Source: Nance ML, Carr BG, Kallan MJ, et al. Variation in pediatric and adolescent firearm mortality rates in rural and urban US counties. Pediatrics. 2010; 125(6): 1112– 1118; doi: 10.1542/peds.2009-3219Researchers from the Children’s Hospital of Philadelphia and the University of Pennsylvania compared firearm mortality rates in children living in urban and rural counties. Using US vital statistics data from 1999–2006, they categorized all firearm injury deaths in youth, 0 to 19 years of age, both by intent (homicide, suicide, or unintentional) and according to the type classification of each county along a 10-point scale from most urban to most rural, based on both population and proximity to metropolitan areas. After controlling for several characteristics of individual counties, the odds ratios (OR) and 95% confidence intervals (CI) for different types of deaths in the most urban and most rural counties were calculated. The authors also compared deaths from causes other than firearms in urban and rural counties.During the eight-year study period, 23,649 firearm-related deaths occurred in US youth, including 15,190 homicides and 7,082 suicides. Firearm homicides were significantly more common in the most urban than most rural counties (OR=3.69; 95% CI, 2.00–6.80). Conversely, increasing rates of both firearm suicide (OR 2.01; 95% CI, 1.43–2.83) and unintentional deaths (OR 2.19; 95% CI, 1.27–3.77) were observed in more rural counties. These variations produced overall firearm mortality rates that were statistically indistinguishable when comparing the most rural with the most urban counties (OR=0.91; 95% CI, 0.63–1.32). Whereas firearm death rates in rural and urban counties were similar, non-firearm injury death rates were much higher in rural than in urban counties.The authors conclude that programs to reduce firearm-related deaths in children are needed in all locales, but that different approaches are needed in urban and rural areas.Since the 1980s, firearm injury has shifted from being an epidemic condition to being endemic in the US.1 The statistics are staggering — during the years covered by the present study, firearm injury accounted for more than 11% of all deaths in those aged 1 to 19 years.2The present study offers convincing evidence that the overall burden of pediatric firearm death is shared by rural and urban communities, although the leading manner of death differs. The predominance of homicide deaths in urban counties, in contrast to the predominance of suicide deaths in rural ones, likely has fostered the mistaken impression that firearm injuries overall are chiefly an urban problem. This is in part because the total numbers (as opposed to rates) of homicides are higher, and in part because suicides are less likely to be publicized.3 The relatively higher rates of non-firearm injury deaths in rural counties may further obscure the importance of firearm injuries there.The strengths of this study lie in its use of nationwide statistics focused on the county level, with clearly defined criteria for designating counties as urban or rural. One might question the authors’ decision to designate the county where the fatal injury occurred as the county of interest; for example, if firearms used for urban homicide are actually acquired in rural counties (which might have more gun shops), part of the prevention effort might need to target the rural counties. On the other hand, the finding that many unintentional deaths occurred away from victims’ county of residence suggests that preventive measures at sites where children visit are critical.Prevention of firearm deaths in urban areas must involve community-level interventions aimed at root causes of crime (poverty, drug abuse, etc.), as well as at reducing access to illegal guns.4 Recent research casts doubt on the notion that gun possession in urban settings protects from gun assault.5 In rural areas, where suicide and unintentional firearm deaths predominate, access to mental health care must be improved,6 but reducing access to firearms is also critical.7,8 Pediatricians should encourage gun owners to consider removing them from their homes, or at least to store them unloaded and locked away, apart from ammunition.
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