- Email: [email protected]
Barriers to Firearm Injury Research
RESEARCH ARTICLE
Barriers to Firearm Injury Research Katie A. Donnelly, MD,1,2 Dariush Kafashzadeh, BS,3 Monika K. Goyal, MD, MSCE,1,2 Gia M. Badolato, MPH,1 Shilpa J. Patel, MD, MPH,1,2 Priti Bhansali, MD, MEd,1 Kathleen M. Roche, MSW, PhD,4 Joanna S. Cohen, MD1,2
Introduction: Firearm injuries and motor vehicle injuries are 2 leading causes of fatal injury in the
U.S., each accounting for approximately 35,000 deaths annually. Research on firearm injuries is under-represented compared with research on motor vehicle collisions. This study seeks to identify perceived barriers to firearm injury research versus motor vehicle injury research.
Methods: This was a mixed-methods survey of corresponding authors of a minimum of 1 study,
archived in PubMed, related to firearm injury or motor vehicle injury between 2014 and 2018. Analyses were performed in 2019. Electronic surveys included both closed- and open-ended questions to assess barriers to research. Bivariable and multivariable logistic regression was performed to identify differences in perceptions to barriers between the 2 groups. Qualitative analysis of freetext responses was performed through inductive derivation of themes.
Results: Surveys were distributed to 113 firearm injury researchers (42% response rate) and 241 motor vehicle injury researchers (31.5% response rate). After adjustment, firearm injury researchers were less likely to cite institutional support (AOR=0.3, 95% CI=0.1, 0.8) as a factor contributing to their success, than motor vehicle injury researchers. Firearm injury researchers were more likely to report fear of personal threats (AOR=10.4, 95% CI=2.4, 44.4) and experiencing personal threats (AOR=16.1, 95% CI=1.6, 165.4). Thematic analysis revealed 4 themes: career, political, funding, and harassment. Conclusions: When compared with motor vehicle injury researchers, firearm injury researchers are significantly more likely to report limited support and threats to personal safety as barriers to research. Further research to understand the impact of these barriers and methods to overcome them is needed. Am J Prev Med 2020;58(6):825−831. © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
T
wo of the leading causes of fatal injury in the U. S. are motor vehicle injuries (MVIs) and firearm injuries, each separately accounting for more than 35,000 deaths in 2016.1 These injuries, both fatal and nonfatal, cost the American healthcare system $671 billion in 2015 alone.2 Research is a key component of a comprehensive strategy to reduce morbidity and mortality from accidental or intentional injury. Since 1996, the federal government has spent $240 million annually on traffic safety research. This has informed a number of evidence-based interventions, leading to an impressive 30% reduction in the
annual rate of motor vehicle collision deaths.1 By contrast, since 1996, there has been almost no publicly funded research on firearm injuries, although firearm injury From the 1Division of Emergency Medicine, Children’s National Hospital, Washington, District of Columbia; 2Departments of Pediatrics and Emergency Medicine, George Washington University Hospital, Washington, District of Columbia; 3School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and 4Milken Institute School of Public Health, George Washington University, Washington, District of Columbia Address correspondence to: Katie Donnelly, MD, Division of Emergency Medicine, Children’s National Hospital, 111 Michigan Avenue NW, Washington DC 20010. E-mail: [email protected]. 0749-3797/$36.00 https://doi.org/10.1016/j.amepre.2020.01.005
© 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
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deaths rival those of motor vehicle collisions.3 Although MVI mortality rates decreased from 14.2 per 100,000 people in 2006 to 11.6 in 2016, firearm injury mortality increased, rising from 10.2 per 100,000 in 2006 to 11.8 per 100,000 in 2016.4−7 In addition to scarce federal funding, social and political factors may contribute to the under-representation of firearm injury research. Firearm researchers report significant pressure to present findings that are socially and politically acceptable to certain groups.8−12 The impact of such factors on researchers’ decisions to engage in firearm injury research is unknown. This study investigates real and perceived barriers to firearm injury research and explored the relative effects of funding restrictions and nonfinancial barriers as described by the researchers themselves. Survey responses from researchers who conduct firearm-related studies are compared with a group of researchers who conduct MVI research. This study hypothesizes that barriers to firearm injury research are multifactorial and include a lack of financial support, lack of institutional support, real or perceived retribution, apprehension around a potentially nonviable career path, and concern for failure to publish research. Furthermore, this study hypothesizes that these barriers are unique to firearm injury researchers and are distinct from barriers perceived by researchers who publish on MVI.
METHODS This was a cross-sectional survey of firearm injury and MVI researchers. A mixed-methods approach was used to compare responses with an electronically distributed survey focused on identifying potential barriers to respective research areas and differences in identified barriers between firearm and MVI researchers. This study was approved by the IRB of Children’s National Hospital.
Study Sample Potential survey participants were identified through the National Center for Biotechnology Information’s PubMed database. Individuals were eligible for participation if they were listed as the corresponding author on a relevant research article published between 2014 and 2018. The years 2014−2018 were chosen as the sampling period to assess the most current information. The articles were identified using the terms gun OR firearm OR motor vehicle accidents OR motor vehicle collisions OR traffic accidents in the title or abstract. Participants were invited to complete the survey regardless of how many publications they authored. Authors of opinion pieces, reviews, practice guidelines, and case reports were excluded unless they also had published an original research manuscript. In addition, researchers who served as corresponding authors on both firearm injury and MVI during the study period were excluded. The study sample was limited by the number of firearms researchers identified during the study period. Given the higher number of MVI researchers relative to firearms researchers, MVI authors were randomly selected to obtain a study group size approximately twice the size of the firearms authors study group.
Measures REDCap electronic data capture tools were used to host and administer the survey. A total of 5 researchers who have a primary focus on injury prevention and/or survey design evaluated the preliminary survey for understandability and completeness of questions. Survey modifications were made based on feedback from this initial review. The final survey contained a combination of multiple choice, Likert scale, and open-ended questions focusing on respondent demographics, academic productivity, and potential barriers to research. Likert responses for each statement were on a 5-point scale, ranging from 1=strongly disagree to 5=strongly agree. The survey is available in Appendix 1 (available online). Web-based surveys were sent via e-mail with an introduction explaining the study purpose. There was no monetary or other material incentive to complete the survey. Study data were collected and managed using REDCap. Reminder e-mails were sent at 1 week, 2 weeks, and 1 month after the initial distribution to those authors who did not respond to the initial survey and who did not decline to participate after the initial e-mail. All incorrect e-mails and bounce-back messages prompted an electronic search by authors for an updated email. If an updated e-mail was found, an updated invitation was sent to the author. Data were collected and analyzed in 2019.
Statistical Analysis Frequencies and descriptive statistics were used to describe the study population and calculate survey responses in aggregate and by researcher type (firearm injury versus MVI) with respect to number of papers published, number of grants applied for and received, continued participation in research, and negative experiences owing to research activities. Bivariate logistic regression analyses were conducted to compare survey responses between the 2 groups of researchers. Because the authors a priori believed that age, race, sex, academic appointment, and tenure status may be associated with the outcomes, these covariates were explored for inclusion in multivariate logistic regression analyses. Tenure status was not included in the final multivariate model because it had a co-linear relationship with academic appointment. Likert scores were dichotomized into the following: 1=strongly agree or agree; 0=strongly disagree, disagree, or neutral. Data were analyzed using SPSS, version 25. Thematic analysis was performed on qualitative data from text comments.13,14 Concepts and variables surrounding specific question items were identified and coded, and theories on the interactions between these concepts and variables were developed via an iterative process.
RESULTS A total of 130 firearm injury researchers were identified. Of those, 18 (13.8%) were excluded for incorrect e-mail addresses or bounce-back messages, leaving 113 potential respondents. A total of 300 MVI researchers were randomly selected. Of these, 59 (19.7%) were excluded for incorrect e-mail addresses or bounce-back messages, for a total of 241 potential respondents. The response rate was 42.5% from the firearm injury researchers and 31.5% from the MVI researchers. Characteristics of respondents are described in Table 1. There were no differences between firearm and MVI researchers with regard to age, race, and www.ajpmonline.org
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Table 1. Respondent Characteristics Characteristics Sex Male Age in years, mean Race White Hispanic Academic appointment Instructor Assistant professor Associate professor Professor Professor emeritus No appointment Tenure
Firearm, (n=48), n (%)
MVI, (n=76), n (%)
p-value
29 (60.4) 51
40 (52.6) 48
0.39
44 (91.6) 3 (6.2)
61 (80.2) 2 (2.6)
0.08 0.38
0 (0) 5 (10.4) 13 (27.1) 19 (39.5) 2 (4.2) 9 (18.8) 21 (43.8)
4 (5) 12 (15.8) 11 (14.5) 16 (21.1) 5 (6.6) 26 (34.2) 20 (26.3)
0.02 — — — — — 0.26
Note: Boldface indicates statistical significance (p<0.05). MVI, motor vehicle injury.
sex. MVI researchers were less likely to hold academic appointments than firearms researchers (p=0.02). After adjusting for sex, age, race, and academic appointment, firearm injury researchers (39.6%) were less likely to cite institutional support as a factor in their success (AOR=0.32, 95% CI=0.13, 0.80) than MVI researchers (59.2%) (Table 2). There was no significant difference in funding or mentorship as factors in success between the 2 groups. Firearm injury researchers were more likely to have published an opinion piece (58.3%) than MVI researchers (30.3%) (AOR=2.47, 95% CI=1.01, 6.09). There were no reported differences between the 2 groups in applying for or receiving funding or in funding sources. After adjustment, firearm injury researchers were less likely than MVI researchers to believe their research was appropriately funded (AOR=0.3, 95% CI=0.1, 1.0) (Table 3). They were more likely to feel encouraged by friends or family to conduct research on this topic than MVI researchers (AOR=8.6, 95% CI=2.0, 25.8). When compared with MVI researchers, firearm injury researchers were significantly more likely to fear personal threats (18.8% vs 2.6%; AOR=10.4, 95% CI=2.4, 44.4) and to experience personal threats (29.2% vs 5.2%; AOR=16.12, 95% CI=1.6, 165.4) (Table 2). There was no statistically significant difference between the groups with regard to fear of or experience of professional repercussions. A total of 4 significant themes were derived from the free-text responses: career, political, funding, and harassment. Harassment was further coded into 3 subcodes: online, in person, and mail. Representative quotes from each theme are included in Table 4. Both firearm injury and MVI researchers shared concerns that their research had negatively impacted career June 2020
options. They both cited concerns about a lack of academic future in their chosen field of research. They also both described frustration with the academic promotion process. Both groups expressed concern that following a research passion would not lead to advancement. Only the firearm injury researchers mentioned the politically fraught nature of their work, citing both the right and the left sides of the political spectrum as negative influences. Firearm injury researchers expressed a desire to not have politics influence the interpretation of their results. There were no similar concerns in MVI research responses. Both groups cited barriers to funding or the need for more funding to support their research. MVI researchers mentioned industry or nonacademic sources of funding in their qualitative responses, whereas firearm injury researchers did not. A total of 15 firearm injury researchers commented about threats compared with only 2 MVI researchers. Three subcodes of harassment—online, in person, and mail—were created. The most commonly discussed type of harassment was online, typically anonymously on message boards or in comments sections.
DISCUSSION In this study, firearm injury research authors reported more barriers to research than MVI research authors. Firearm injury researchers received fewer grants than their MVI counterparts and were more likely to report that their research was not appropriately supported by their institution nor appropriately funded. Firearm injury researchers were more likely to write opinion
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Table 2. Reported Differences Between Firearm and MVI Researchers Measure What has contributed to your success? Mentorship Funding Institutional support Other Other types of publications Review article Opinion piece Other Applied for funding (yes) Received funding (yes) (n=75) From where did you receive funding? (n=61) Home institution Local government Federal government Private funding Other Number of publications, median (IQR) Number of times applied for funding, median (IQR) Number of grants received, median (IQR) Maximum amount for a single grant, median (IQR) Negative consequences of research I have feared professional repercussions because of my research. I have experienced professional repercussions because of my research. I have feared of personal threats because of my research. I have experienced personal threats because of my research.
Firearm, (n=48) (%)
MVI, (n=76) (%)
AOR, (95% CI) or p-value
26 (54.2) 21 (43.8) 19 (39.6) 13 (27.1)
47 (61.8) 48 (63.2) 45 (59.2) 13 (17.1)
0.8 (0.3, 1.8) 0.4 (0.2, 1.2) 0.3 (0.1, 0.8) 1.5 (0.5, 4.2)
22 (45.8) 28 (58.3) 5 (10.4) 26 (54.2) 21 (80.8)
27 (35.5) 23 (30.3) 8 (10.5) 49 (64.5) 40 (81.6)
1.3 (0.5, 3.1) 2.5 (1.0, 6.1) 0.7 (0.2, 2.6) 0.4 (0.2, 1.1) 1.1 (0.3, 4.4)
8 (38.1) 10 (47.6) 15 (57.7) 14 (66.7) 0 (0) 4 (2−11.5) 3.5 (2−10) 2 (1−4) $675,000 ($88,750−$1,617,500)
14 (35) 19 (47.5) 31 (77.5) 26 (65) 9 (22.5) 7 (3−30) 5 (2−12.7) 5 (2−12) $750,000 ($277,095−$2,300,000)
1.1 (0.3, 3.9) 0.9 (0.2, 3.2) 0.7 (0.2, 3.0) 1.2 (0.3, 4.2) — 0.11 0.19 0.02 0.50
10 (20.8)
4 (5.3)
2.9 (0.8, 10.9)
7 (14.6)
6 (7.9)
2.1 (0.6, 7.6)
14 (29.2)
4 (5.2)
10.4 (2.4, 44.4)
9 (18.8)
2 (2.6)
16.1 (1.6, 165.4)
Note: Boldface indicates statistical significance (p<0.05). MVI, motor vehicle injury.
Table 3. Comparison of Proportion of Strongly Agree/Agree Responses by Researcher Type Measure My research is appropriately funded. I have been able to find collaborators for research. My research is supported by my institution. I have been encouraged to do this research by my friends or family. I have been encouraged to do this research by a colleague. I continue to have strong interest in this research.
Firearm, (n=48) (%)
MVI, (n=76), (%)
AOR, (95% CI)
4 (8.3) 39 (81.3) 32 (66.7) 24 (50.0) 50 (65.8) 62 (81.6)
18 (23.7) 57 (75.0) 51 (67.1) 13 (17.1) 28 (58.3) 44 (91.7)
0.3 (0.1, 1.0) 2.2 (0.8, 6.3) 1.1 (0.5, 2.8) 8.6 (2.0, 25.8) 0.9 (0.4, 2.3) 1.6 (0.4, 6.0)
Note: Boldface indicates statistical significance (p<0.05). MVI, motor vehicle injury.
papers and felt more supported by friends and family in their work. Finally, firearm injury researchers both feared and experienced more personal threats than MVI researchers. Discordance in support is consistent with previous work that has shown that firearm injury research is
financially undersupported.15 MVI researchers have both the National Highway Traffic Safety Administration and a robust private industry to support research. This may be why there was a difference in academic standing among the respondent groups, as many MVI researchers are employed by industry. There is no www.ajpmonline.org
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Table 4. Representative Thematic Quotes Type Career
Political
Funding
Harassment Online
In person
Mail
Firearms
MVI
“The professional risks of doing this work (e.g., not a big area of research in my discipline, lack of mentorship in this area, lack of funding) means I don’t feel able to spend more time on this type of work to make my agenda look less ‘scattered.’” “I attribute this not only to the more extreme pro-gun folks but also to the gun control folks who don’t understand how to find common ground with gun owners and diffuse the hyper-politics around this issue.” “My research led to the conclusion that firearms have a beneficial aspect that dwarfs criminal uses. I feared repercussions because of the fact of those conclusions that went against the grain of public health dogma. If my conclusions had proclaimed that guns were a public health hazard, I would have expected no repercussions but only the plaudits of the public health establishment.” “Federal agencies have been absurd in their overinterpretation of the prohibition on using federal funds to promote gun control.”
“When I transitioned from academia (as a sociologist) to working for a state agency doing applied traffic safety research, this involved a substantial loss in professional status.”
“Not physical threats, more internet hostility. Most of it has been social media based ridicule by folks who clearly hadn’t read the actual research, along with a handful of accusatory e-mails with colorful language (libtard, snowflake, gun snatcher, etc.).” “In addition to peer-reviewed research, I have published two pro-control Op Eds and was horrified by the hostile reactions I received via e-mail.” “A far right extremist group came upon my research and discussed it on their website chat space. I found it when searching my name on google. They spent a good deal of time personally insulting me and saying quite vile things.” “Some men followed me out of a meeting one evening and threatened me.” “I had more repercussions from testifying for gun violence prevention policies. Was chased into a rest room!” “Multiple threatening letters with no return addresses sent to my workplace from firearm owners.” “Letters from those unhappy with my work—threatening things like investigations but not physical violence.”
“Name calling in mass media.”
—
“Lack of (large, varied, frequent) funding for MV research means hard to be successful in academia.”
“Threats during testimony for issues such as helmet laws.” —
MV, motor vehicle; MVI, motor vehicle injury.
commensurate funding mechanism for firearm injury research, contributing to the inequality of grants and appropriateness of funding. The paucity of funding for firearm injury research is accordant with restrictions in funding dictated by the Dickey Amendment, a policy rider enacted by Congress in 1996 that prevents the appropriation of any funds for the Centers for Disease Control and Prevention (CDC) to advocate or promote gun control.3,16 That same year, Congress also reduced the appropriations to CDC by $2.6 million, the exact amount CDC had spent on gun violence research the previous year.17 Since the time of budget reductions for firearm injury research, there has been a 64% decline in the number of firearm studies per million citations in Scopus between 1998 and 2012.18 June 2020
Consequently, firearm injury is the least studied cause of death, receiving only 1.6% of funding expected for its mortality rate.15 A dedicated funding source to support firearm injury research would likely improve the quality and quantity of this public health issue. In addition to financial barriers, firearm injury researchers were more likely than MVI researchers to report fear of threats and having experienced threats as barriers to research. This concern was mirrored in the qualitative findings, as firearm injury researchers were more concerned about the politicization of their research than MVI researchers. There was also a sharp difference in threats experienced, including an ever-increasing presence of anonymous, online harassment. Doxing, the “intentional public release onto the Internet of personal
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information about an individual by a third party,” is a rising fear among many engaged in controversial research, including firearm injury research.19 These concerns and experiences are not surprising, given the growing polarization and rhetoric surrounding firearms in America.20 This study analyzed these threats in both quantitative and qualitative methods. Previously, only anecdotal evidence suggested the existence and influence of these concerns. For instance, after a 1988 New England Journal of Medicine article associated higher rates of homicide with availability of handguns, the research director of the National Rifle Association demanded that 2 of the study’s authors be investigated by the NIH Office of Scientific Integrity.9 More recently, the National Rifle Association Twitter account asked “self-important anti-gun doctors” to “stay in their lane” regarding a recently published Annals of Internal Medicine guideline for future firearm injury prevention research.10 In addition, individual researchers have reported personal threats in response to publishing firearm injury research. After publishing a study that revealed that restrictive policies regulating gun shows in California resulted in fewer illegal purchases, the researcher’s photograph and identifying information was posted on a blog called War On Guns with a warning to call security if he was seen at a gun show.10,11 Depolarizing the discussion around firearm injury prevention will lead to constructive conversations and productive research around the prevention of firearm-related injuries and deaths. Allowing more research to assess a wide array of scientific questions about firearms, including both risks and benefits of gun ownership, could serve to defuse some of this tension.21 In contrast to MVI researchers, firearm injury researchers reported more support of friends and family for their research. They were also more likely to write an opinion piece pertaining to their field of research. These findings suggest that firearm injury researchers may feel more personally invested and may have more interest in advocacy around their research. These findings may point to unique ways firearm injury researchers can be supported in their work. The creation of research groups may help to foster and support early career researchers, as firearm injury researchers feel they lack institutional support. The Firearm Safety Among Children and Teens Consortium recently held their first research conference. The Consortium also published a research agenda that can guide future directions for investigators.22 Innovative research partnerships may be needed to overcome the disparity of funding. Educators, criminologists, and law enforcement officials all recognize the impact firearm violence has on
communities. These groups may be able to apply for grants inaccessible to healthcare providers. Owing to longstanding funding restrictions, there is now a lack of trained firearm injury researchers ready to apply for grants.15,18 Specific training programs, institutions, or funding opportunities may be needed to develop a new generation of researchers.23 Finally, the authors believe that shifting the discussion around prevention of firearm injury from the political arena and into the healthcare arena will help depolarize firearm injury research and reduce social barriers to productive research.
Limitations There are several limitations to this study that deserve consideration. The study may have limited generalizability owing to a low response rate. This low response rate was expected by the authors. The authors may have been contacting researchers that do not identify strongly with an injury prevention niche. Also, with stronger spam filters on many institutional e-mail servers, it is likely that many of the targeted respondents never received the survey invitation. A more robust response rate may have shown more differences between the 2 groups, especially in the number and amount of grants awarded. In addition, firearms researchers had a higher response rate than MVI researchers. This may be because of firearms researchers having stronger opinions about barriers affecting their work, leading to a potential source of bias. The 2 comparison researcher groups may not have the same initial motivations in their research, as many firearm injuries and deaths often have intent, whereas motor vehicle deaths do not. This may lead to bias in results when asking about barriers to research. The study may also be limited by the process for identifying authors of published studies. Though only those who had published at least 1 paper in the selected injury field were invited, potential respondents may not identify as a firearm injury or MVI researcher. This may have affected the results and response rate. Attempting to only contact the corresponding author of the paper may have introduced bias as well. Secondary authors on a study may experience different barriers that are not quantified in this study. Also, although the sample of MVI researchers was chosen randomly in an attempt to reduce bias, it is possible that sampling 1 population but not the other introduced potential bias in the MVI sample that was not introduced in the firearms sample. Furthermore, the authors have no way to identify authors who have conducted research but have not published a paper. Those researchers likely experienced barriers that are not quantified in this article. Finally, only the comments provided by respondents were analyzed. Thematic saturation may not have been reached with this limited number of comments. www.ajpmonline.org
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CONCLUSIONS Firearm injury researchers are more likely to report limited funding, political pressure, and concerns about harassment than MVI researchers. Future directions include further research into these barriers and investigating unique ways to overcome them to support firearm injury research.
ACKNOWLEDGMENTS No financial disclosures were reported by the authors of this paper.
SUPPLEMENTAL MATERIAL Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j. amepre.2020.01.005.
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Barriers to Firearm Injury Research Katie A. Donnelly, MD,1,2 Dariush Kafashzadeh, BS,3 Monika K. Goyal, MD, MSCE,1,2 Gia M. Badolato, MPH,1 Shilpa J. Patel, MD, MPH,1,2 Priti Bhansali, MD, MEd,1 Kathleen M. Roche, MSW, PhD,4 Joanna S. Cohen, MD1,2
Introduction: Firearm injuries and motor vehicle injuries are 2 leading causes of fatal injury in the
U.S., each accounting for approximately 35,000 deaths annually. Research on firearm injuries is under-represented compared with research on motor vehicle collisions. This study seeks to identify perceived barriers to firearm injury research versus motor vehicle injury research.
Methods: This was a mixed-methods survey of corresponding authors of a minimum of 1 study,
archived in PubMed, related to firearm injury or motor vehicle injury between 2014 and 2018. Analyses were performed in 2019. Electronic surveys included both closed- and open-ended questions to assess barriers to research. Bivariable and multivariable logistic regression was performed to identify differences in perceptions to barriers between the 2 groups. Qualitative analysis of freetext responses was performed through inductive derivation of themes.
Results: Surveys were distributed to 113 firearm injury researchers (42% response rate) and 241 motor vehicle injury researchers (31.5% response rate). After adjustment, firearm injury researchers were less likely to cite institutional support (AOR=0.3, 95% CI=0.1, 0.8) as a factor contributing to their success, than motor vehicle injury researchers. Firearm injury researchers were more likely to report fear of personal threats (AOR=10.4, 95% CI=2.4, 44.4) and experiencing personal threats (AOR=16.1, 95% CI=1.6, 165.4). Thematic analysis revealed 4 themes: career, political, funding, and harassment. Conclusions: When compared with motor vehicle injury researchers, firearm injury researchers are significantly more likely to report limited support and threats to personal safety as barriers to research. Further research to understand the impact of these barriers and methods to overcome them is needed. Am J Prev Med 2020;58(6):825−831. © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
T
wo of the leading causes of fatal injury in the U. S. are motor vehicle injuries (MVIs) and firearm injuries, each separately accounting for more than 35,000 deaths in 2016.1 These injuries, both fatal and nonfatal, cost the American healthcare system $671 billion in 2015 alone.2 Research is a key component of a comprehensive strategy to reduce morbidity and mortality from accidental or intentional injury. Since 1996, the federal government has spent $240 million annually on traffic safety research. This has informed a number of evidence-based interventions, leading to an impressive 30% reduction in the
annual rate of motor vehicle collision deaths.1 By contrast, since 1996, there has been almost no publicly funded research on firearm injuries, although firearm injury From the 1Division of Emergency Medicine, Children’s National Hospital, Washington, District of Columbia; 2Departments of Pediatrics and Emergency Medicine, George Washington University Hospital, Washington, District of Columbia; 3School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and 4Milken Institute School of Public Health, George Washington University, Washington, District of Columbia Address correspondence to: Katie Donnelly, MD, Division of Emergency Medicine, Children’s National Hospital, 111 Michigan Avenue NW, Washington DC 20010. E-mail: [email protected]. 0749-3797/$36.00 https://doi.org/10.1016/j.amepre.2020.01.005
© 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
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deaths rival those of motor vehicle collisions.3 Although MVI mortality rates decreased from 14.2 per 100,000 people in 2006 to 11.6 in 2016, firearm injury mortality increased, rising from 10.2 per 100,000 in 2006 to 11.8 per 100,000 in 2016.4−7 In addition to scarce federal funding, social and political factors may contribute to the under-representation of firearm injury research. Firearm researchers report significant pressure to present findings that are socially and politically acceptable to certain groups.8−12 The impact of such factors on researchers’ decisions to engage in firearm injury research is unknown. This study investigates real and perceived barriers to firearm injury research and explored the relative effects of funding restrictions and nonfinancial barriers as described by the researchers themselves. Survey responses from researchers who conduct firearm-related studies are compared with a group of researchers who conduct MVI research. This study hypothesizes that barriers to firearm injury research are multifactorial and include a lack of financial support, lack of institutional support, real or perceived retribution, apprehension around a potentially nonviable career path, and concern for failure to publish research. Furthermore, this study hypothesizes that these barriers are unique to firearm injury researchers and are distinct from barriers perceived by researchers who publish on MVI.
METHODS This was a cross-sectional survey of firearm injury and MVI researchers. A mixed-methods approach was used to compare responses with an electronically distributed survey focused on identifying potential barriers to respective research areas and differences in identified barriers between firearm and MVI researchers. This study was approved by the IRB of Children’s National Hospital.
Study Sample Potential survey participants were identified through the National Center for Biotechnology Information’s PubMed database. Individuals were eligible for participation if they were listed as the corresponding author on a relevant research article published between 2014 and 2018. The years 2014−2018 were chosen as the sampling period to assess the most current information. The articles were identified using the terms gun OR firearm OR motor vehicle accidents OR motor vehicle collisions OR traffic accidents in the title or abstract. Participants were invited to complete the survey regardless of how many publications they authored. Authors of opinion pieces, reviews, practice guidelines, and case reports were excluded unless they also had published an original research manuscript. In addition, researchers who served as corresponding authors on both firearm injury and MVI during the study period were excluded. The study sample was limited by the number of firearms researchers identified during the study period. Given the higher number of MVI researchers relative to firearms researchers, MVI authors were randomly selected to obtain a study group size approximately twice the size of the firearms authors study group.
Measures REDCap electronic data capture tools were used to host and administer the survey. A total of 5 researchers who have a primary focus on injury prevention and/or survey design evaluated the preliminary survey for understandability and completeness of questions. Survey modifications were made based on feedback from this initial review. The final survey contained a combination of multiple choice, Likert scale, and open-ended questions focusing on respondent demographics, academic productivity, and potential barriers to research. Likert responses for each statement were on a 5-point scale, ranging from 1=strongly disagree to 5=strongly agree. The survey is available in Appendix 1 (available online). Web-based surveys were sent via e-mail with an introduction explaining the study purpose. There was no monetary or other material incentive to complete the survey. Study data were collected and managed using REDCap. Reminder e-mails were sent at 1 week, 2 weeks, and 1 month after the initial distribution to those authors who did not respond to the initial survey and who did not decline to participate after the initial e-mail. All incorrect e-mails and bounce-back messages prompted an electronic search by authors for an updated email. If an updated e-mail was found, an updated invitation was sent to the author. Data were collected and analyzed in 2019.
Statistical Analysis Frequencies and descriptive statistics were used to describe the study population and calculate survey responses in aggregate and by researcher type (firearm injury versus MVI) with respect to number of papers published, number of grants applied for and received, continued participation in research, and negative experiences owing to research activities. Bivariate logistic regression analyses were conducted to compare survey responses between the 2 groups of researchers. Because the authors a priori believed that age, race, sex, academic appointment, and tenure status may be associated with the outcomes, these covariates were explored for inclusion in multivariate logistic regression analyses. Tenure status was not included in the final multivariate model because it had a co-linear relationship with academic appointment. Likert scores were dichotomized into the following: 1=strongly agree or agree; 0=strongly disagree, disagree, or neutral. Data were analyzed using SPSS, version 25. Thematic analysis was performed on qualitative data from text comments.13,14 Concepts and variables surrounding specific question items were identified and coded, and theories on the interactions between these concepts and variables were developed via an iterative process.
RESULTS A total of 130 firearm injury researchers were identified. Of those, 18 (13.8%) were excluded for incorrect e-mail addresses or bounce-back messages, leaving 113 potential respondents. A total of 300 MVI researchers were randomly selected. Of these, 59 (19.7%) were excluded for incorrect e-mail addresses or bounce-back messages, for a total of 241 potential respondents. The response rate was 42.5% from the firearm injury researchers and 31.5% from the MVI researchers. Characteristics of respondents are described in Table 1. There were no differences between firearm and MVI researchers with regard to age, race, and www.ajpmonline.org
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Table 1. Respondent Characteristics Characteristics Sex Male Age in years, mean Race White Hispanic Academic appointment Instructor Assistant professor Associate professor Professor Professor emeritus No appointment Tenure
Firearm, (n=48), n (%)
MVI, (n=76), n (%)
p-value
29 (60.4) 51
40 (52.6) 48
0.39
44 (91.6) 3 (6.2)
61 (80.2) 2 (2.6)
0.08 0.38
0 (0) 5 (10.4) 13 (27.1) 19 (39.5) 2 (4.2) 9 (18.8) 21 (43.8)
4 (5) 12 (15.8) 11 (14.5) 16 (21.1) 5 (6.6) 26 (34.2) 20 (26.3)
0.02 — — — — — 0.26
Note: Boldface indicates statistical significance (p<0.05). MVI, motor vehicle injury.
sex. MVI researchers were less likely to hold academic appointments than firearms researchers (p=0.02). After adjusting for sex, age, race, and academic appointment, firearm injury researchers (39.6%) were less likely to cite institutional support as a factor in their success (AOR=0.32, 95% CI=0.13, 0.80) than MVI researchers (59.2%) (Table 2). There was no significant difference in funding or mentorship as factors in success between the 2 groups. Firearm injury researchers were more likely to have published an opinion piece (58.3%) than MVI researchers (30.3%) (AOR=2.47, 95% CI=1.01, 6.09). There were no reported differences between the 2 groups in applying for or receiving funding or in funding sources. After adjustment, firearm injury researchers were less likely than MVI researchers to believe their research was appropriately funded (AOR=0.3, 95% CI=0.1, 1.0) (Table 3). They were more likely to feel encouraged by friends or family to conduct research on this topic than MVI researchers (AOR=8.6, 95% CI=2.0, 25.8). When compared with MVI researchers, firearm injury researchers were significantly more likely to fear personal threats (18.8% vs 2.6%; AOR=10.4, 95% CI=2.4, 44.4) and to experience personal threats (29.2% vs 5.2%; AOR=16.12, 95% CI=1.6, 165.4) (Table 2). There was no statistically significant difference between the groups with regard to fear of or experience of professional repercussions. A total of 4 significant themes were derived from the free-text responses: career, political, funding, and harassment. Harassment was further coded into 3 subcodes: online, in person, and mail. Representative quotes from each theme are included in Table 4. Both firearm injury and MVI researchers shared concerns that their research had negatively impacted career June 2020
options. They both cited concerns about a lack of academic future in their chosen field of research. They also both described frustration with the academic promotion process. Both groups expressed concern that following a research passion would not lead to advancement. Only the firearm injury researchers mentioned the politically fraught nature of their work, citing both the right and the left sides of the political spectrum as negative influences. Firearm injury researchers expressed a desire to not have politics influence the interpretation of their results. There were no similar concerns in MVI research responses. Both groups cited barriers to funding or the need for more funding to support their research. MVI researchers mentioned industry or nonacademic sources of funding in their qualitative responses, whereas firearm injury researchers did not. A total of 15 firearm injury researchers commented about threats compared with only 2 MVI researchers. Three subcodes of harassment—online, in person, and mail—were created. The most commonly discussed type of harassment was online, typically anonymously on message boards or in comments sections.
DISCUSSION In this study, firearm injury research authors reported more barriers to research than MVI research authors. Firearm injury researchers received fewer grants than their MVI counterparts and were more likely to report that their research was not appropriately supported by their institution nor appropriately funded. Firearm injury researchers were more likely to write opinion
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Table 2. Reported Differences Between Firearm and MVI Researchers Measure What has contributed to your success? Mentorship Funding Institutional support Other Other types of publications Review article Opinion piece Other Applied for funding (yes) Received funding (yes) (n=75) From where did you receive funding? (n=61) Home institution Local government Federal government Private funding Other Number of publications, median (IQR) Number of times applied for funding, median (IQR) Number of grants received, median (IQR) Maximum amount for a single grant, median (IQR) Negative consequences of research I have feared professional repercussions because of my research. I have experienced professional repercussions because of my research. I have feared of personal threats because of my research. I have experienced personal threats because of my research.
Firearm, (n=48) (%)
MVI, (n=76) (%)
AOR, (95% CI) or p-value
26 (54.2) 21 (43.8) 19 (39.6) 13 (27.1)
47 (61.8) 48 (63.2) 45 (59.2) 13 (17.1)
0.8 (0.3, 1.8) 0.4 (0.2, 1.2) 0.3 (0.1, 0.8) 1.5 (0.5, 4.2)
22 (45.8) 28 (58.3) 5 (10.4) 26 (54.2) 21 (80.8)
27 (35.5) 23 (30.3) 8 (10.5) 49 (64.5) 40 (81.6)
1.3 (0.5, 3.1) 2.5 (1.0, 6.1) 0.7 (0.2, 2.6) 0.4 (0.2, 1.1) 1.1 (0.3, 4.4)
8 (38.1) 10 (47.6) 15 (57.7) 14 (66.7) 0 (0) 4 (2−11.5) 3.5 (2−10) 2 (1−4) $675,000 ($88,750−$1,617,500)
14 (35) 19 (47.5) 31 (77.5) 26 (65) 9 (22.5) 7 (3−30) 5 (2−12.7) 5 (2−12) $750,000 ($277,095−$2,300,000)
1.1 (0.3, 3.9) 0.9 (0.2, 3.2) 0.7 (0.2, 3.0) 1.2 (0.3, 4.2) — 0.11 0.19 0.02 0.50
10 (20.8)
4 (5.3)
2.9 (0.8, 10.9)
7 (14.6)
6 (7.9)
2.1 (0.6, 7.6)
14 (29.2)
4 (5.2)
10.4 (2.4, 44.4)
9 (18.8)
2 (2.6)
16.1 (1.6, 165.4)
Note: Boldface indicates statistical significance (p<0.05). MVI, motor vehicle injury.
Table 3. Comparison of Proportion of Strongly Agree/Agree Responses by Researcher Type Measure My research is appropriately funded. I have been able to find collaborators for research. My research is supported by my institution. I have been encouraged to do this research by my friends or family. I have been encouraged to do this research by a colleague. I continue to have strong interest in this research.
Firearm, (n=48) (%)
MVI, (n=76), (%)
AOR, (95% CI)
4 (8.3) 39 (81.3) 32 (66.7) 24 (50.0) 50 (65.8) 62 (81.6)
18 (23.7) 57 (75.0) 51 (67.1) 13 (17.1) 28 (58.3) 44 (91.7)
0.3 (0.1, 1.0) 2.2 (0.8, 6.3) 1.1 (0.5, 2.8) 8.6 (2.0, 25.8) 0.9 (0.4, 2.3) 1.6 (0.4, 6.0)
Note: Boldface indicates statistical significance (p<0.05). MVI, motor vehicle injury.
papers and felt more supported by friends and family in their work. Finally, firearm injury researchers both feared and experienced more personal threats than MVI researchers. Discordance in support is consistent with previous work that has shown that firearm injury research is
financially undersupported.15 MVI researchers have both the National Highway Traffic Safety Administration and a robust private industry to support research. This may be why there was a difference in academic standing among the respondent groups, as many MVI researchers are employed by industry. There is no www.ajpmonline.org
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Table 4. Representative Thematic Quotes Type Career
Political
Funding
Harassment Online
In person
Firearms
MVI
“The professional risks of doing this work (e.g., not a big area of research in my discipline, lack of mentorship in this area, lack of funding) means I don’t feel able to spend more time on this type of work to make my agenda look less ‘scattered.’” “I attribute this not only to the more extreme pro-gun folks but also to the gun control folks who don’t understand how to find common ground with gun owners and diffuse the hyper-politics around this issue.” “My research led to the conclusion that firearms have a beneficial aspect that dwarfs criminal uses. I feared repercussions because of the fact of those conclusions that went against the grain of public health dogma. If my conclusions had proclaimed that guns were a public health hazard, I would have expected no repercussions but only the plaudits of the public health establishment.” “Federal agencies have been absurd in their overinterpretation of the prohibition on using federal funds to promote gun control.”
“When I transitioned from academia (as a sociologist) to working for a state agency doing applied traffic safety research, this involved a substantial loss in professional status.”
“Not physical threats, more internet hostility. Most of it has been social media based ridicule by folks who clearly hadn’t read the actual research, along with a handful of accusatory e-mails with colorful language (libtard, snowflake, gun snatcher, etc.).” “In addition to peer-reviewed research, I have published two pro-control Op Eds and was horrified by the hostile reactions I received via e-mail.” “A far right extremist group came upon my research and discussed it on their website chat space. I found it when searching my name on google. They spent a good deal of time personally insulting me and saying quite vile things.” “Some men followed me out of a meeting one evening and threatened me.” “I had more repercussions from testifying for gun violence prevention policies. Was chased into a rest room!” “Multiple threatening letters with no return addresses sent to my workplace from firearm owners.” “Letters from those unhappy with my work—threatening things like investigations but not physical violence.”
“Name calling in mass media.”
—
“Lack of (large, varied, frequent) funding for MV research means hard to be successful in academia.”
“Threats during testimony for issues such as helmet laws.” —
MV, motor vehicle; MVI, motor vehicle injury.
commensurate funding mechanism for firearm injury research, contributing to the inequality of grants and appropriateness of funding. The paucity of funding for firearm injury research is accordant with restrictions in funding dictated by the Dickey Amendment, a policy rider enacted by Congress in 1996 that prevents the appropriation of any funds for the Centers for Disease Control and Prevention (CDC) to advocate or promote gun control.3,16 That same year, Congress also reduced the appropriations to CDC by $2.6 million, the exact amount CDC had spent on gun violence research the previous year.17 Since the time of budget reductions for firearm injury research, there has been a 64% decline in the number of firearm studies per million citations in Scopus between 1998 and 2012.18 June 2020
Consequently, firearm injury is the least studied cause of death, receiving only 1.6% of funding expected for its mortality rate.15 A dedicated funding source to support firearm injury research would likely improve the quality and quantity of this public health issue. In addition to financial barriers, firearm injury researchers were more likely than MVI researchers to report fear of threats and having experienced threats as barriers to research. This concern was mirrored in the qualitative findings, as firearm injury researchers were more concerned about the politicization of their research than MVI researchers. There was also a sharp difference in threats experienced, including an ever-increasing presence of anonymous, online harassment. Doxing, the “intentional public release onto the Internet of personal
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information about an individual by a third party,” is a rising fear among many engaged in controversial research, including firearm injury research.19 These concerns and experiences are not surprising, given the growing polarization and rhetoric surrounding firearms in America.20 This study analyzed these threats in both quantitative and qualitative methods. Previously, only anecdotal evidence suggested the existence and influence of these concerns. For instance, after a 1988 New England Journal of Medicine article associated higher rates of homicide with availability of handguns, the research director of the National Rifle Association demanded that 2 of the study’s authors be investigated by the NIH Office of Scientific Integrity.9 More recently, the National Rifle Association Twitter account asked “self-important anti-gun doctors” to “stay in their lane” regarding a recently published Annals of Internal Medicine guideline for future firearm injury prevention research.10 In addition, individual researchers have reported personal threats in response to publishing firearm injury research. After publishing a study that revealed that restrictive policies regulating gun shows in California resulted in fewer illegal purchases, the researcher’s photograph and identifying information was posted on a blog called War On Guns with a warning to call security if he was seen at a gun show.10,11 Depolarizing the discussion around firearm injury prevention will lead to constructive conversations and productive research around the prevention of firearm-related injuries and deaths. Allowing more research to assess a wide array of scientific questions about firearms, including both risks and benefits of gun ownership, could serve to defuse some of this tension.21 In contrast to MVI researchers, firearm injury researchers reported more support of friends and family for their research. They were also more likely to write an opinion piece pertaining to their field of research. These findings suggest that firearm injury researchers may feel more personally invested and may have more interest in advocacy around their research. These findings may point to unique ways firearm injury researchers can be supported in their work. The creation of research groups may help to foster and support early career researchers, as firearm injury researchers feel they lack institutional support. The Firearm Safety Among Children and Teens Consortium recently held their first research conference. The Consortium also published a research agenda that can guide future directions for investigators.22 Innovative research partnerships may be needed to overcome the disparity of funding. Educators, criminologists, and law enforcement officials all recognize the impact firearm violence has on
communities. These groups may be able to apply for grants inaccessible to healthcare providers. Owing to longstanding funding restrictions, there is now a lack of trained firearm injury researchers ready to apply for grants.15,18 Specific training programs, institutions, or funding opportunities may be needed to develop a new generation of researchers.23 Finally, the authors believe that shifting the discussion around prevention of firearm injury from the political arena and into the healthcare arena will help depolarize firearm injury research and reduce social barriers to productive research.
Limitations There are several limitations to this study that deserve consideration. The study may have limited generalizability owing to a low response rate. This low response rate was expected by the authors. The authors may have been contacting researchers that do not identify strongly with an injury prevention niche. Also, with stronger spam filters on many institutional e-mail servers, it is likely that many of the targeted respondents never received the survey invitation. A more robust response rate may have shown more differences between the 2 groups, especially in the number and amount of grants awarded. In addition, firearms researchers had a higher response rate than MVI researchers. This may be because of firearms researchers having stronger opinions about barriers affecting their work, leading to a potential source of bias. The 2 comparison researcher groups may not have the same initial motivations in their research, as many firearm injuries and deaths often have intent, whereas motor vehicle deaths do not. This may lead to bias in results when asking about barriers to research. The study may also be limited by the process for identifying authors of published studies. Though only those who had published at least 1 paper in the selected injury field were invited, potential respondents may not identify as a firearm injury or MVI researcher. This may have affected the results and response rate. Attempting to only contact the corresponding author of the paper may have introduced bias as well. Secondary authors on a study may experience different barriers that are not quantified in this study. Also, although the sample of MVI researchers was chosen randomly in an attempt to reduce bias, it is possible that sampling 1 population but not the other introduced potential bias in the MVI sample that was not introduced in the firearms sample. Furthermore, the authors have no way to identify authors who have conducted research but have not published a paper. Those researchers likely experienced barriers that are not quantified in this article. Finally, only the comments provided by respondents were analyzed. Thematic saturation may not have been reached with this limited number of comments. www.ajpmonline.org
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CONCLUSIONS Firearm injury researchers are more likely to report limited funding, political pressure, and concerns about harassment than MVI researchers. Future directions include further research into these barriers and investigating unique ways to overcome them to support firearm injury research.
ACKNOWLEDGMENTS No financial disclosures were reported by the authors of this paper.
SUPPLEMENTAL MATERIAL Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j. amepre.2020.01.005.
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