It Is Time We Start Asking: Handgun Carrying Among Youth in Rural Contexts

Abstract

See Related Article on p.416Firearms are the second leading cause of death among U.S. adolescents and contribute to substantial medical and societal costs [[1]Cunningham R.M. Walton M.A. Carter P.M. The major causes of death in children and adolescents in the United States.N Engl J Med. 2018; 379: 2468-2475Crossref PubMed Scopus (310) Google Scholar,[2]Centers for Disease Control and PreventionNational Center for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS).www.cdc.gov/injury/wisqars/index.htmlDate accessed: December 13, 2019Google Scholar]. Increases in both firearm homicide and suicide rates have resulted in a 28% relative increase in the rate of firearm deaths among children and adolescents between 2013 and 2016 [[1]Cunningham R.M. Walton M.A. Carter P.M. The major causes of death in children and adolescents in the United States.N Engl J Med. 2018; 379: 2468-2475Crossref PubMed Scopus (310) Google Scholar]. Often misconceived of as “an urban problem,” firearm-related mortality impacts communities across the U.S. Firearm-related mortality rates are similar in rural settings (3.84 per 100,000) and urban settings (4.05 per 100,000), with a higher burden of firearm suicide in rural counties and a higher burden of firearm homicide in urban counties [[1]Cunningham R.M. Walton M.A. Carter P.M. The major causes of death in children and adolescents in the United States.N Engl J Med. 2018; 379: 2468-2475Crossref PubMed Scopus (310) Google Scholar]. See Related Article on p.416 Firearm carrying among adolescents plays a large role in firearm-related morbidity and mortality. Studies demonstrate links between firearm carrying (especially handgun carrying), violence exposure and involvement, and multiple adolescent health risk behaviors [[3]Dong B. Wiebe D.J. Violence and beyond: Life-course features of handgun carrying in the urban United States and the associated long-term life consequences.J Crim Justice. 2018; 54: 1-11Crossref Scopus (20) Google Scholar]. A recent scoping review synthesized the science on adolescent firearm carrying and highlighted patterns of intermittent carrying, firearm carrying for protection, and co-occurring risk behaviors including substance use and violence involvement [[4]Oliphant S.N. Mouch C.A. Rowhani-Rahbar A. et al.A scoping review of patterns, motives, and risk and protective factors for adolescent firearm carriage.J Behav Med. 2019; 42: 763-810Crossref Scopus (38) Google Scholar]. Importantly, the vast majority of research on adolescent firearm carrying has been conducted in urban settings, often relying on cross-sectional data, and very little is known about firearm carrying in rural contexts [[4]Oliphant S.N. Mouch C.A. Rowhani-Rahbar A. et al.A scoping review of patterns, motives, and risk and protective factors for adolescent firearm carriage.J Behav Med. 2019; 42: 763-810Crossref Scopus (38) Google Scholar]. In this edition of the Journal of Adolescent Health, Rowhani-Rahbar et al. [[5]Rowhani-Rahbar A. Oesterle S. Skinner M.L. Initiation age, cumulative prevalence, and longitudinal patterns of handgun carrying among rural adolescents: A multistate study.J Adolesc Health. 2020; 66: 416-422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar] shed important light on the prevalence and correlates of handgun carrying in rural settings. This rigorous, longitudinal analysis used data from control communities in the Community Youth Development Study, which included 1,039 males and 963 females residing in 12 rural towns across seven states, who were surveyed annually between grade 6 and age 19 years. The authors found high prevalence of lifetime handgun carrying, especially among males; one in three males and one in 10 females carried a handgun at least once between sixth grade and age 19 years [[5]Rowhani-Rahbar A. Oesterle S. Skinner M.L. Initiation age, cumulative prevalence, and longitudinal patterns of handgun carrying among rural adolescents: A multistate study.J Adolesc Health. 2020; 66: 416-422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Notably, among youth who ever carried a handgun, the first carriage happened at an early age, with approximately a third of both male and female participants carrying in sixth grade or earlier [[5]Rowhani-Rahbar A. Oesterle S. Skinner M.L. Initiation age, cumulative prevalence, and longitudinal patterns of handgun carrying among rural adolescents: A multistate study.J Adolesc Health. 2020; 66: 416-422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. The rate of past-year handgun carriage (9%–12% for males and 1%–3% for females) was similar to one previous study among rural youth in Texas (10% past 12-month gun carriage to school) [[6]Kingery P.M. Pruitt B.E. Heuberger G. A profile of rural Texas adolescents who carry handguns to school.J Sch Health. 1996; 66: 18-22Crossref PubMed Scopus (69) Google Scholar]. Importantly, similar to patterns observed in longitudinal studies in urban settings [[3]Dong B. Wiebe D.J. Violence and beyond: Life-course features of handgun carrying in the urban United States and the associated long-term life consequences.J Crim Justice. 2018; 54: 1-11Crossref Scopus (20) Google Scholar], the majority of participants (55% of males and 72% of females) only carried a handgun on one survey. The population-level burden of morbidity and mortality associated with handgun carrying [[1]Cunningham R.M. Walton M.A. Carter P.M. The major causes of death in children and adolescents in the United States.N Engl J Med. 2018; 379: 2468-2475Crossref PubMed Scopus (310) Google Scholar,[2]Centers for Disease Control and PreventionNational Center for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS).www.cdc.gov/injury/wisqars/index.htmlDate accessed: December 13, 2019Google Scholar] lends support to universally address handgun access and carrying among all youth. Despite endorsement from the American Academy of Pediatrics [[7]Dowd M.D. Sege R.D. Firearm-related injuries affecting the pediatric population.Pediatrics. 2012; 130: e1416-e1423Crossref PubMed Scopus (173) Google Scholar], the Society of Adolescent Health and Medicine [[8]The Society for Adolescent Health and MedicinePreventing firearm violence in youth through evidence-informed strategies.J Adolesc Health. 2020; 66: 260-264Abstract Full Text Full Text PDF Scopus (6) Google Scholar], and many other leading health professional organizations, few pediatric providers routinely screen for firearm access [[7]Dowd M.D. Sege R.D. Firearm-related injuries affecting the pediatric population.Pediatrics. 2012; 130: e1416-e1423Crossref PubMed Scopus (173) Google Scholar,[9]Roszko P.J. Ameli J. Carter P.M. et al.Clinician attitudes, screening practices, and interventions to reduce firearm-related injury.Epidemiol Rev. 2016; 38: 87-110Crossref PubMed Scopus (106) Google Scholar]. The majority of caregivers feel it is appropriate for youth-serving professionals to provide information about firearm safety in clinical settings, and studies suggest that the provision of safety information can impact safe storage intentions and practices [9Roszko P.J. Ameli J. Carter P.M. et al.Clinician attitudes, screening practices, and interventions to reduce firearm-related injury.Epidemiol Rev. 2016; 38: 87-110Crossref PubMed Scopus (106) Google Scholar, 10Ngo Q.M. Sigel E. Moon A. et al.State of the science: A scoping review of primary prevention of firearm injuries among children and adolescents.J Behav Med. 2019; 42: 811-829Crossref Scopus (28) Google Scholar, 11Campbell B.T. Thaker S. Fallat M.E. et al.A multicenter evaluation of a firearm safety intervention in the pediatric outpatient setting.J Pediatr Surg. 2020; 55: 140-145Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. The current findings are a poignant reminder for all youth-serving professionals that assessing and addressing firearm carrying among both male and female youth across all geographic contexts is a critical component of adolescent health. There are an estimated 265 million firearms in civilian possession across the U.S.; four in 10 of these are handguns [[12]Deborah A. Lisa H. David H. Matthew M. The stock and flow of U.S. Firearms: Results from the 2015 National Firearms Survey.RSF: Russell Sage Found J Soc Sci. 2017; 3: 38-57Google Scholar]. Approximately 4.6 million children and adolescents live in homes with loaded and unlocked firearms [[13]Azrael D. Cohen J. Salhi C. Miller M. Firearm storage in gun-owning households with children: Results of a 2015 National Survey.J Urban Health. 2018; 95: 295-304Crossref PubMed Scopus (127) Google Scholar]. Federal law prohibits handgun possession before age 18 years [[14]Giffords Law Center to Prevent Gun ViolenceMinimum age to purchase & possess.https://lawcenter.giffords.org/gun-laws/policy-areas/who-can-have-a-gun/minimum-age/Date accessed: December 13, 2019Google Scholar]. Among minors, households are an important source of handguns [[15]Vittes K.A. Vernick J.S. Webster D.W. Legal status and source of offenders' firearms in states with the least stringent criteria for gun ownership.Inj Prev. 2013; 19: 26Crossref PubMed Scopus (41) Google Scholar]. According to a 2017 Pew Research Center national survey, adults in rural settings are more likely to have a firearm in the household (58% of adults in rural settings vs. 29% of adults in urban areas) and are more likely to report getting their first firearm before age 18 years (47% vs. 27%) [[16]Pew Research CenterRural and urban gun owners have different experiences, views on gun policy.https://www.pewresearch.org/fact-tank/2017/07/10/rural-and-urban-gun-owners-have-different-experiences-views-on-gun-policy/Date: 2017Date accessed: December 13, 2019Google Scholar]. Research on screening, counseling, and interventions should be attuned to how geographic contextual differences in household firearm ownership may shape strategies to engage youth and families in handgun access, carriage, and safety discussions [[17]Cunningham R.M. Carter P.M. Ranney M.L. et al.Prevention of firearm injuries among children and adolescents: Consensus-driven research agenda from the firearm safety among children and teens (FACTS) Consortium.JAMA Pediatr. 2019; 173: 780-789Crossref PubMed Scopus (43) Google Scholar]. Rowhani-Rahbar et al. [[5]Rowhani-Rahbar A. Oesterle S. Skinner M.L. Initiation age, cumulative prevalence, and longitudinal patterns of handgun carrying among rural adolescents: A multistate study.J Adolesc Health. 2020; 66: 416-422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar] found that handgun carrying was positively correlated with personal and peer norms around handgun carrying and with peer handgun carrying. Youth who identified having at least one friend who carried a handgun in the past year were significantly more likely to report carrying a handgun [[5]Rowhani-Rahbar A. Oesterle S. Skinner M.L. Initiation age, cumulative prevalence, and longitudinal patterns of handgun carrying among rural adolescents: A multistate study.J Adolesc Health. 2020; 66: 416-422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. These findings are in keeping with studies in urban settings [[4]Oliphant S.N. Mouch C.A. Rowhani-Rahbar A. et al.A scoping review of patterns, motives, and risk and protective factors for adolescent firearm carriage.J Behav Med. 2019; 42: 763-810Crossref Scopus (38) Google Scholar] as well as a study among nonmetropolitan and rural youth [[18]Cunningham P.B. Henggeler S.W. Limber S.P. et al.Patterns and correlates of gun ownership among nonmetropolitan and rural middle school students.J Clin Child Psychol. 2000; 29: 432-442Crossref PubMed Scopus (52) Google Scholar] and highlight the influence of peer networks on handgun access, carrying behavior, and firearm-related injury [[4]Oliphant S.N. Mouch C.A. Rowhani-Rahbar A. et al.A scoping review of patterns, motives, and risk and protective factors for adolescent firearm carriage.J Behav Med. 2019; 42: 763-810Crossref Scopus (38) Google Scholar,[15]Vittes K.A. Vernick J.S. Webster D.W. Legal status and source of offenders' firearms in states with the least stringent criteria for gun ownership.Inj Prev. 2013; 19: 26Crossref PubMed Scopus (41) Google Scholar,[19]Tracy M. Braga A.A. Papachristos A.V. The transmission of gun and other weapon-involved violence within social networks.Epidemiol Rev. 2016; 38: 70-86Google Scholar,[20]Hemenway D. Vriniotis M. Johnson R.M. et al.Gun carrying by high school students in Boston, MA: Does overestimation of peer gun carrying matter?.J Adolesc. 2011; 34: 997-1003Crossref PubMed Scopus (39) Google Scholar]. Although much of the data come from urban contexts, networks where handgun carrying is common can foster opportunities for the diversion of firearms from legal to illegal channels and serve as key mechanisms for adolescent firearm acquisition [[15]Vittes K.A. Vernick J.S. Webster D.W. Legal status and source of offenders' firearms in states with the least stringent criteria for gun ownership.Inj Prev. 2013; 19: 26Crossref PubMed Scopus (41) Google Scholar,[21]Carter P.M. Walton M.A. Newton M.F. et al.Firearm possession among adolescents presenting to an urban emergency department for assault.Pediatrics. 2013; 132: 213-221Crossref PubMed Scopus (81) Google Scholar]. Assessing and addressing peer norms during clinical encounters may offer additional opportunities to mitigate carriage behavior. Thinking beyond clinical encounters, legislation may also play an important role in youth access and carriage of firearms. Overall, child access protection laws have the strongest evidence of reductions in firearm suicides and unintentional firearm deaths among children and adolescents [[22]Zeoli A.M. Goldstick J. Mauri A. et al.The association of firearm laws with firearm outcomes among children and adolescents: A scoping review.J Behav Med. 2019; 42: 741-762Crossref Scopus (25) Google Scholar]. A state-level analysis found that a more restrictive firearm law environment was associated with lower odds of youth firearm carrying, with the association mediated through adult ownership [[23]Xuan Z. Hemenway D. State gun law environment and youth gun carrying in the United States.JAMA Pediatr. 2015; 169: 1024-1031Crossref Scopus (25) Google Scholar]. A recent study found that the combination of the National Instant Criminal Background Check System with universal background check laws was associated with a 25% reduction in adolescent firearm carrying [[24]Timsina L.R. Qiao N. Mongalo A.C. et al.National instant criminal background check and youth gun carrying.Pediatrics. 2020; 145Crossref Scopus (6) Google Scholar]. Careful attention to the impact of policies across varying geographic contexts can inform both state- and national-level efforts to enact evidence-informed legislation to reduce adolescent firearm carrying and firearm-related morbidity and mortality. With firearms the second leading cause of death among adolescents and firearm-related mortality on the rise [[1]Cunningham R.M. Walton M.A. Carter P.M. The major causes of death in children and adolescents in the United States.N Engl J Med. 2018; 379: 2468-2475Crossref PubMed Scopus (310) Google Scholar,[2]Centers for Disease Control and PreventionNational Center for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS).www.cdc.gov/injury/wisqars/index.htmlDate accessed: December 13, 2019Google Scholar], this timely contribution from Rowhani-Rahbar et al. [[5]Rowhani-Rahbar A. Oesterle S. Skinner M.L. Initiation age, cumulative prevalence, and longitudinal patterns of handgun carrying among rural adolescents: A multistate study.J Adolesc Health. 2020; 66: 416-422Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar] provides critically important data on patterns and correlates of rural handgun carrying. Firearm-related injury and mortality are preventable and, as youth-serving professionals, it is time we start asking about it. When professionals learn a young person is carrying a handgun, it is essential to ask follow-up questions about reasons for carrying and patterns of carrying and to assess for factors that may increase injury risk (e.g., suicidality and prior violent injury). Using a motivational interviewing approach, key messages to convey include (1) your concern for their safety, (2) handgun carrying increases their risk of injury [[25]Branas C.C. Richmond T.S. Culhane D.P. et al.Investigating the link between gun possession and gun assault.Am J Public Health. 2009; 99: 2034-2040Crossref PubMed Scopus (104) Google Scholar], and (3) your commitment to partnering together to keep them safe. As researchers, it is time we start asking important follow-up questions to enrich these descriptive data: Is handgun carrying in rural settings associated with the same constellation of health risk behaviors observed in urban settings? How do patterns of handgun carrying in rural settings map onto higher rates of suicide and relatively lower rates of homicide compared with urban settings? What setting-specific strategies are most efficacious at reducing handgun carrying and firearm-related injury? Funding to support additional rigorous firearm safety research across geographic contexts is urgently needed [[17]Cunningham R.M. Carter P.M. Ranney M.L. et al.Prevention of firearm injuries among children and adolescents: Consensus-driven research agenda from the firearm safety among children and teens (FACTS) Consortium.JAMA Pediatr. 2019; 173: 780-789Crossref PubMed Scopus (43) Google Scholar]. Future studies should specifically examine individual-, family-, peer-, community-, and policy-level risk and protective factors for handgun carriage in rural settings to identify opportunities for interventions that are attuned to the experiences, challenges, and strengths of young people living in rural communities. It is time we start asking. Initiation Age, Cumulative Prevalence, and Longitudinal Patterns of Handgun Carrying Among Rural Adolescents: A Multistate StudyJournal of Adolescent HealthVol. 66Issue 4PreviewAdolescent handgun carrying is a behavioral marker for youth interpersonal conflicts and an intervention point for violence prevention. Our knowledge about the epidemiology of adolescent handgun carrying mainly pertains to urban settings. Evidence on the initiation age, cumulative prevalence, and longitudinal patterns of this behavior and on handgun-related norms and peer behavior among male and female rural adolescents is scant. Full-Text PDF