Historic redlining, structural racism, and firearm violence: A structural equation modeling approach

Community-Academic Partnership to Assess the Role of Physical Disinvestment on Firearm Violence in Toledo, OH

Reversing physical disinvestment, e.g., by remediating abandoned buildings and vacant lots, is an evidence-based strategy to reduce urban firearm violence. However, adoption of this strategy has been inconsistent across US cities. Our community-academic partnership sought to support adoption in Toledo, OH, USA, by generating locally relevant analyses on physical disinvestment and firearm violence. We used a spatial case-control design with matching. Physical disinvestment measures were derived from a citywide parcel foot audit conducted by the Lucas County Land Bank in summer 2021. Firearm violence outcomes were incident-level shootings data from the Toledo Police Department from October 2021 through February 2023. Shooting locations were matched to controls 1:4 on poverty rate, roadway characteristics, and zoning type. Exposures were calculated by aggregating parcels within 5-min walking buffers of each case and control point. We tested multiple disinvestment measures, including a composite index. Models were logistic regressions that adjusted for the matching variables and for potential spatial autocorrelation. Our sample included N = 281 shooting locations and N = 1124 matched controls. A 1-unit increase in the disinvestment score, equal to approximately 1 additional disrepair condition for the average parcel within the walking buffer, was associated with 1.68 times (95% CI: 1.36, 2.07) higher odds of shooting incidence. Across all other measures, greater disinvestment was associated with higher odds of shooting incidence. Our finding of a strong association between physical disinvestment and firearm violence in Toledo can inform local action. Community-academic partnership could help increase adoption of violence prevention strategies focused on reversing physical disinvestment.

Historical Redlining and Present-Day Nonsuicide Firearm Fatalities

BACKGROUND

Redlining began in the 1930s with the Home Owners' Loan Corporation (HOLC); this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. It is important to understand the potential health implications of this federally sanctioned segregation.

OBJECTIVE

To examine the relationship between historical redlining policies and present-day nonsuicide firearm fatalities.

DESIGN

Maps from the HOLC were overlaid with incidence of nonsuicide firearm fatalities from 2014 to 2022. A multilevel negative binomial regression model tested the association between modern-day firearm fatalities and HOLC historical grading (A ["best"] to D ["hazardous"]), controlling for year, HOLC area-level demographics, and state-level factors as fixed effects and a random intercept for city. Incidence rates (IRs) per 100 000 persons, incidence rate ratios (IRRs), and adjusted IRRs (aIRRs) for each HOLC grade were estimated using A-rated areas as the reference.

SETTING

202 cities with areas graded by the HOLC in the 1930s.

PARTICIPANTS

Population of the 8597 areas assessed by the HOLC.

MEASUREMENTS

Nonsuicide firearm fatalities.

RESULTS

From 2014 to 2022, a total of 41 428 nonsuicide firearm fatalities occurred in HOLC-graded areas. The firearm fatality rate increased as the HOLC grade progressed from A to D. In A-graded areas, the IR was 3.78 (95% CI, 3.52 to 4.05) per 100 000 persons per year. In B-graded areas, the IR, IRR, and aIRR relative to A areas were 7.43 (CI, 7.24 to 7.62) per 100 000 persons per year, 2.12 (CI, 1.94 to 2.32), and 1.42 (CI, 1.30 to 1.54), respectively. In C-graded areas, these values were 11.24 (CI, 11.08 to 11.40) per 100 000 persons per year, 3.78 (CI, 3.47 to 4.12), and 1.90 (CI, 1.75 to 2.07), respectively. In D-graded areas, these values were 16.26 (CI, 16.01 to 16.52) per 100 000 persons per year, 5.51 (CI, 5.05 to 6.02), and 2.07 (CI, 1.90 to 2.25), respectively.

LIMITATION

The Gun Violence Archive relies on media coverage and police reports.

CONCLUSION

Discriminatory redlining policies from 80 years ago are associated with nonsuicide firearm fatalities today.

PRIMARY FUNDING SOURCE

Fred Lovejoy Housestaff Research and Education Fund.

Determinants of long-term physical and mental health outcomes after intensive care admission for trauma survivors

INTRODUCTION

Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury.

METHODS

Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission ​≥ ​3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors.

RESULTS

2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR ​= ​1.57; 95% CI ​= ​1.21, 2.03), and worse SF-12 mental (mean Δ ​= ​-1.43; 95% CI ​= ​-2.79, -0.09) and physical scores (mean Δ ​= ​-2.61; 95% CI ​= ​-3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group.

CONCLUSIONS

Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.

Gun Violence Exposure and Suicide Among Black Adults

Importance

Black individuals are disproportionately exposed to gun violence in the US. Suicide rates among Black US individuals have increased in recent years.

Objective

To evaluate whether gun violence exposures (GVEs) are associated with suicidal ideation and behaviors among Black adults.

Design, Setting, and Participants

This cross-sectional study used survey data collected from a nationally representative sample of self-identified Black or African American (hereafter, Black) adults in the US from April 12, 2023, through May 4, 2023.

Exposures

Ever being shot, being threatened with a gun, knowing someone who has been shot, and witnessing or hearing about a shooting.

Main Outcomes and Measures

Outcome variables were derived from the Self-Injurious Thoughts and Behaviors Interview, including suicidal ideation, suicide attempt preparation, and suicide attempt. A subsample of those exhibiting suicidal ideation was used to assess for suicidal behaviors.

Results

The study sample included 3015 Black adults (1646 [55%] female; mean [SD] age, 46.34 [0.44] years [range, 18-94 years]). Most respondents were exposed to at least 1 type of gun violence (1693 [56%]), and 300 (12%) were exposed to at least 3 types of gun violence. Being threatened with a gun (odds ratio [OR], 1.44; 95% CI, 1.01-2.05) or knowing someone who has been shot (OR, 1.44; 95% CI, 1.05-1.97) was associated with reporting lifetime suicidal ideation. Being shot was associated with reporting ever planning a suicide (OR, 3.73; 95% CI, 1.10-12.64). Being threatened (OR, 2.41; 95% CI, 2.41-5.09) or knowing someone who has been shot (OR, 2.86; 95% CI, 1.42-5.74) was associated with reporting lifetime suicide attempts. Cumulative GVE was associated with reporting lifetime suicidal ideation (1 type: OR, 1.69 [95% CI, 1.19-2.39]; 2 types: OR, 1.69 [95% CI, 1.17-2.44]; ≥3 types: OR, 2.27 [95% CI, 1.48-3.48]), suicide attempt preparation (≥3 types; OR, 2.37; 95% CI, 2.37-5.63), and attempting suicide (2 types: OR, 4.78 [95% CI, 1.80-12.71]; ≥3 types: OR, 4.01 [95% CI, 1.41-11.44]).

Conclusions and Relevance

In this cross-sectional study, GVE among Black adults in the US was significantly associated with lifetime suicidal ideation and behavior. Public health efforts to substantially reduce interpersonal gun violence may yield additional benefits by decreasing suicide among Black individuals in the US.

Screening for Youth Firearm Violence Exposure in Primary Care

Introduction

The aim of this study was to assess a modified gun violence exposure tool at a pediatric clinic on the West Side of Chicago to identify youth at high risk of future gun violence.

Methods

A modified version of the SaFETy gun violence exposure tool, studied in a community pediatric primary care setting, was implemented from June to August 2021. Patients and pediatric clinicians were surveyed after pilot.

Results

Of 508 eligible patients, 341 youth (67.1%) completed the SaFETy tool. None had a SaFETy score ≥6, the threshold for immediate referral. Over a quarter (26.4%) of youth had scores of 1-5, and of those, 7.8% were referred at the clinician's discretion. Youth (n=84) participants randomly selected to complete an anonymous survey provided feedback about the SaFETY tool, reporting that the questions were easy to understand (92%). All 6 pediatric clinicians surveyed agreed that the tool helped to identify youth exposed to gun violence.

Conclusions

Screening for gun violence exposure among youth is logistically feasible in the pediatric outpatient setting. A more sensitive validated tool to stratify low-/medium-risk patients in the primary care setting is needed.

Development of an interactive dashboard for gun violence pattern analysis and intervention design at the local level

Introduction

Gun violence remains a concerning and persistent issue in our country. Novel dashboards may integrate and summarize important clinical and non-clinical data that can inform targeted interventions to address the underlying causes of gun violence.

Methods

Data from various clinical and non-clinical sources were sourced, cleaned, and integrated into a customizable dashboard that summarizes and provides insight into the underlying factors that impact local gun violence episodes.

Results

The dashboards contained data from 7786 encounters and 1152 distinct patients from our Emergency Department's Trauma Registry with various patterns noted by the team. A multidisciplinary executive team, including subject matter experts in community-based interventions, epidemiology, and social sciences, was formed to design targeted interventions based on these observations.

Conclusion

Targeted interventions to reduce gun violence require a multimodal data sourcing and standardization approach, the inclusion of neighborhood-level data, and a dedicated multidisciplinary team to act on the generated insights.

The Epidemiology of Violence Exposure in Children

Exposure to violence remains a significant issue for children in the United States. The COVID-19 pandemic exacerbated many of these exposures. Violence unequally impacts children of color and lesbian, gay, bisexual, transgender, and questioning youth. Pediatricians can and must continue to advocate and intervene to decrease pediatric violence exposure and its effects.

Association Between Markers of Structural Racism and Mass Shooting Events in Major US Cities

Importance

The root cause of mass shooting events (MSEs) and the populations most affected by them are poorly understood.

Objective

To examine the association between structural racism and mass shootings in major metropolitan cities in the United States.

Design, Setting, and Participants

This cross-sectional study of MSEs in the 51 largest metropolitan statistical areas (MSAs) in the United States analyzes population-based data from 2015 to 2019 and the Gun Violence Archive. The data analysis was performed from February 2021 to January 2022.

Exposure

Shooting event where 4 or more people not including the shooter were injured or killed.

Main Outcome and Measures

MSE incidence and markers of structural racism from demographic data, Gini income coefficient, Black-White segregation index, and violent crime rate.

Results

There were 865 MSEs across all 51 MSAs from 2015 to 2019 with a total of 3968 injuries and 828 fatalities. Higher segregation index (ρ = 0.46, P = .003) was associated with MSE incidence (adjusted per 100 000 population) using Spearman ρ analysis. Percentage of the MSA population comprising Black individuals (ρ = 0.76, P < .001), children in a single-parent household (ρ = 0.44, P < .001), and violent crime rate (ρ = 0.34, P = .03) were other variables associated with MSEs. On linear regression, structural racism, as measured by percentage of the MSA population comprising Black individuals, was associated with MSEs (β = 0.10; 95% CI, 0.05 to 0.14; P < .001). Segregation index (β = 0.02, 95% CI, -0.03 to 0.06; P = .53), children in a single-parent household (β = -0.04, 95% CI, -0.11 to 0.04; P = .28), and Gini income coefficient (β = -1.02; 95% CI, -11.97 to 9.93; P = .93) were not associated with MSEs on linear regression.

Conclusions and Relevance

This study found that major US cities with higher populations of Black individuals are more likely to be affected by MSEs, suggesting that structural racism may have a role in their incidence. Public health initiatives aiming to prevent MSEs should target factors associated with structural racism to address gun violence.

Examining the Relationship between Anti-Black Racism, Community and Police Violence, and COVID-19 Vaccination

In 2020, the COVID-19 pandemic emerged against a backdrop of long-standing racial inequities that contributed to significant disparities in COVID-19 mortality, morbidity, and eventually, vaccination rates. COVID-19 also converged with two social crises: anti-Black racism and community and police violence. The goal of this study was to examine the associations between community violence, police violence, anti-Black racism, and COVID-19 vaccination. Survey data were collected from a sample of 538 Black residents of Chicago between September 2021 and March 2022. Structural equation modeling was used to test associations between neighborhood violence, police violence, racism, medical mistrust, trust in COVID-related information, depressive symptoms, and having received a COVID-19 vaccination. In line with predictions, neighborhood violence had a significant indirect effect on vaccination via trust in COVID-related information from a personal doctor. Additionally, racism had a significant indirect effect on vaccination via trust in COVID-related information from a personal doctor, as well as via medical mistrust and trust in COVID-related information from a personal doctor. These findings add to the growing body of literature demonstrating the importance of medical mistrust when examining COVID-19 vaccination disparities. Furthermore, this study highlights the importance of considering how social and structural factors such as violence and racism can influence medical mistrust.

Trends in Mortality From Poisonings, Firearms, and All Other Injuries by Intent in the US, 1999-2020

Importance

Although deaths due to external causes are a leading cause of mortality in the US, trends over time by intent and demographic characteristics remain poorly understood.

Objective

To examine national trends in mortality rates due to external causes from 1999 to 2020 by intent (homicide, suicide, unintentional, and undetermined) and demographic characteristics. External causes were defined as poisonings (eg, drug overdose), firearms, and all other injuries, including motor vehicle injuries and falls. Given the repercussions of the COVID-19 pandemic, US death rates for 2019 and 2020 were also compared.

Design, Setting, and Participants

Serial cross-sectional study using national death certificate data obtained from the National Center for Health Statistics and including all external causes of 3 813 894 deaths among individuals aged 20 years or older from January 1, 1999, to December 31, 2020. Data analysis was conducted from January 20, 2022, to February 5, 2023.

Exposures

Age, sex, and race and ethnicity.

Main Outcomes and Measures

Trends in age-standardized mortality rates and average annual percentage change (AAPC) in rates calculated by intent (suicide, homicide, unintentional, and undetermined), age, sex, and race and ethnicity for each external cause.

Results

Between 1999 and 2020, there were 3 813 894 deaths due to external causes in the US. From 1999 to 2020, poisoning death rates increased annually (AAPC, 7.0%; 95% CI, 5.4%-8.7%). From 2014 to 2020, poisoning death rates increased the most among men (APC, 10.8%; 95% CI, 7.7%-14.0%). During the study period, poisoning death rates increased in all the racial and ethnic groups examined; the most rapid increase was among American Indian and Alaska Native individuals (AAPC, 9.2%; 95% CI, 7.4%-10.9%). During the study period, death rates for unintentional poisoning had the most rapid rate of increase (AAPC, 8.1%; 95% CI, 7.4%-8.9%). From 1999 to 2020, firearm death rates increased (AAPC, 1.1%; 95% CI, 0.7%-1.5%). From 2013 to 2020, firearm mortality increased by an average of 4.7% annually (95% CI, 2.9%-6.5%) among individuals aged 20 to 39 years. From 2014 to 2020, mortality from firearm homicides increased by an average of 6.9% annually (95% CI, 3.5%-10.4%). From 2019 to 2020, mortality rates from external causes accelerated further, largely from increases in unintentional poisoning, and homicide due to firearms and all other injuries.

Conclusions and Relevance

Results of this cross-sectional study suggest that from 1999 to 2020, death rates due to poisonings, firearms, and all other injuries increased substantially in the US. The rapid increase in deaths due to unintentional poisonings and firearm homicides is a national emergency that requires urgent public health interventions at the local and national levels.

Using a Latent Variable Method to Develop a Composite, Multidimensional Measure of Structural Racism at the City Level

INTRODUCTION

Although structural racism is strongly related to racial health disparities, we are not aware of any composite, multidimensional measure of structural racism at the city level in the United States. However, many of the policies, programs, and institutions that create and maintain structural racism are located at the city level. To expand upon previous research, this paper uses a novel measure to measure structural racism at the city level for the non-Hispanic Black population.

METHODS

We used confirmatory factor analysis to model the latent construct of structural racism for 776 U.S. cities. The model included six indicators across five dimensions: racial segregation, incarceration, educational attainment, employment, and economic status. We generated factor scores that weighted the indicators in order to produce the best model fit. The resulting factor scores represented the level of structural racism in each city. We demonstrated the utility of this measure by demonstrating its strong correlation with Black-White disparities in firearm homicide rates.

RESULTS

There were profound differences in the magnitude of structural racism across cities. There were also striking differences in the magnitude of the racial disparity in firearm homicide across cities. Structural racism was a significant predictor of the magnitude of these racial disparities in firearm homicide. Each one standard deviation increase in the structural racism factor score increased the firearm homicide rate ratio by a factor of approximately 1.2 (95% confidence interval, 1.1-1.3).

CONCLUSIONS

These new measures can be utilized by researchers to relate structural racism to racial health disparities at the city level.

Neighborhood collective efficacy and environmental exposure to firearm homicide among a national sample of adolescents

BACKGROUND

Living near an incident of firearm violence can negatively impact youth, regardless of whether the violence is experienced firsthand. Inequities in household and neighborhood resources may affect the prevalence and consequences of exposure across racial/ethnic groups.

FINDINGS

Using data from the Future of Families and Child Wellbeing Study and the Gun Violence Archive, we estimate that approximately 1 in 4 adolescents in large US cities lived within 800 m (0.5 miles) of a past-year firearm homicide during 2014-17. Exposure risk decreased as household income and neighborhood collective efficacy increased, though stark racial/ethnic inequities remained. Across racial/ethnic groups, adolescents in poor households in moderate or high collective efficacy neighborhoods had a similar risk of past-year firearm homicide exposure as middle-to-high income adolescents in low collective efficacy neighborhoods.

CONCLUSIONS

Empowering communities to build and leverage social ties may be as impactful for reducing firearm violence exposure as income supports. Comprehensive violence prevention efforts should include systems-level strategies that jointly strengthen family and community resources.

Voicing narratives of structural violence in interpersonal firearm violence research and prevention in the United States

Violence is defined as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation." Encompassed in this definition are multiple, interrelated forms of violence, including interpersonal firearm death and injury, but also the systems, policies, and practices enacted by those with power to advantage some groups while depriving others of meaningful opportunities for meeting their basic needs-known as "structural violence". Yet dominant violence prevention narratives too often ignore or deemphasize the deeply intertwined threads of structural violence with other forms of violence, leading to policies and practices that are frequently insufficient, and often harmful, for reducing interpersonal firearm violence and building community safety, particularly in minoritized and structurally marginalized communities. We highlight ways in which limited scrutiny of structural violence, the omission of its defining characteristics-power and deprivation-from functional characterizations and frameworks of interpersonal firearm violence, and the inadequate distribution of power and resources to those most impacted by violence to self-determine narratives of and solutions to interpersonal firearm violence grossly impacts how interpersonal firearm violence is collectively conceived, discussed, and addressed. Expanding dominant narratives of interpersonal firearm violence, guided by the wisdom and determination of those most impacted, such that the goal of prevention and intervention efforts is not merely the absence of violence but rather the creation of a community safety and health ecosystem is essential to meet this critical moment in firearm violence research and prevention.

Assessing the Gun Violence Archive as an Epidemiologic Data Source for Community Firearm Violence in 4 US Cities

Importance

Firearm injury is a major public health burden in the US, and yet there is no single, validated national data source to study community firearm violence, including firearm homicide and nonfatal shootings that result from interpersonal violence.

Objective

To assess the validity of the Gun Violence Archive as a source of data on events of community firearm violence and to examine the characteristics of individuals injured in shootings.

Design, Setting, and Participants

This cross-sectional observational study compared data on community firearm violence from the Gun Violence Archive with publicly available police department data, which were assumed to be the reference standard, between January 1, 2015, and December 31, 2020. Cities included in the study (Philadelphia, Pennsylvania; New York, New York; Chicago, Illinois; and Cincinnati, Ohio) had a population of greater than 300 000 people according to the 2020 US Census and had publicly available shooting data from the city police department. A large city was defined as having a population greater than or equal to 500 000 (ie, Philadelphia, New York City, and Chicago). Data analysis was performed in December 2022.

Main Outcomes and Measures

Events of community firearm violence from the Gun Violence Archive were matched to police department shootings by date and location. The sensitivity and positive predictive value of the data were calculated (0.9-1.0, excellent; 0.8-0.9, good; 0.7-0.8, fair; 0.6-0.7, poor; and <0.6, failed).

Results

A total of 26 679 and 32 588 shooting events were documented in the Gun Violence Archive and the police department databases, respectively, during the study period. The overall sensitivity of the Gun Violence Archive over the 6-year period was 81.1%, and the positive predictive value was 99.0%. The sensitivity steadily improved over time. Shootings involving multiple individuals and those involving women and children were less likely to be missing from the Gun Violence Archive, suggesting a systematic missingness.

Conclusions and Relevance

These findings support the use of the Gun Violence Archive in large cities for research requiring its unique advantages (ie, spatial resolution, timeliness, and geographic coverage), albeit with caution regarding a more granular examination of epidemiology given its apparent bias toward shootings involving multiple persons and those involving women and children.

Examining characteristics and experiences of Black firearm owners

OBJECTIVE

The present study sought to better understand the characteristics of those who own firearms in the Black community; and to understand how Black firearm owners differ from nonfirearm owning Black individuals on a variety of variables related to safety, threat concerns, and suicide risk.

METHODS

Two samples were utilized in this study. The first was a subsample of those who identified as Black from a nationally representative sample (N = 502) seeking to understand firearm ownership within the United States. The second used a subsample of those who identified as Black (N = 1086) from a representative sample from New Jersey, Minnesota, and Mississippi. Variables related to safety and threat concerns were included in the second sample.

RESULTS

In both samples, multiple demographic variables, such as being a woman and having higher education, predicted firearm ownership. In the second sample, experiences of everyday discrimination and crime experiences were associated with firearm ownership. Additionally, Black firearm owners reported significantly more suicidal ideation than Black nonfirearm owners.

CONCLUSION

The findings demonstrate the unique characteristics and experiences of Black firearm owners and show that firearm ownership is associated with increased suicide risk factors for Black adults. Findings should be used to advocate for the creation of more culturally relevant suicide prevention and firearm means safety strategies.

Racial and Ethnic Disparities in Violent Penetrating Injuries and Long-Term Adverse Outcomes

Violent injury is known to be a chronic, recurrent issue, with high rates of recidivism following initial injury. While the burden of violence is disproportionately felt among young Black men and in communities of color, examination of distinct risk factors and long-term outcomes for other racial and ethnic groups could lead to improved violence intervention strategies. In this study, we examined the risk of violent penetrating injury and long-term adverse outcomes by race and ethnicity. This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a violent penetrating injury between 2006 and 2016. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (95%CI) for the risk of all-cause mortality and violent re-injury at one and 3 years after surviving a penetrating injury.Of the 4191 victims of violent injury, 12% were White, 18% were Hispanic, and the remaining 70% self-identified as Black. Within 3 years after initial injury, Black patients were at the greatest risk of all-cause violent re-injury (vs. Hispanic: HR = 1.46, 95%CI[1.15,1.85], p = 0.002; vs. White: HR = 1.89, 95%CI[1.40,2.57], p < 0.0001), particularly by gunshot wound (vs. Hispanic: HR = 2.04, 95%CI[1.29,3.22] p = 0.002; vs. White: HR = 2.34, 95%CI[1.19,4.60], p = 0.01). At 3-years following initial injury, White patients were at 2.03 times the risk for all-cause mortality, likely due to a 4.96 times greater risk of death by drug or alcohol overdose for White patients compared to Black patients (HR = 4.96, 95%CI[2.25,10.96], p < 0.0001). In conclusion, Black survivors of violent injury have a significantly higher risk of violent re-injury, particularly by gun violence, while White patients are at the highest risk for mortality due to the incidence of drug and alcohol overdose. Violence intervention programs with similar patient populations should explore options to collaborate with drug treatment programs to reach this vulnerable population.

Historical Neighborhood Redlining and Contemporary Environmental Racism

To stabilize the housing market during the great depression, the government-sanctioned Home Owners' Loan Corporation (HOLC) created color coded maps of nearly 200 United States cities according to lending risk. These maps were largely driven by racial segregation, with the worst graded neighborhoods colored in red, later termed redlined neighborhoods. We sought to investigate the association between historical redlining, and trends in environmental disparities across the US over the past few decades. We characterized environmental exposures including air pollutants (e.g., NO2 and fine particulate matter), vegetation, noise, and light at night, proximity hazardous emission sources (e.g., hazardous water facilities, wastewater discharge indicator) and other environmental and social indicators harnessed from various sources across HOLC graded neighborhoods and extrapolated census tracts (A [lowest risk neighborhoods] to D [highest risk neighborhoods]). Lower graded areas (C and D) had consistently higher exposures to worse environmental factors. Additionally, there were consistent relative disparities in the exposures to PM2.5 (1981-2018) and NO2 (2005-2019), without significant improvement in the gap compared with HOLC grade A neighborhoods. Our findings illustrate that historical redlining, a form of residential segregation largely based on racial discrimination is associated with environmental injustice over the past 2-4 decades.

The Relationship of Historical Redlining with Present-Day Neighborhood Environmental and Health Outcomes: A Scoping Review and Conceptual Model

Following the Great Depression and related home foreclosures, the federal government established new agencies to facilitate access to affordable home mortgages, including the Home Owners' Loan Corporation (HOLC) and Federal Housing Administration (FHA). HOLC and FHA directed widespread neighborhood appraisals to determine investment risk, referred to as "redlining," which took into account residents' race. Redlining thereby contributed to segregation, disinvestment, and racial inequities in opportunities for homeownership and wealth accumulation. Recent research examines associations between historical redlining and subsequent environmental determinants of health and health-related outcomes. In this scoping review, we assess the extent of the current body of evidence, the range of outcomes studied, and key study characteristics, examining the direction and strength of the relationship between redlining, neighborhood environments, and health as well as different methodological approaches. Overall, studies nearly universally report evidence of an association between redlining and health-relevant outcomes, although heterogeneity in study design precludes direct comparison of results. We critically consider evidence regarding HOLC's causality and offer a conceptual framework for the relationship between redlining and present-day health. Finally, we point to key directions for future research to improve and broaden understanding of redlining's enduring impact and translate findings into public health and planning practice.

Emerging research areas and contributions of NIH in violence research across the lifespan and throughout different settings

This commentary provides background for NIH’s interest in research designed to better understand the causes and consequences of violence and the development, evaluation, and implementation of preventive and treatment interventions to address the resulting trauma, injuries, and mortality from violence. The manuscript describes the context that contributed to a range of initiatives from the NIH focused on violence research, with a particular emphasis on firearms violence prevention research, and opportunities and gaps for future research.

Global burden and trends of firearm violence in 204 countries/territories from 1990 to 2019

Background

Gaps remained in the updated information of the firearm violence (FV) burden from a global landscape. Understanding the global burden of FV could contribute to decision-making.

Methods

Data on the FV burden, including physical violence by firearm (PVF), self-harm by firearm (SHF), and unintentional firearm injuries (UFI), were extracted from the Global Burden of Disease 2019. The temporal trends of age-standardized rate (ASR) were estimated using estimated annual percentage change (EAPC).

Results

In 2019, PVF, SHF, and UFI reported 710.64 × 10³, 335.25 × 10³, and 2,133.88 × 10³, respectively, incident cases worldwide. Their ASR (/100,000 people-years) were 9.31, 4.05, and 28.07. During 1990-2019, the overall incident ASRs of PVF presented an increasing trend (EAPC = 0.61, 95% confidence interval [CI]: 0.48 to 0.75). Notably, pronounced increasing trends were observed in Tropical Latin America, and North Africa and Middle East. However, incident trends of SHF and UFI declined globally, with the respective EAPCs being -0.68 (95% CI: -0.83 to -0.54) and -0.98 (95% CI: -1.19 to -0.77). In 2019, the ASR of death due to PVF, SHF, and UFI were 2.23, 0.65, and 0.26, and that of DALYs were 127.56, 28.10, and 17.64, respectively. Decreasing trends in the ASRs of FV were observed in most regions and countries worldwide over the past three decades, particularly that of PVF in Estonia.

Conclusion

The FV burden was heterogeneous across regions and countries, which was deeply subjected to socioeconomic factors. The findings highlighted that specific prevention strategies and interventions were required, particularly in the high prevalent settings.

Inequities in Community Exposure to Deadly Gun Violence by Race/Ethnicity, Poverty, and Neighborhood Disadvantage among Youth in Large US Cities

Understanding the burden of gun violence among youth is a public health imperative. While most estimates are based on direct and witnessed victimization, living nearby gun violence incidents may be consequential too. Yet detailed information about these broader experiences of violence is lacking. We use data on a population-based cohort of youth merged with incident-level data on deadly gun violence to assess the prevalence and intensity of community exposure to gun homicides across cross-classified categories of exposure distance and recency, overall and by race/ethnicity, household poverty, and neighborhood disadvantage. In total, 2-18% of youth resided within 600 m of a gun homicide occurring in the past 14-365 days. These percentages were 3-25% for incidents within 800 m and 5-37% for those within a 1300-m radius. Black and Latinx youth were 3-7 times more likely, depending on the exposure radius, to experience a past-year gun homicide than white youth and on average experienced incidents more recently and closer to home. Household poverty contributed to exposure inequities, but disproportionate residence in disadvantaged neighborhoods was especially consequential: for all racial/ethnic groups, the difference in the probability of exposure between youth in low vs high poverty households was approximately 5-10 percentage points, while the difference between youth residing in low vs high disadvantage neighborhoods was approximately 50 percentage points. Given well-documented consequences of gun violence exposure on health, these more comprehensive estimates underscore the importance of supportive strategies not only for individual victims but entire communities in the aftermath of gun violence.

County-Level Variation in Changes in Firearm Mortality Rates Across the US, 1989 to 1993 vs 2015 to 2019

IMPORTANCE

Firearm violence remains a critical public health challenge, disproportionately impacting some US regions. County-level variation may hold key insights into how firearm mortality rates vary across the US.

OBJECTIVE

To model county-level changes in firearm mortality rates (total, homicide, and suicide) from 1989 to 1993 vs 2015 to 2019 and identify and characterize hot spots showing unexpected changes over time.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional study with 2 time points using a novel small area estimation method to analyze restricted access mortality microdata by cause of death and US county. The analysis included 3111 US counties from 49 states and the District of Columbia from January 1, 1989, to December 31, 2019. Bayesian spatial models were fitted to map geographical variation in changes in age-standardized firearm mortality rates (per 100 000 person-years) from 1989 to 1993 vs 2015 to 2019. County outliers (or hot spots) were defined as having observed rates that fell outside the 95% credible intervals of their expected posterior predictive distribution. These counties were characterized using visualization and descriptive statistics of their characteristics. Data were analyzed from June to December 2021.

EXPOSURES

County of residence.

MAIN OUTCOMES AND MEASURES

Five-year age-standardized mortality rates by US county, age, and cause of death for 1989 to 1993 and 2015 to 2019.

RESULTS

Between 1989 and 2019, 1 036 518 firearm deaths were recorded in counties across the US. Suicide was the most common cause of firearm mortality (589 285 deaths) followed by homicide (412 231 deaths). Age-standardized rates (deaths per 100 000 individuals) for firearm deaths and suicides increased from 1989 to 1993 vs 2015 to 2019 (mean [SD] change, 0.16 [8.78] for firearm deaths and 1.21 [6.91] for suicides), while firearm homicides decreased (mean [SD] change, -0.39 [3.96]). However, these national trends were not homogeneous across counties and often varied by geographical region. The West and Midwest showed the most pronounced increases in firearm suicide rates, whereas the Southeast showed localized increases in firearm homicide rates, despite the national decreasing trend. Critical hot spots were identified in urban counties of Alabama, and firearm homicide rates (per 100 000) in Baltimore City, Maryland, almost doubled from 29.71 to 47.43, and by 2015 to 2019 it accounted for 66.7% of all firearm homicide in Maryland. By contrast, District of Columbia showed promising improvements over time, decreasing from 56.5 firearm homicides per 100 000 in 1989 to 1993 to 14.45 in 2015 to 2019.

CONCLUSIONS AND RELEVANCE

There was substantial variation in rates and changes in firearm deaths among US counties. Geographical hot spots may be useful to inform targeted prevention efforts and local policy responses.