Gun Deaths in Rural and Urban Settings
While the hypothesized differences between rural and urban gun deaths are supported by study data, the unforeseen similarities are more impressive. Handguns accounted for more than 50% of rural and urban gun deaths (Figure 2), and suicides accounted for about 70% of gun deaths in both areas (Figure 3). Consequently, efforts to prevent handgun and suicide gun deaths have the potential to prevent most gun deaths. Nevertheless, the differences between rural and urban gun deaths were statistically significant and are worth noting as violence prevention strategies relevant to the clinical setting are developed.

To avoid wasting time and effort on ineffective or even harmful interventions, interventions should be evidence-based when possible. Unfortunately, in gun death prevention, well-designed outcome studies in many areas are still lacking. Such studies are hard to design given the myriad of biopsychosocial factors that play a role in gun deaths. This problem is not unique to gun death prevention: "for many decisions, there is simply no evidence available." Lack of evidence, however, does not mandate inaction. Ideally, if an intervention lacking evidence is considered, physicians should implement the intervention in the context of a well-designed outcome study so that others can learn from the experience.

Family physicians can play an important role in promoting violence prevention through work in their communities and through legislation. The following discussion, however, will focus on gun death prevention strategies that can be applied in a clinical setting.

Handguns were the weapons most often involved in both rural and urban Washington gun deaths (Figure 2). Figure 4 and Figure 5 show that the high percentage of rural Washington deaths by handguns contrasts with findings in Tennessee and Wisconsin but is consistent with the North Carolina data. This study did not address why the Washington rural handgun death rate was higher than expected. Regardless of the reason for the high rural handgun death rate in this study, the finding indicates a need to stress handgun safety not only in urban but also in rural areas. Strategies can range from discouraging gun ownership and usage to promoting gun safety for patients who own or plan to own guns. Many strategies to prevent handgun deaths are relevant to preventing gun deaths in general.



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Wisconsin vs Washington rural gun deaths.





In clinical work, family physicians have the opportunity to educate patients on the dangers of owning a handgun. Well-designed studies have shown that, contrary to popular belief, it is not safer to have a gun in the house. A gun in the home is 43 times more likely to kill a family member or friend than it is to kill in self-defense. Kellerman found "the presence of one or more guns in the home was associated with an increased risk of suicide (adjusted odds ration (OR) 4.8; 95% CI 2.7-8.5)." Kellermann and other researchers have similarly found an increased risk of gun death by homicide when a gun is in the home. In contrast, guns are rarely used for self-protection even though 75% of persons who own a handgun give protection as their reason for owning the gun. Perhaps many would rethink gun ownership if a physician presented them with these statistics. Outcomes research can evaluate the impact of physician counseling regarding the relative risks of having a gun in the home.

Several approaches to office-based intervention are effective in preventing handgun and other gun deaths. The HELP Network for Concerned Professionals developed the acronym GUNS as a guide for questions to ask as part of every medical history (Figure 6). Responses to these routine questions give the physician information on risk factors for gun violence and misconceptions of gun safety. Counseling can be individualized, based on the answers to these questions. The GUNS pneumonic can serve as a good teaching device if medical education is part of the practice. Future research could examine whether simply using the GUNS acronym at each visit results in decreased handgun or other gun deaths.



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Tennessee vs Washington handgun deaths.







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GUNS acronym. Developed by the HELP Network of Concerned Professionals.[28] Reprinted with permission.





Another mnemonic used to remember recent recommendations from the American Academy of Pediatrics (AAP) for clinical violence prevention and management is EnLiST: early nurturing, limit-setting, screening for risk and assurance of safety, and treatment of the physical and psychologic consequences of violence.

The AAP recommendations are "a historic step because it makes pediatrics the first medical specialty to fully embrace the idea that violence is a health issue and that the responsibility for violence prevention does not rest solely in the hands of the criminal justice system." Family physicians now also have a historic opportunity to evaluate the effectiveness of the AAP recommendations.

Because most family physicians provide primary care for children, we need to look at what clinical interventions are most effective in preventing pediatric gun deaths. Patterson and Smith noted that "play involving toy guns is thought to contribute to the behavior patterns seen in gun-related deaths in children." In one study of accidental shootings, "the most common activity associated with the fatalities was playing with a gun." Perhaps counseling parents on ways to discourage their children from playing with guns can have an impact. Future outcomes research can look at which prevention strategies are most effective with children.

Promoting gun locks and safety storage mechanisms might help reduce gun deaths, whether by shotguns and rifles or handguns. Physicians can familiarize themselves with the latest in safety technology and pass this along to their patients. Safety devices include gun locks, lockable plastic boxes, metal lock boxes, security cabinets, and gun safes. At a gun store in Milwaukee, one can buy a trigger lock for only $9.99 or spend $1,499.99 to purchase a fire-resistant, 800-pound storage cabinet. The effectiveness of different gun lock and storage mechanisms can be compared and contrasted in future outcome studies.

In clinical practice physicians can incorporate secondary prevention strategies such as education and intervention after an injury. These strategies might prevent gun deaths resulting from re-victimization and revenge violence. Moments after a gunshot injury a patient might be more open to life-changing modifications that will reduce the chance of future gun death or injury. Prothrow-Stith in Boston recommends that all patients inflicted with intentional injuries be assessed for (1) circumstances of the injury event, (2) victim's relationship to the assailant, (3) use of drugs or alcohol, (4) underlying emotional or psychosocial risk, (5) history of intentional injuries or violent behaviors, (6) predisposing biologic risk factors, and (7) intent to seek revenge. Future research could examine whether simply asking and following up on these questions have an impact on gun deaths.

Times of crisis can provide an excellent intervention opportunity for preventing violence. In Milwaukee, for example, Project Ujima, out of the Children's Hospital of Wisconsin, uses trained counselors on call to intervene whenever a youth gun victim arrives in the emergency department. After the initial contact, a multidisciplinary team follows the youth into the community to provide medical, psychiatric, and social support to make major life modifications. Most health systems have secondary prevention protocols when someone arrives at the emergency department who is suicidal or who has chest pain. These protocols are designed to prevent the patient from committing suicide or having a heart attack after they leave the hospital. Physicians have the opportunity to intervene with victims of violence to reduce their risk of being revictimized or seeking revenge after recovering from their acute injury. Outcome studies could be designed for such secondary prevention programs.

Findings from this study strongly suggest that suicide is the major cause of gun deaths in rural and urban Washington (Figure 3). National data indicate that suicide is a greater cause of US gun deaths than homicide, which is especially true in Washington in both urban and rural areas. These findings counter popular assumptions that homicide is uniformly the leading cause of gun deaths in cities and that accidents are the major cause of gun deaths in rural areas. Given this information, family physicians might want to place extra emphasis on suicide prevention when trying to reduce gun deaths wherever they live and work. Unfortunately, well-designed outcome studies of office-based interventions to prevent suicide gun deaths are lacking.

The low percentage of rural gun deaths from accidents and high percentage of rural gun deaths from suicides contrast with the studies cited in the introduction. Unlike the Oklahoma, Kentucky, and Texas studies, this study showed the accidental gun death rate to be low and approximately equal in rural (0.4 per 100,000) and urban (0.3 per 100,000) Washington. Also, contrasting with these studies, the percentage of gun deaths from suicides was high and approximately equal in rural and urban Washington (Figure 3). A North Carolina study did not contrast urban and rural gun deaths, but reported a low accidental rural gun death rate, a finding similar to that of this study. As with handgun deaths, this study did not examine why suicide gun death rates are so high in rural and urban areas, but the results suggest a need to focus efforts on preventing gun deaths by suicide in rural and urban areas.

Suicide prevention most likely requires traditional interventions to screen for and treat mental illnesses, substance abuse, and domestic violence. One study found that 81.9% of adolescent suicides involved diagnosis of bipolar disorder, affective disorder with comorbidity, lack of previous mental health treatment, or availability of firearms in the house. Usually patients see a physician within a few months before committing suicide. Physicians need to have both primary and secondary prevention strategies in place for suicide prevention, whether in a rural or urban area. Outcomes research can be used to decide which clinical interventions are most effective in preventing gun deaths by suicide.

Suicide prevention in clinical practice can also involve some of the general gun safety measures discussed above. In one study, "the presence of a gun in the home, particularly if the gun was loaded, seemed to be most closely associated with suicide in the absence of a diagnosable psychiatric condition." There are about 200 million guns in the United States. An increase in the suicide rate in recent years can be attributed mostly to an increase in suicide by firearms. Women attempt suicide more often than men, but men die from suicide more often because men are more likely to use a gun with a suicide attempt. Outcome studies can help evaluate how to incorporate most effectively general gun death prevention measures into suicide prevention measures.

This study supports the hypotheses that compared with urban Washington, rural Washington has a higher percentage of gun deaths from shotguns and rifles (Figure 2) and that rural Washington has a higher percentage of gun deaths from suicides and accidents (Figure 3). These results agree with those of national studies discussed in the introduction.

In reality, the occurrence of shotgun and rifle deaths in rural areas might be even greater for Washington state than this study indicates. The data in this study were from place of residence of the gun death victim because these data were more reliable. If data based on place of occurrence of gun deaths had been used, those who were killed by a shotgun or rifle when they traveled from an urban area to hunt in a rural area would have been included as a rural rather than urban gun death.

Good outcome data are again needed to show how to reduce shotgun and rifle gun deaths as well as suicide and accidental gun deaths in rural areas. Some of the measures to prevent handgun deaths might apply to preventing shotgun and rifle deaths. The interventions to reduce rural gun deaths from shotguns and rifles could be important in reducing rural gun deaths from suicides. Brent found that "long-guns in the home were associated with suicide only in rural areas." Accidental deaths account for a minority of gun deaths in rural and urban areas, but each one is tragic. Trigger locks and other devices that do not require behavioral change could be especially effective in preventing these deaths.

This study, as do many, poses at least as many questions as it answers. Future research can focus both on collecting better epidemiologic data on which to base interventions and on assessing the effectiveness of various interventions.

As mentioned, the data in this study were from place of residence of death victims, rather than place of death. A study comparing results using place of residence and place of occurrence data might provide useful insights.

This study was retrospective. A better research design would be a controlled prospective study. Although more than 13,000 gun deaths per year is alarmingly high, gun death rates in individual communities are low enough that getting a sufficient number of participants in intervention studies to give a study significant power could be difficult. A national gun death registry could help coordinate data collection and improve the potential power of studies that are undertaken.

Because of a new gun death reporting system in Washington State and the desire to collect relatively recent statistics, data were collected for a relatively short period. Future studies can compare rural and urban gun deaths within different periods and in different regions of the country and look for trends with time. The scope of the study could be expanded to compare rural and urban nonfatal firearm injuries. This study looked at gun deaths, but as many as two thirds of firearm injuries are not fatal.

This study does not address why some of the Washington data differ from national data. Perhaps demographics in rural Washington are different from rural demographics in Wisconsin and Tennessee but are similar to those in North Carolina. Furthermore, why rural and urban gun death rates differ within a given state was not addressed. Future research could be designed to assess possible causes for differences in gun death rates. Demographics, such as age, sex, ethnicity, income level, and education, could be assessed. Future research could also assess the subset of gun deaths related to domestic violence and investigate potential legal, transportation, confidentiality, and financial barriers to domestic violence prevention in rural and urban areas.

Many interventions for gun death prevention lack outcome studies, though there are several areas of intervention where outcome data are needed. Given the magnitude of the gun death epidemic and the variety of interventions to consider, research is warranted to document which interventions are most effective. Such research can look at what family physicians are already doing in addition to testing new strategies. It is hoped that a continued partnership between research and interventions will help control the current violence epidemic in the United States.