factors such as age, geographic location, and political affiliation were considered. Data were weighted to geodemographic distributions from the US Census Bureau's 2022 Current Population Survey.

Results

Of 3542 participants, 527 (14.9%) were American Indian or Alaska Native (280 [53.1%] female) and 3015 (85.1%) were Black (1646 [54.6%] female). Both groups exhibited high firearm access rates (American Indian or Alaska Native adults: 238 [45.4%; 95% CI, 39.4%-51.7%]; Black adults: 909 [30.4%; 95% CI, 28.0%-32.9%]), predominantly owning handguns for home protection. The groups demonstrated similar firearm storage patterns, and a substantial proportion endorsed always or almost always carrying firearms outside the home (American Indian or Alaska Native adults: 18.9%; Black adults: 15.2%). Self-protection was a common reason for carrying a firearm (American Indian or Alaska Native adults: 104 [84.9%; 95% CI, 74.1%-91.7%]; Black adults: 350 [88.3%; 95% CI, 82.3%-92.4%]), and a minority of participants cited lack of faith in the police (American Indian or Alaska Native adults: 19 [15.2%; 95% CI, 8.2%-26.7%]; Black adults: 61 [15.4%; 95% CI, 10.3%-21.2%]), indicating potential shifts in public safety dynamics.

Conclusions and Relevance

In this survey study of American Indian or Alaska Native and Black US adults, a substantial percentage of both groups reported living in homes with firearms, storing firearms loaded and unlocked, frequently carrying firearms outside the home, and having been exposed directly and indirectly to gun violence. These findings underscore the need for nuanced public health campaigns and policies and highlight challenges for law enforcement in contexts of racial disparities and changing legal frameworks.

Identifying overlaps and disconnects between media reports and official records of nonfatal firearm injuries in Indianapolis, Indiana, 2021-2022

OBJECTIVE

Open-source data systems, largely drawn from media sources, are commonly used by scholars due to the lack of a comprehensive national data system. It is unclear if these data provide an accurate and complete representation of firearm injuries and their context. The study objectives were to compare firearm injuries in official police records with media reports to better identify the characteristics associated with media reporting.

METHODS

Firearm injuries were identified in open-source media reports and compared to nonfatal firearm injury (n = 1642) data from official police records between January 1, 2021 to December 31, 2022 in Indianapolis, Indiana. Events were matched on date, location, and event circumstances. Four multivariate, multi-level mixed effects logistic regression models were conducted to assess which survivor, event, and community characteristics were associated with media reporting. Data were analyzed 2023 - January 2024.

RESULTS

Media reported 41% of nonfatal shootings in 2021 and 45% in 2022(p < 0.05), which is approximately two out of every five shootings. Shootings involving multiple survivors, children, and self-defense were more likely to be reported, whereas unintentional shootings and shootings that occurred in structurally disadvantaged communities were less likely to be reported.

CONCLUSIONS

Findings suggest that relying on media reports of firearm injuries alone may misrepresent the numbers and contexts of shootings. Public health interventions that educate journalists about these important issues may be an impactful firearm violence prevention strategy. Also, it is critical to link data systems at the local level to ensure interventions are designed and evaluated using accurate data.

Individual and cumulative firearm violence exposure: Implications for sleep among Black and American Indian/Alaska Native adults

PURPOSE

We investigated the relationship between various forms of firearm violence exposure and sleep problems among nationally representative samples of Black (N = 3015) and American Indian and Alaska Native (AI/AN) (N = 527) adults, focusing on difficulties falling asleep, staying asleep, and waking too early. Survey data were collected in April and May 2023.

METHODS

We employed negative binomial regression models to analyze the associations between the different types of firearm violence exposure and sleep problems. We further examined associations between cumulative firearm violence exposure and sleep outcomes.

RESULTS

A substantial proportion of Black (59%) and AI/AN (56%) adults reported experiencing some form of firearm violence exposure. Being threatened with a firearm emerged as a consistent factor associated with sleep problems for both racial groups. Witnessing or hearing about shootings was linked to sleep problems in the Black sample, while cumulative firearm violence exposure was associated with all sleep problems in both groups.

CONCLUSIONS

Individual and cumulative firearm violence exposure is associated with increased sleep problems among Black and AI/AN adults.

Civilian Ballistic Arthrotomies: Infection Rates and Operative Versus Nonoperative Management

OBJECTIVES

The purpose of this study was to determine whether a significant difference existed in the rate of infection after ballistic traumatic arthrotomy managed operatively compared with those managed without surgery.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level I Trauma Center.

PATIENT SELECTION CRITERIA

Patients with ballistic traumatic arthrotomies of the shoulder, elbow, wrist, hip, knee, or ankle who received operative or nonoperative management.

OUTCOME MEASURES AND COMPARISONS

The rates of infection and septic arthritis in those who received operative or nonoperative management.

RESULTS

One hundred ninety-five patients were studied. Eighty patients were treated nonoperatively (Non-Op group), 16 patients were treated with formal irrigation and debridement in the operating room (I&D group), and 99 patients were treated with formal I&D and open reduction and internal fixation (ORIF) (I&D + ORIF group). Patients in all 3 groups received local wound care and systemic antibiotics. No patients in the Non-Op or I&D group developed an infection. Six patients in the I&D + ORIF group developed extra-articular postoperative infections requiring additional interventions.

CONCLUSIONS

The infection rate in the I&D + ORIF group was consistent with the infection rates reported in orthopaedic literature after fixation alone. In addition, none of the infections were cases of septic arthritis. This suggests that traumatic arthrotomy does not increase the risk for infection beyond what is expected after fixation alone. Importantly, the Non-Op group represented a series of 80 patients who were treated nonoperatively without developing an infection, indicating that I&D may not be necessary to prevent infection after ballistic arthrotomy. The results suggest that septic arthritis after civilian ballistic arthrotomy is a rare complication regardless of the choice of treatment.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Portrayals of gun violence victimization and public support for firearm policies: an experimental analysis

Objectives

This study examines how characteristics of victims and types of incidents described in a media account of gun violence affect public support for three categories of policies that regulate firearms.

Methods

A randomized experiment with a sample of US public (N = 3410).

Results

Victim race, particularly if the victim was Black, was a strong predictor of less public support for all tested categories of firearm regulation. Respondents were less supportive of policies to address gun suicide or accidents and more supportive of policy solutions to mass shootings, compared to street-level gun homicides. Depictions of victim gender, mental illness, prior incarceration, and age were less salient to support across categories of firearm regulation, compared to race and type of incident.

Conclusions

Media coverage of gun violence has heterogenous effects on public support for firearm regulation and may influence support for policies aimed at reducing specific types of gun violence.

Reciprocal Neighborhood Dynamics in Gun Violence Exposure, Community Health, and Concentrated Disadvantage in One Hundred US Cities

Gun violence imparts a tremendous human and financial toll on local communities. Researchers have documented extensive mental and physical health consequences of generalized violence exposure but few studies have analyzed the particular impacts of gun violence on community well-being using nationally comprehensive data. We leverage a unique database of almost 16,000 neighborhoods in 100 US cities (2014-2019) to examine how year-over-year rates of gun violence correspond to overall neighborhood well-being and three aspects of community health: (1) health behaviors, (2) physical and mental health status, and (3) health prevention efforts. We simultaneously consider the reciprocal influence of neighborhood well-being on subsequent gun violence while accounting for concentrated disadvantage in communities. The results demonstrate that gun violence is associated with poorer community health in subsequent years, particularly health behaviors and mental/physical health status. Furthermore, we find substantial reciprocal effects for both gun violence and community health in their relationship to neighborhood concentrated disadvantage. These findings highlight the consequential role of gun violence in perpetuating cycles of harm in local communities.

Firearm injuries in Missouri

Firearm deaths continue to be a major public health problem, but the number of non-fatal firearm injuries and the characteristics of patients and injuries is not well known. The American College of Surgeons Committee on Trauma, with support from the National Collaborative on Gun Violence Research, leveraged an existing data system to capture lethal and non-lethal injuries, including patients treated and discharged from the emergency department and collect additional data on firearm injuries that present to trauma centers. In 2020, Missouri had the 4th highest firearm mortality rate in the country at 23.75/100,000 population compared to 13.58/100,000 for the US overall. We examined the characteristics of patients from Missouri with firearm injuries in this cross-sectional study. Of the overall 17,395 patients, 1,336 (7.7%) were treated at one of the 11 participating trauma centers in Missouri during the 12-month study period. Patients were mostly male and much more likely to be Black and uninsured than residents in the state as a whole. Nearly three-fourths of the injuries were due to assaults, and overall 7.7% died. Few patients received post-discharge services.

Concentrated disadvantage and functional disability: a longitudinal neighbourhood analysis in 100 US cities

BACKGROUND

Socioeconomic disadvantage related to poverty, unemployment and social disinvestment contributes to significant disparities in community health in the USA. Yet, there remains limited ecological research on the relationship between neighbourhood disadvantage and functional disability. Much of the work in this area has focused on elderly populations without attention to variation across age and sex groups.

METHODS

Using a longitudinal dataset of almost 16 000 neighbourhoods, we examine the relationship between neighbourhood disadvantage and functional disability. Leveraging a series of cross-lagged panel models, we account for reciprocal dynamics and a range of pertinent covariates while assessing differences across age- and sex-specific groups.

RESULTS

Accounting for reciprocal effects, we found that the association between concentrated disadvantage and functional disability varies across age and sex groups. Concentrated disadvantage is most consistently associated with increased functional disability among boys (5-17 years), young men (18-34 years) and middle-aged men (35-64 years). Similar associations are found among girls (5-17 years) and middle-aged women (35-64 years).

CONCLUSION

Local neighbourhood economic conditions are significantly associated with functional disability among relatively young populations of males and females. Exposure to neighbourhood disadvantage and deprivation may accelerate disablement processes and shift the age curve of disability risk.

Firearm violence exposure and health in 2 national samples of Black and American Indian/Alaska Native adults

Exposure to firearm violence is widespread and disproportionately experienced by communities of color, with implications for broad health disparities. Survey data were collected from 2 nationally representative samples of Black (n = 3015) and American Indian/Alaska Native (AI/AN) (n = 527) adults in the United States in April and May 2023. The exposure measures were 4 types of firearm violence exposure. The outcome measures were self-rated health, number of poor physical health days, and number of poor mental health days. Regression results demonstrate that being threatened with a firearm and hearing about or witnessing a shooting were associated with poorer self-rated, mental, and physical health across both samples. Cumulative exposure to firearm violence was particularly associated with increasing harms to health for all outcomes. In general, individual and cumulative firearm violence exposures are linked to poorer health among Black and AI/AN adults in the United States. Significant enhancements and long-term investment are needed for firearm violence prevention to yield improvements to population health, particularly among communities burdened with high levels of exposure to firearm violence.

Trends in paediatric firearm-related encounters during the COVID-19 pandemic by age group, race/ethnicity and schooling mode in Tennessee

BACKGROUND

Increases in paediatric firearm-related injuries during the COVID-19 pandemic may be due to changes in where children and adolescents spent their time. This study examines changes in the frequency of paediatric firearm-related encounters as a function of schooling mode overall and by race/ethnicity and age group at a large trauma centre through 2021.

METHODS

We use data from a large paediatric and adult trauma centre in Tennessee from January 2018 to December 2021 (N=211 encounters) and geographically linked schooling mode data. We use Poisson regressions to estimate smoothed monthly paediatric firearm-related encounters as a function of schooling mode overall and stratified by race and age.

RESULTS

Compared with pre pandemic, we find a 42% increase in paediatric encounters per month during March 2020 to August 2020, when schools were closed, no significant increase during virtual/hybrid instruction, and a 23% increase in encounters after schools returned to in-person instruction. The effects of schooling mode are heterogeneous by patient race/ethnicity and age. Encounters increased among non-Hispanic black children across all periods relative to pre pandemic. Among non-Hispanic white children, encounters increased during the closure period and decreased on return to in-person instruction. Compared with pre pandemic, paediatric firearm-related encounters increased 205% for children aged 5-11 and 69% for adolescents aged 12-15 during the school closure period.

CONCLUSION

COVID-19-related changes to school instruction mode in 2020 and 2021 are associated with changes in the frequency and composition of paediatric firearm-related encounters at a major trauma centre in Tennessee.

Comprehensive Framework of Firearm Violence Survivor Care: A Review

Importance

Firearm violence is a public health crisis placing significant burden on individuals, communities, and health care systems. After firearm injury, there is increased risk of poor health, disability, and psychopathology. The newest 2022 guidelines from the American College of Surgeons Committee on Trauma require that all trauma centers screen for risk of psychopathology and provide referral to intervention. Yet, implementing these guidelines in ways that are responsive to the unique needs of communities and specific patient populations, such as after firearm violence, is challenging.

Observations

The current review highlights important considerations and presents a model for trauma centers to provide comprehensive care to survivors of firearm injury. This model highlights the need to enhance standard practice to provide patient-centered, trauma-informed care, as well as integrate inpatient and outpatient psychological services to address psychosocial needs. Further, incorporation of violence prevention programming better addresses firearm injury as a public health concern.

Conclusions and Relevance

Using research to guide a framework for trauma centers in comprehensive care after firearm violence, we can prevent complications to physical and psychological recovery for this population. Health systems must acknowledge the socioecological context of firearm violence and provide more comprehensive care in the hospital and after discharge, to improve long-term recovery and serve as a means of tertiary prevention of firearm violence.

Healthcare utilization and mental health outcomes among nonfatal shooting assault victims

Victims of nonfatal shooting (NFS) assaults suffer from emotional and physical trauma; however, little is understood about clinical care utilization patterns among victims. This study examines the healthcare utilization and mental health outcomes before and after an index NFS victimization. A longitudinal dataset of police and clinical data were linked at the individual level to define a cohort of NFS victims with one or more clinical encounter in the 24-months preceding an index NFS injury (N = 2,681) in Indianapolis, Indiana between 2005 and 2018. Mental health was defined using ICD diagnosis codes from any emergency department, inpatient, or outpatient encounter and clinical care utilization was the number of unique encounters within the 24-months preceding and following an index NFS injury. Multivariable logistic regression was conducted to examine factors associated with a mental health diagnosis in the post injury period. Analyses were conducted in October 2021-March 2022. Overall clinical care utilization (Mean: pre = 277.7 (SD 235.3) vs. post = 333.9 (SD 255.1), p < 0.001) and mental health prevalence (14.4% pre vs. 18.8% post, p < 0.001) increased in the 24-months following an index NFS compared to the prior 24-months. Preinjury mental health utilization increased the odds of receiving a mental health diagnosis in the 24-months following an index NFS injury - particularly for Black victims (Odds Ratio 1.69, 95% CI 1.01, 2.85). The findings indicate missed opportunities within the healthcare system to connect NFS victims with needed mental health services, as well as the importance of premorbid connection to mental health care.

Changing epidemiology of firearm injury: a cohort study of non-fatal firearm victimisation before and during the COVID-19 pandemic, Indianapolis, Indiana

OBJECTIVE

To examine victimisation rates, geographic patterns and neighbourhood characteristics associated with non-fatal firearm injury rates before and during the COVID-19 pandemic.

DESIGN

A retrospective cohort study.

SETTING

City of Indianapolis, Indiana, USA, 1 January 2017-30 June 2021.

PARTICIPANTS

Intentional non-fatal firearm injury victims from Indianapolis Metropolitan Police Department records. The study included information on 2578 non-fatal firearm injury victims between ages 0 and 77 years. Of these victims, 82.5% were male and 77.4% were black.

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates of non-fatal firearm injuries per 100 000 population by victim age, race, sex and incident motive. Prepandemic and peripandemic non-fatal firearm injury rates.

RESULTS

Non-fatal shooting rates increased 8.60%, from 57.0 per 100 000 person-years in prepandemic years to 65.6 per 100 000 person-years during the pandemic (p<0.001). Rates of female victims (15.2 vs 23.8 per 100,000; p<0.001) and older victims (91.3 vs 120.4 per 100,000; p<0.001) increased significantly during the pandemic compared with the prepandemic period. Neighbourhoods with higher levels of structural disadvantage (IRR: 1.157, 95% CI 1.012 to 1.324) and prepandemic firearm injury rates (IRR: 1.001, 95% CI 1.001 to 1.002) was positively associated with higher rates of non-fatal firearm injuries during the pandemic, adjusting for neighbourhood characteristics.

CONCLUSIONS

Non-fatal firearm injuries increased significantly during the COVID-19 pandemic, particularly among female and older victims. Efforts are needed to expand and rethink current firearm prevention efforts that both address the diversification of victimisation and the larger societal trauma of firearm violence.