Shook Ones: Understanding the Intersection of Nonfatal Violent Firearm Injury, Incarceration, and Traumatic Stress Among Young Black Men

Using the Socio-Ecological Model to Understand Increased Risk of Gun Violence in the African American Community

Gun violence is a major public health issue of growing concern in the United States (U.S.) with 48,830 lives lost to gun related violence in 2021, documenting the highest number of gun related homicides and suicides ever recorded. The African American community is disproportionately impacted by gun violence and members of this community are almost 14x more likely to die by gun homicide than their white counterparts. The Centers for Disease Control and Prevention (CDC) has identified a socio-ecological framework as a lens through which to better understand violence and inform potential prevention strategies to address it. This model identifies four levels (individual, relationship, community, societal) which help to enhance our understanding of the complex interplay between individuals and their environments. Here, we use this model to understand why the African American community experiences elevated risk of gun violence in the U.S. and propose strategies for prevention. Understanding the issue of gun violence beyond individual level risk, this analysis highlights the interplay between multiple levels including the ways in which societal level factors influence violence. While this paper provides a lens through which to understand the multi-leveled factors that contribute to gun violence in the African American community, it also serves as a call to action for policymakers, scholars, and agencies to develop culturally informed policy and programming efforts specific to those who are most impacted.

Hospital Based Violence Intervention Programs Using Peer Support Specialists: A Concise Review

BACKGROUND

Interpersonal violence remains a significant public health problem in the United States. The toll of violence has spurred the development of hospital-based violence intervention programs that use peer support specialists or navigators. Yet, their effectiveness remains uncertain. This study aims to concisely review the recent literature on the effectiveness of hospital-based violence intervention programs using the peer support specialist role.

METHODS

A systematic search of articles from PubMed, OVID, and Google Scholar was performed for this review. Peer reviewed studies addressing hospital-based violence intervention programs using peer support specialists between 2017 and 2022 were selected. Key data points were extracted and analyzed by consensus of the authors.

RESULTS

Eight of the 232 studies reviewed met eligibility requirements. Across these studies, the recidivism rate was reduced between 43% and 95% in victims participating in hospital-based violence intervention programs with peer support specialists.

CONCLUSION

The peer support specialist (navigator) role is central to the success of the violence intervention programs. This role guides and coordinates health services for victims of violence, extending after discharge into the community. Programs showed the most success with helping victims reach short-term goals focused on immediate basic needs but are more challenged meeting longer-term goals, such as education or relocation. This review reveals that hospital-based violence intervention programs using peer support specialists (navigators) lead to the achievement of meeting victim goals and reduce recidivism rates.

What's missing? Violently injured Black men's narratives around Adverse Childhood Experiences (ACEs)

BACKGROUND

Adverse childhood experiences have been associated with future outcomes; however, Felitti's 1998 ACEs questionnaire fails to capture the experiences of Black populations living in disinvested neighborhoods making it necessary to expand the ACEs questionnaire to examine the life experiences of violently injured Black men.

OBJECTIVE

The aim of the study was to advance the understanding of ACEs among Black male firearm violence survivors using the ACEs questionnaire and semi-structured interviews.

PARTICIPANTS AND SETTING

Ten Black male firearm violence survivors were recruited from an urban HVIP. Case managers conducted recruitment using the HVIP's REDcap database; active and previous HVIP participants were eligible for the study.

METHODS

A qualitative study design was used to understand the childhood experiences of Black male firearm violence survivors using Felitti's ACEs questionnaire and a semi-structured interview examining perceptions of their childhood experiences. Due to the COVID-19 pandemic, recruitment and interviews were conducted over the phone.

RESULTS

All participants experienced at least one ACE. Three themes arose from the interviews: youth incarceration, family separation and loss, and housing transition. Men at risk for violent injury experience ACEs beyond those measured in the current instrument.

Improved follow-up care for gun violence survivors in the Trauma Quality of Life Clinic

Background

Outpatient follow-up represents a crucial opportunity to re-engage with gun violence survivors (GVS) and to facilitate positive health outcomes. Current outpatient models for firearm-related injuries and trauma care are inconsistent and unstandardized across trauma centers. This project describes the patient population served by the multidisciplinary Trauma Quality of Life (TQoL) Clinic for GVS. Also of primary interest was the outpatient follow-up services used by patients prior to their clinic appointment. Subsequent referrals placed during Clinic, as well as rate of attendance, was a secondary aim.

Methods

This was a descriptive retrospective analysis of a quality improvement project of the TQoL Clinic. Data were extracted from the electronic medical record and were supplemented with information from the trauma registry and the hospital-based violence intervention program database. Descriptive statistics characterized the patient population served. A Χ2 analysis was used to compare no-show rates for the TQoL Clinic against two historical cohorts of trauma clinic attendees.

Results

Most attendees were young (M=32.0, SD=1.8, range=15-88 years), Black (80.1%), and male (82.0%). Of the 306 total TQoL Clinic attendees, 82.3% attended their initial scheduled appointment. Most non-attendee patients rescheduled their appointments (92.1%), and 89.5% attended the rescheduled appointment. TQoL Clinic demonstrated a significantly lower no-show rate than the traditional trauma clinic model, including after the implementation of the hospital's inpatient violence intervention program (χ2(2)=75.52, p<0.001).

Conclusion

The TQoL Clinic has demonstrated improved outpatient follow-up to address the comprehensive needs of GVS. Trauma centers with high gunshot wound volume should consider the implementation of the multidisciplinary TQoL Clinic model to increase access to care and to continue partnership with violence intervention programs to address health outcomes in those most at risk of future morbidity and mortality.

Level of evidence

Therapeutic/care management, level III.

Protect and Provide: Perceptions of Manhood and Masculinities Among Disabled Violently Injured Black Men in a Hospital-Based Violence Intervention Program

Exploring the post-injury lives of those who have survived gunshot wounds is essential to understanding the entire scope of firearm violence. The lives of Black male firearm violence survivors are transformed in various ways due to their injuries both visible and invisible. This study explored how Black men who suffer from disabilities via a firearm negotiated their masculine identities. Semi-structured, qualitative interviews were conducted with 10 violently injured Black men participating in a hospital-based violence intervention program. Survivors expressed their thoughts on how their injuries impacted their manhood and masculinities. Three themes emerged: (1) perceptions of manhood, (2) loss of independence and burden on others, and (3) and mobility. These themes highlighted and described how their lives were impacted post-injury and characterized their psychological and physical experience of recovery. The research findings suggest the need for more qualitative studies to further explore the relationship between firearm injury, Black masculinity, and perceptions of manhood. While Black men are understudied in health research and invisible in disability research, they continue to be hyper-invisible when discussing violently acquired disabilities.

Hospital-Based Violence Intervention Programs to Reduce Firearm Injuries in Children: A Scoping Review

INTRODUCTION

Hospital-based violence intervention programs (HVIPs) have shown promise in preventing reinjury and enhancing recovery from violent injuries, including those related to firearms. Historically, HVIPs have primarily focused on at-risk adolescents and young adults. The aim of this study is to perform a scoping review of HVIPs targeting children under the age of 18, describe the evidence supporting these programs, and deduce the potential impact of expanding HVIPs to younger children.

METHODS

A scoping review was performed utilizing PubMed database with search terms "violence intervention program" and pediatric, or children, or youth. Articles were screened for youth-inclusive violence programs, and the literature was analyzed for program descriptions, evidence supporting interventions, and barriers to evaluation.

RESULTS

36 studies (covering 23 programs) were identified that met criteria (including patients ≤18 years old), with only 4 programs including children under 10. Many HVIPs utilize brief hospital interventions with longitudinal wraparound outpatient services. Despite heterogeneity in programs and studied outcomes, many HVIPs demonstrated positive outcomes, such as reduction of risk factors, decreased reinjury, decreased violent behaviors, decreased criminal justice involvement, and positive attitude or behavioral changes. Only a few studies reported increased odds of enrollment and positive impact in younger patients specifically.

CONCLUSIONS

Children are an impressionable population in which HVIPs may have significant impact; however, there remains a gap in targeted programs. Given that firearm injuries are the leading cause of death in children and adolescents, priority should be given to piloting, implementing, and evaluating HVIPs among younger age groups.

LEVEL OF EVIDENCE

Level IV.

Engagement With Mental Health Services Among Survivors of Firearm Injury

Importance

Despite the prevalence of posttraumatic stress symptoms after firearm injury, little is known about how firearm injury survivors connect with mental health services.

Objective

To determine facilitators and barriers to mental health care engagement among firearm injury survivors.

Design, Setting, and Participants

A qualitative study of 1-on-1, semistructured interviews conducted within a community setting in Indianapolis, Indiana, between June 2021 and January 2022. Participants were recruited via community partners and snowball sampling. Participants who survived an intentional firearm injury, were shot within Indianapolis, were aged 13 years or older, and were English speaking were eligible. Participants were asked to discuss their lives after firearm injury, the emotional consequences of their injury, and their utilization patterns of mental health services. Data were analyzed from August 2022 to June 2023.

Main Outcomes and Measures

Survivors' lived experience after firearm injury, sources of emotional support, mental health utilization, and their desired engagement with mental health care after firearm injury.

Results

A total of 18 participants (17 were Black [94%], 16 were male [89%], and 14 were aged between 13 and 24 years [77%]) who survived a firearm injury were interviewed. Survivors described family members, friends, and informal networks as their main source of emotional support. Barriers to mental health care utilization were perceived as a lack of benefit to services, distrust in practitioners, and fear of stigma. Credible messengers served as facilitators to mental health care. Survivors also described the emotional impact their shooting had on their families, particularly mothers, partners, and children.

Conclusions and Relevance

In this study of survivors of firearm injury, findings illustrated the consequences of stigma and fear when seeking mental health care, inadequate trusted resources, and the need for awareness of and access to mental health resources for family members and communities most impacted by firearm injury. Future studies should evaluate whether community capacity building, digital health delivery, and trauma-informed public health campaigns could overcome these barriers to mitigate the emotional trauma of firearm injuries to reduce health disparities and prevent future firearm violence.

The gap between hospital-based violence intervention services and client needs: A systematic review

BACKGROUND

Survivors of intentional interpersonal violence face social challenges related to social determinants of health that led to their initial injury. Hospital-based violence intervention programs reduce reinjury. It is unclear how well they meet clients' reported needs. This systematic review aimed to quantify how well hospital-based violence intervention program services addressed clients' reported needs.

METHODS

Medline, The Cochrane Library, CINAHL Plus with Full Text, and PsycInfo were queried for studies addressing hospital-based violence intervention programs services and intentional injury survivors' needs in the United States. Case reports, reviews, editorials, theses, and studies focusing on pediatric patients, victims of intimate partner violence, or sexual assault were excluded. Data extracted included program structure, hospital-based violence intervention program services, and client needs assessments before and after receiving hospital-based violence intervention program services.

RESULTS

Of the 3,339 citations identified, 13 articles were selected for inclusion. Hospital-based violence intervention programs clients' most reported needs included mental health (10 studies), employment (7), and education (5) before receiving hospital-based violence intervention programs services. Only 4 studies conducted quantitative client needs assessments before and after receiving hospital-based violence intervention program services. All 4 studies were able to meet at least 50% of each of the clients' reported needs. The success rate depended on the need and program location: success in meeting mental health needs ranged from 65% to 90% of clients. Conversely, time-intensive long-term needs were least met, including employment 60% to 86% of clients, education 47% to 73%, and housing 50% to 71%.

CONCLUSION

Few hospital-based violence intervention programs studies considered clients' reported needs. Employment, education, and housing must be a stronger focus of hospital-based violence intervention programs.

Spiritual coping behaviors among injured urban black men in Philadelphia

PURPOSE

High rates of firearm injury among urban Black men in the US can lead to long physical and psychological recovery times, worsened by limited access to mental health services. Spirituality can propel positive thoughts, actions, perceptions and behaviors about self and others yet how it is used among Black men recovering from firearm injury is underexplored. This study examined the role of spirituality in the recovery of Black male survivors of firearm injury.

METHOD

Ten injured urban Black men in Philadelphia were interviewed using descriptive phenomenology. A subset of participants from the Emotional Responses and Recovery from Injury in Urban Black Men study who agreed to be recontacted for future studies were enrolled. Informed consent was obtained, semi-structured interviews were conducted via phone and were audiotaped, transcribed, and de-identified. Thematic content analysis was used to understand perceptions of spirituality and to identify spiritual coping behavior themes.

RESULTS

Findings suggest that injured urban Black men engaged in theistic and non-theistic spiritual activities that resulted in positive character development, reduced risk of re-injury, hope, improved mental health and social bonds.

CONCLUSION

Spirituality may serve as a protective factor against firearm re-injury or retaliation by promoting desired behaviors and mental health among injured urban Black men. Combining culturally sensitive spiritual resources and psychotherapy may lead to effective trauma-informed care in addressing spiritual and existential challenges of injured urban Black men who may find spirituality important.

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.

Law enforcement in the trauma bay: a survey of members of the American Academy for the Surgery of Trauma

Background

Trauma patients frequently come into contact with law enforcement officers (LEOs) during the course of their medical care, but little is known about how LEO presence affects processes of care. We surveyed members of the American Association for the Surgery of Trauma (AAST) to assess their perspectives on frequency, circumstances, and implications of LEO presence in trauma bays nationwide.

Methods

Survey items addressed respondents' experience with the frequency and context of LEO presence and their perspectives on the impact of LEO presence for patients, clinical care, and public safety. Respondent demographics, professional characteristics, and practice setting were collected. The survey was distributed electronically to AAST members in September and October of 2020. Responses were compared by participant age, gender, race, ethnicity, urban versus rural location using χ2 tests.

Results

Of 234 respondents, 189 (80.7%) were attending surgeons, 169 (72.2%) identified as white, and 144 (61.5%) as male. 187 respondents (79.9%) observed LEO presence at least weekly. Respondents found LEO presence was most helpful for public safety, followed by clinical care, and then for patients. Older respondents rated LEO presence as helpful more often than younger respondents regarding the impact on patients, clinical care, and public safety (p<0.001 across all domains). When determining LEO access, respondents assessed severity of the patient's condition, the safety of emergency department staff, the safety of LEOs, and a patient's potential role as a threat to public safety.

Conclusions

Respondents described a wide range of perspectives on the impact and consequence of LEO in the trauma bay, with little policy to guide interactions. The overlap of law enforcement and healthcare in the trauma bay deserves attention from institutional and professional policymakers to preserve patient safety and autonomy and patient-centered care.

Level of evidence

IV, survey study.

An intersectional analysis of historical and contemporary structural racism on non-fatal shootings in Baltimore, Maryland

Introduction Non-fatal shooting rates vary tremendously within cities in the USA. Factors related to structural racism (both historical and contemporary) could help explain differences in non-fatal shooting rates at the neighbourhood level. Most research assessing the relationship between structural racism and firearm violence only includes one dimension of structural racism. Our study uses an intersectional approach to examine how the interaction of two forms of structural racism is associated with spatial non-fatal shooting disparities in Baltimore, Maryland. Methods We present three additive interaction measures to describe the relationship between historical redlining and contemporary racialized economic segregation on neighbourhood-level non-fatal shootings. Results Our findings revealed that sustained disadvantage census tracts (tracts that experience contemporary socioeconomic disadvantage and were historically redlined) have the highest burden of non-fatal shootings. Sustained disadvantage tracts had on average 24 more non-fatal shootings a year per 10 000 residents compared with similarly populated sustained advantage tracts (tracts that experience contemporary socioeconomic advantage and were not historically redlined). Moreover, we found that between 2015 and 2019, the interaction between redlining and racialized economic segregation explained over one-third of non-fatal shootings (approximately 650 shootings) in sustained disadvantage tracts. Conclusion These findings suggest that the intersection of historical and contemporary structural racism is a fundamental cause of firearm violence inequities in Baltimore. Intersectionality can advance injury prevention research and practice by (1) serving as an analytical tool to expose inequities in injury-related outcomes and (2) informing the development and implementation of injury prevention interventions and policies that prioritise health equity and racial justice.

Examining risky firearm behaviors among high-risk gun carriers in New York City

Precarious firearm conduct among inexperienced gun possessors has the potential to intensify firearm-related fatalities and injuries. The current study involves face-to-face interviews with 51 high-risk (and prohibited) residents of Brooklyn and the Bronx, NY, each of whom have either been shot or shot at. We analyze study participants' lived experiences regarding urban gun violence (including as victims and perpetrators), firearm handling, sharing, and improper storage. Despite claiming to be knowledgeable about firearm fundamentals, the vast majority of respondents acknowledged never having received professional instruction, but rather "figured it out" by "playing around" with available guns. These informal methods were shaped by respondents' desire to arm themselves despite inadequate access to firearm training. Study participants also described routinely stashing firearms in unsecure, easily accessible locations. Our study findings have important implications for informing community-based harm reduction and safety strategies among persons within high-risk networks.

Exploring emergent barriers to hospital-based violence intervention programming during the COVID-19 pandemic

National rates of gun violence have risen during the COVID-19 pandemic. There are many contributing factors to this increase, including the compounding consequences of social isolation, unstable housing, decreased economic stability, and ineffective and violent policing of communities of color. The effects of these factors are exacerbated by the pandemic's impact on the provision and availability of psychosocial services for individuals in marginalized communities, particularly those who have been violently injured. Hospital-based violence intervention programs (HVIPs) have been identified as a crucial intervention strategy in reducing repeat violent injury. The ongoing COVID-19 pandemic has engendered, significant barriers in HVIPs' attempts to assist program participants in achieving their health-related and social goals. This research offers insight into the complexities of providing social services during the convergence of two public health crises-COVID-19 and gun violence-at the HVIPs associated with the two busiest trauma centers in the state of Maryland. In considering the effects of inadequate financial support and resources, issues with staffing, and the shift to virtual programming due to restrictions on in-person care, we suggest possible changes to violence prevention programming to increase the quality of care provided to participants in a manner reflective of their unique structural positions.

Rethinking "recidivism" in firearm injury research and prevention

Interpersonal firearm injuries pose a persistent public health threat in the United States (US). Strategic interventions to curb these injuries require evaluation of measurable outcomes that prove effectiveness and substantiate efforts for wider scaling and implementation. One common outcome of interest used among injury prevention researchers and practitioners is 'recidivism' referring to recurrent injury from acts of violence in a previously firearm injured person. In this commentary we urge that the term which can insinuate racialized criminality and reinforce stigma, no longer be used to describe people who experience firearm injuries. We also advocate for reconsideration of 'recidivism' as an ideal evaluation metric for the success of tertiary firearm injury prevention programs.

The commission of crime from the perspective of decision-making differences

A criminal act can be regarded as an irrational decision-making process. Therefore, understanding differences in the criminal decision-making process would shed light on criminal behavior. We utilized dual processing theory to propose that offenders' differences in decision-making may cause them to adopt non-adaptive behaviors, such as high reference point setting, abnormal reward-punishment sensitivity, delayed discounting rate, and decision-making style. Our study compares differences in these indicators between offenders (n = 518) and non-offenders (n = 636) in a diverse sample of Chinese adults. The results showed that compared with non-offenders, offenders had higher relative deprivation, reward sensitivity, and delayed discounting rates but lower punishment sensitivity and vigilance in decision-making. A logistic regression analysis also shows that the above factors were significant predictive indicators for the commission of crimes.

Repeat assault injuries: A scoping review of the incidence and associated risk factors

OBJECTIVE

Individuals who experience assault are at high risk of being re-assaulted. Our objective was to identify reported incidences of re-assault and associated risk factors to better inform prevention strategies.

METHODS

We conducted a scoping review and searched databases (MEDLINE, PsychINFO, CINAHL, Cochrane Reviews, and Scopus) and grey literature. We performed abstract and full-text screening, and abstracted incidence of re-assault and information related to age, sex, socioeconomic status, mental illness, and incarceration.

RESULTS

We included 32 articles. Studies varied based on setting where index assaults were captured (n=18 inpatient only, n=13 emergency department or inpatient, n=1 other). Reported incidences ranged from 0.8% over one month to 62% through the lifetime. Important risk factors identified include young age, low socioeconomic status, racialized groups, history of mental illness or substance use disorder, and history of incarceration.

CONCLUSIONS

Rates of re-assault are high and early intervention is necessary for prevention. We identified notable risk factors that require further in-depth analysis, including sex, gender and age-stratified analyses.

POLICY IMPLICATIONS

Key risk factors identified should inform timely and targeted intervention strategies for prevention.

Not All Survivors Are the Same: Qualitative Assessment of Prior Violence, Risks, Recovery and Perceptions of Firearms and Violence Among Victims of Firearm Injury

Qualitative exploration into the risk, experiences, and outcomes of victims of firearm injury is imperative to informing not only further research, but prevention and intervention strategies. The purpose of this study was to explore prior violent exposures, risks, recovery, supportive services, outcomes, and views of firearms and violence among survivors of firearm assaults and unintentional injuries. Adults treated at a level 1 trauma center in Seattle, WA, for assault and unintentional firearm injuries were interviewed utilizing a semistructured instrument. Interview responses were coded to identify common themes and representative quotes are reported. Sixteen participants were interviewed. Notable themes included the following: (a) prior violent exposures were experienced by half of survivors, mostly through community violence; (b) risk for firearm injury was felt to be related to general societal violence, unsafe communities, and firearm practices; (c) important aspects of recovery included family/social support, mental health care and financial support services; (d) notable outcomes included psychological problems such as PTSD and anxiety, changes in relationships, and developing a new sense of purpose or mission in life; (e) generally negative views toward firearms, supporting restricted access and firearm safety practices; (f) acknowledgement of the complexity of firearm violence in society with prevention geared toward equitable education, economic opportunities and safety net programs to reduce community violence; and (g) disappointment in the criminal justice system. These findings demonstrate the varied experiences, needs, and outcomes after injury, but highlight the significance of community and societal violence, and need for improved mental health services. Integration of mental health services and victim assistance programs into trauma centers and hospital-based violence intervention programs is imperative for all survivors. Encouraging survivors to engage in new aspirations after injury can be empowering, and there is an unmet need for victim support and advocacy within the criminal justice system.

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

This study uses data on neighborhoods in four U.S. cities over five years to examine the relationship between fatal and non-fatal gun violence and rates of functional disability among men. Descriptive analyses indicate significant disparities in shooting rates across neighborhoods and heightened associated disability in high shooting communities. Multivariate results show that rates of non-fatal shootings correspond to greater functional disability among young men, but not older men. Fatal gun violence is not associated with increased community disability. The findings suggest that improvements in local gun violence prevention may serve to address broader community disparities in health and well-being.