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Community distress predicts youth gun violence
YJPSU-59185; No of Pages 7 Journal of Pediatric Surgery xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Community distress predicts youth gun violence☆,☆☆ Brett M. Tracy a,⁎, Randi N. Smith a, Krista Miller b, Eric Clayton b, Kathryn Bailey b, Carrol Gerrin b, Tatiana Eversley-Kelso b, David Carney b, Heather MacNew b a b
Department of Surgery, Emory University School of Medicine, Atlanta, Georgia Department of Surgery, Memorial University Medical Center, Savannah, Georgia
a r t i c l e
i n f o
Article history: Received 31 December 2018 Received in revised form 14 February 2019 Accepted 25 March 2019 Available online xxxx Key words: Pediatric trauma Youth gun violence Firearm violence Distressed community index Socioeconomic distress
a b s t r a c t Background: The purpose of this study was to investigate our institution's experience with pediatric firearm events. We sought to determine the relationship between a community's level of socioeconomic distress and the incidence of youth gun violence. Methods: We performed a retrospective review of children b18 years involved in firearm events. Using visual cluster analysis, we portrayed all firearm events and violent firearm events (assaults + homicides). Distressed community indices (DCIs) were obtained from an interface that uses US Census Bureau data. Incident rate ratios (IRRs) were calculated for firearm circumstances (i.e. assault, homicide, suicide) using a DCI. Significant IRRs were analyzed to discern which DCI metrics contributed most to gun violence. Results: There were 114 children involved in firearm events; 66 were county residents. The DCI of injury location significantly predicted total firearm events (IRR 1.02, 95% CI 1.01–1.03), assaults (IRR 1.02, 95% CI 1.01–1.05), and violent firearm events (IRR 1.03, 95% CI 1.01–1.05). The proportion of adults without a high school diploma, poverty rate, median income ratio, and housing vacancy rate were highly predictive of gun violence (VIP N 1). Conclusion: Community distress significantly predicts pediatric firearm violence. Local interventions should target neighborhoods with high levels of distress to prevent further youth gun violence. Level of evidence: Retrospective study, IV. © 2019 Elsevier Inc. All rights reserved.
In 2016, there were 1,637 firearm fatalities nationwide in children aged 17 years and younger in the US. The corresponding crude death rate was 2.22 per 100,000 and has been steadily increasing since 2013 [1]. In the Southern region of the country, the death rate is even higher at 2.66 per 100,000, which makes it the census region with the most youth killed by firearms [1,2]. Several explanations have been offered for this geographic variability. For example, higher levels of firearms ownership typically seen in the South have been shown to positively correlate with increasing gun assaults
☆ Conflicts disclosure: The authors have no conflicts of interest to disclose. ☆☆ Funding disclosure: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author at: 69 Jesse Hill Jr Dr SE, Glenn Memorial Bldg 3rd Floor, Atlanta, GA 30303. E-mail addresses: [email protected] (B.M. Tracy), [email protected] (R.N. Smith), [email protected] (K. Miller), [email protected] (E. Clayton), [email protected] (K. Bailey), [email protected] (C. Gerrin), [email protected] (T. Eversley-Kelso), [email protected] (D. Carney), [email protected] (H. MacNew).
and homicides [3,4]. Additionally, Fleeger and colleagues found a significant association between the laxity of Southern states' firearm legislation and a higher rate of firearm fatalities [5]. Another plausible explanation for the discrepancy in regional firearm deaths is the concept of distressed communities created by the Economic Innovation Group (EIG). Using the US Census Bureau's American Community Survey, the EIG found that the South has the largest portion of its population living in distressed geographic areas. Further analysis revealed that mortality rates and violent deaths are higher in economically distressed areas by 25% and 52%, respectively [6]. These precarious Southern neighborhoods teeter with poverty, which according to Charles Bruner, PhD, afflicts young children more than any other American age group [7]. The purpose of this study was to investigate our institution's experience with pediatric firearm-related injuries. We sought to determine the relationship between a region's level of socioeconomic distress and the incidence of firearm-related events. We hypothesize that youth gun violence accounts for a significant portion of the overall pediatric firearm-related traumas in our county and that individual distressed communities harbor greater rates of pediatric gun violence.
https://doi.org/10.1016/j.jpedsurg.2019.03.021 0022-3468/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
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B.M. Tracy et al. / Journal of Pediatric Surgery xxx (2019) xxx–xxx
1. Methods We performed a retrospective chart review from January 2010 to March 2017 after obtaining approval from our institutional review board. The trauma registry was queried for all pediatric patients b 18 years involved in a firearm-related event. We extracted patient age, gender, race, injury severity score (ISS), Glasgow coma scale (GCS) score, and hospital length of stay (LOS). We identified the zip code of the patient's home residence as well as the zip code of the location where the injury occurred. Using the home zip code, we divided the group into Chatham county residents and nonresidents. The patients were further classified by circumstance of injury: accidental, assault, homicide, attempted suicide, suicide, or unknown. 1.1. Visual cluster analysis Nonresidents were compared with residents of Chatham County for differences in demographic data. Using only residents of the county, visual cluster analysis (i.e. heat maps) was created using patient home zip codes and injury location zip codes to reflect (A) all firearm events, and (B) violent firearm events (assaults & homicides). 1.2. Distressed community index To classify a zip code's level of economic distress, we obtained a Distressed Communities Index (DCI) using the interactive mapping feature on the Economic Innovation Group's website. The DCI is calculated using seven economic indicators extracted from the US Census Bureau's American Community Survey 5-Year Estimates and Business Patterns dataset (2012–2016). The components include: 1. Percentage of adults aged 25 years and older without a high school diploma (or the equivalent). 2. Percentage of habitable housing that is unoccupied. 3. Percentage of adults aged 25 to 64 years not working. 4. Percentage of the population living beneath the poverty line. 5. Median household income as a percentage of the state's median household income. 6. Percent change in the number of jobs. 7. Percent change in the number of business establishments. Each metric is weighted equally in calculating a DCI, which ranges from 0 (most prosperous) to 100 (most distressed). Of note, zip codes for a DCI reflect United States Postal Service lines and routes.
than 1 impart the most relevant variables, a VIP value below 0.5 is considered an irrelevant variable in a model [9]. Data analyses were performed with JMP® Pro software, Version 13 of the SAS® System for Windows®. Copyright © 2016 SAS Institute Inc., SAS Campus Drive, Cary, North Carolina, 27513, USA. 2. Results During the study period, 1,937 pediatric traumas presented to our institution. Of this number, there were 114 children involved in firearm-related events of which 66 children were residents of Chatham County and 48 were not. The mean age for residents and non-residents was 12 years. There was no significant difference in mean GCS, ISS, or hospital LOS between groups (Table 1). The majority of patients were male and black in both groups. Homicide occurred significantly more often among residents than nonresidents of the county (19.7% vs 2.1%, p = 0.0018), which made the overall mortality rate for residents 24.2% (n = 16) and 8.3% (n = 4) for nonresidents (p = 0.0275) (Table 1). 2.1. Temporal trends Most gunshot incidents transpired in August for county residents; however, this finding was not significant among individual months (p = 0.1394). Nonresidents experienced the most firearm trauma in December, which was significant compared to the remaining months (p = 0.0316). Years 2015 and 2016 saw the highest incidence of firearm events for residents and nonresidents (Fig. 1). 2.2. Visual cluster analysis Regarding all firearm events, home zip codes 31404 and 31405 each accounted for a quarter of all the events in the county. Location of injury zip code 31401 and 31404 had the highest frequency of firearm events at 30.3% (n = 17) and 23.2% (n = 13), respectively (Table 2, Fig. 2). In terms of violent firearm events, home zip code 31405 was also found to house the highest number of residents who were victims of a violent firearm event (Table 2, Fig. 2). The most violence transpired in injury zip code 31401 (n = 12, 21.4%) and 31404 (n = 9, 16.1%) (Table 2, Fig. 3). Significantly more overall firearm events and violent firearm events occurred in injury zip code 31401 compared to home zip code 31401 (p = 0.0259, p = 0.0396).
1.3. Distressed community index metrics Using linear regression, the DCI for each Chatham County zip code was used to determine incident rate ratios for each injury circumstance. These ratios were calculated for both the patient's home zip code and the injury location zip code. Any significant incident rate ratios were further analyzed to determine which of the seven DCI metrics contributed most to the variance explanation amongst these ratios. 1.4. Statistical analyses Student t-tests were used to discern differences in continuous variables among groups and chi-square tests were used to calculate differences in categorical variables. Generalized regression using a Poisson distribution was performed to predict incidence rate ratios. All results were deemed significant if a p-value was b0.05. In addition, partial least squares analysis was utilized to generate variable importance (or influence) on projection (VIP) scores for each DCI metric. VIP is a parameter used for determining the overall measure of the importance/influence of each unique independent variable on a model. The average of the squared VIP scores equals 1; thus, a VIP N1 is used for selecting the most important variables in the model [8]. While values greater
Table 1 Demographics for Chatham County residents and nonresidents. Continuous values represent means.
Age, years (±SD) Circumstance Accidental (%) Assault (%) Homicide (%) Attempted suicide (%) Suicide (%) Unknown (%) GCS (±SD) Gender, male (%) ISS (±SD) LOS, days (±SD) Mortality (%) Race Black (%) White (%) Hispanic (%) Unknown (%)
Residents n = 66
Nonresidents n = 48
P value
12.7 (5.5)
12.8 (4.7)
0.8540
20 (30.3) 30 (45.5) 13 (19.7) 1 (1.5) 2 (3.0) 0 (0.0) 11.8 (5.1) 55 (83.3) 15.3 (14.8) 5.2 (6.4) 16 (24.2)
16 (33.3) 26 (54.2) 1 (2.1) 3 (6.3) 1 (2.1) 1 (2.1) 13.1 (4.2) 39 (81.3) 11.6 (13.2) 6.1 (7.9) 4 (8.3)
0.7314 0.3580 0.0018 0.1739 0.7523 0.1869 0.1528 0.7728 0.1781 0.5009 0.0275
46 (69.7) 17 (25.8) 1 (1.5) 2 (3.0)
28 (58.3) 15 (31.3) 4 (8.3) 1 (2.1)
0.2104 0.5204 0.0762 0.7523
GCS Glasgow coma scale, ISS injury severity score, LOS length of stay, SD standard deviation.
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
B.M. Tracy et al. / Journal of Pediatric Surgery xxx (2019) xxx–xxx
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Fig. 1. Temporal trends for Chatham County residents and non-residents by (A) month and (B) year. Year 2017 data excluded owing to study's completion before year's end.
2.3. Distressed community index metrics The DCI was lowest for zip code 31322 and highest for 31401 (Fig. 4). The percentage of adults older than 25 years without a diploma, percentage of adults not working, poverty rate, and housing vacancy rate were the lowest in 31322 compared to any other zip code in Chatham County. Meanwhile, the percent change in employment, percent change
in establishments, and median income ratio were the highest in 31322 (Table 3). Using Poisson regression, the DCI was used to predict the circumstances of firearm injury for home and injury location zip codes. The DCI did not significantly correlate with any circumstance based on a patient's home zip code. However, using the location of injury zip codes, the DCI significantly correlated with firearm events (IRR 1.02, 95% CI 1.01–1.03), assaults (IRR 1.02, 95% CI 1.01–1.05), and violent
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
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Table 2 Firearm events and violent firearm events by home and injury location zip codes. All Firearm Events
31322 31401 31404 31405 31406 31408 31415 31419
Violent Firearm Events
Home n = 66 (%)
Injury n = 56 (%)
P value
Home n = 66 (%)
Injury n = 56 (%)
P value
3 (4.6) 8 (12.1) 16 (24.2) 17 (25.8) 4 (6.1) 2 (3.0) 10 (15.1) 6 (9.1)
2 (3.6) 17 (30.3) 13 (23.2) 10 (17.9) 0 (0) 1 (1.8) 7 (12.5) 6 (10.7)
0.7902 0.0259 0.9075 0.3516 0.6582 0.6948 0.7761
1 (1.5) 5 (7.6) 9 (13.6) 10 (15.2) 4 (6.1) 2 (3.0) 9 (13.6) 3 (4.5)
0 (0.0) 12 (21.4) 9 (16.1) 5 (8.9) 0 (0.0) 1 (1.8) 6 (10.7) 5 (8.9)
0.0396 0.7276 0.3225 0.6582 0.6450 0.3461
firearm events (IRR 1.03, 95% CI 1.01–1.05) (Table 4). We selected these three significant event categories and determined the VIP for each of the DCI metrics (Table 5). The percentage of adults without a high school diploma, poverty rate, housing vacancy rate, and median income ratio were found to strongly predict all three firearm event categories (VIP N 1). 3. Discussion The youth firearm mortality rate at our institution was 24% for Chatham County residents and significantly lower at 8% for nonresidents. Interestingly, the Pediatric National Trauma Database reports a 12.4% firearm mortality rate [10]. We investigated this mortality discrepancy using the CDC's WISQARS™ and confirmed that Chatham County has a much higher youth firearm-related death rate (4.63 per 100,000 children) compared to the nation and most parts of Georgia [1]. While our hospital does serve a large volume of rural patients, Chatham County is defined as a medium metropolitan area, rendering the county urban [11]. Nance and colleagues explain that rural counties have higher rates of pediatric firearm-related suicide while urban counties have significantly higher rates of homicide [12]. Furthermore, assaults accounted for almost half of all firearm events among our sample of Chatham County's children. Kalesan and colleagues report that for each pediatric fatality from firearms, there are seven to eight nonfatal firearm-related injuries [13]. Thus, this geographic predilection helps to explain why we witnessed more assaults than homicides as well as more homicides than suicides. In congruence with national trends, the frequency of firearm-related traumas in our study is increasing and these traumas were noted to occur most frequently in August for county residents. This temporal finding is consistent with work by Veenstra and colleagues who identified June and August as the most likely time for children to incur a firearm injury [14]. Children often have less supervision in summer, placing them at increased risk for gun-related events. Regardless of this discovery, gun violence can still occur at any time during the year. Specifically, in 2011, the CDC surveyed high school students for violent and risky behaviors and received 15,425 completed questionnaires from 43 states. Georgia was found to be one of the most violent states with 23% of the state's students carrying a knife or gun compared to the 16.6% national average. During the 12-months prior to the survey, 11.7% of Georgia high school students reported being threatened or injured by a weapon at school, making Georgia schools again the most dangerous surveyed in this category [15]. Regarding weapon type, research by Anderson shows that violence in disadvantaged communities is more likely to involve guns compared to other weapons, further explaining Chatham County's high firearm violence rates. Our data show that victims of gun violence are black, adolescent males, which are supported by numerous studies [2,14,16,17]. Similarly, racial minority groups also account for more than half of the population living in distressed communities in the US and the majority of the nation's black population resides in distressed communities [6]. Felson et al. explain that young black children with no innate violent
tendencies adopt aggressive postures and begin carrying guns to protect themselves. Consequently, a neighborhood arms race ensues and Griffiths and colleagues describe that firearm homicides spread from the most violent areas to adjacent ones [18]. This dispersion is true in Chatham County where zip codes 31401 and 31404 are the epicenter of firearm violence. Using heat mapping analysis, a shift of gun violence toward adjacent zip codes 31415 and 31408 is seen. In addition to these zip codes being geographically proximate, 31401, 31415, and 31408 also have DCIs that are within mere points of each other and are all notably distressed (N80). Based on regression analysis using injury location zip codes, the DCI significantly predicted total firearm events, firearm assaults, and violent firearm events. Of note, the DCI did not significantly predict any firearm-related event based on a patient's home zip code. This finding is supported by Graif et al. who argue that the neighborhood of home residence is not typically the place of crime or being victimized because much of the time is spent inside the home. In fact, up to 70% of crimes are committed outside the neighborhood of residence [19]. Wikstrӧm and colleagues add that urban youth routinely travel outside their home and/or school zone and those children with a higher crime propensity spend more time in these central, but still outside-the-home areas. These locations ultimately become criminogenic [20]. Consequently, while most children lived in 31404 and 31405, the most firearm trauma actually occurred in 31401. This zip code is the downtown region of Chatham County where there are not only a plethora of bars and clubs, but also the highest poverty rate, highest housing vacancy rate, and second lowest median income ration in all of the county. We determined that of the DCI metrics, the poverty rate, rate of adults without a diploma, median income ratio, and the housing vacancy rate were the most important variables predicting firearmrelated events. Bushman et al. support that most youth gun violence, excluding school shooters, occurs in densely populated areas where poverty rates approach 40% [21]. Bushman and colleagues also suggest that academic achievement predicts lower rates of urban youth violence [21]. This notion is in line with work by Kodjo and associates who demonstrate that academic achievement is protective against gun carrying at school. They additionally believe that adolescents with school connectedness are more likely to make positive choices and not engage in violent behavior [22]. Unfortunately, the odds of graduating are not favorable in a distressed community where 7.4 million adults have not completed high school compared to prosperous zip codes where only 3.3 million people have not [6]. High school dropouts are estimated to earn $300,000 less than high school graduates throughout their lifetime and $1,300,000 less than college graduates with a 4-year degree [23]. The margins are steeper for higher educational attainment and reinforce the close relationship between education and financial income. The median income ratio nadir for the average distressed community in America is 68.2%. However, zip code 31401 is much lower at 53% and is where the most pediatric firearm injuries transpired in Chatham County. It is no surprise that Kalesan et al. found that
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
B.M. Tracy et al. / Journal of Pediatric Surgery xxx (2019) xxx–xxx
Fig. 2. All firearm events by (A) home zip code (n = 66) and (B) injury zip code (n = 56).
injury-related hospitalizations and fatalities in children are more likely to occur in low-income households [13]. While the relationship between low income and youth gun violence is striking, the relationship between the housing vacancy rate and firearm-events is stronger. According to the EIG, the housing vacancy rate is the best predictor of a zip code's DCI and a rising vacancy rate suggests socioeconomic disinvestment and decline [6]. It is estimated that 1.12 million vacant housing units are located in distressed zip
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Fig. 3. Violent firearm events by (A) home zip code (n = 66) and (B) injury zip code (n = 56).
codes while only 0.5 million are located in prosperous ones. Furthermore, the nationwide average vacancy rate for a distressed community is 14.7%, yet the rate in 31401 was 18.9%. Accordingly, our results show that the highest VIP scores for youth gun violence were in the housing vacancy category but were lowest for overall firearm events, which include suicide and accidental injuries. Therefore, we believe that of the seven metrics comprising the DCI score, the housing vacancy rate is the best predictor of violent youth firearm events.
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
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B.M. Tracy et al. / Journal of Pediatric Surgery xxx (2019) xxx–xxx
Fig. 4. Distressed community index map of Chatham County by zip code.
This study does have inherent limitations. While we saw no differences in our county cohort when compared to all-comers, our findings may not be unequivocally generalizable to all parts of the US given our geographic location in the South. Furthermore, our analysis centered on zip codes, which can change over time and did not account for individual zones within a zip code. Therefore, our findings represent estimates for a region without definite geographic lines. Our analysis was also limited by power and we were unable to find the injury location zip code for 10 patients in the Chatham County cohort. This issue may have led to an over or underestimation of firearm violence patterns for the zip codes. Lastly, though each individual chart was reviewed for specific details regarding the circumstances of the firearm event, we did not have access to formal police reports. Thus, our determination
of intent of injury relied on details provided by emergency medical personnel and any law enforcement present during the initial trauma resuscitation as documented in the medical record. 4. Conclusion Youth firearm violence most often affects adolescent, black males and occurs in our Southern communities that are most economically distressed. An increasing DCI significantly correlates with a greater volume of pediatric firearm violence and a community's housing vacancy rate is the strongest predictive metric that comprises the index. Armed with this information, local outreach efforts and violence intervention programs can be better tailored to address the socioeconomic
Table 3 Distressed community index with individual metrics for each zip code. Values represent percentages.
31322 31401 31404 31405 31406 31408 31415 31419
DCI
Adults without Diploma
Poverty Rate
Adults not Working
Housing Vacancy Rate
Median Income Ratio
Change in Employment
Change in Establishments
2.2 83.8 67.4 61.6 51.6 82.2 82.1 49.4
6.3 13.0 14.6 11.4 11.5 22.6 25.6 10.1
7.5 39.4 26.2 22.9 19.0 25.6 35.2 13.9
20.8 34.1 29.2 33.5 25.1 44.3 38.6 28.1
4.4 18.9 12.5 10.1 9.1 10.3 18.6 9.5
140.2 53.0 65.6 87.4 91.2 75.5 47.7 101.0
54.6 5.6 19.4 10.9 9.6 27.1 43.6 4.2
37.1 9.0 8.6 6.2 3.3 −0.8 11.9 4.1
DCI distressed community index.
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
B.M. Tracy et al. / Journal of Pediatric Surgery xxx (2019) xxx–xxx Table 4 Incident rate ratio of firearm circumstances using distressed community indices.
Home Zip Code Accidental Assault Homicide Suicide & Self-Injury Total Firearm Events Violent Firearm Events Injury Zip Code Accidental Assault Homicide Suicide & Self-Injury Total Firearm Events Violent Firearm Events
Incident Rate Ratio (95% CI)
P value
1.00 (0.98–1.02) 1.02 (0.99–1.03) 1.01 (0.98–1.04) 0.99 (0.95–1.03) 1.01 (0.99–1.02) 1.01 (0.99–1.03)
0.8051 0.0927 0.3656 0.6557 0.1125 0.0571
1.01 (0.99–1.03) 1.02 (1.00–1.05) 1.04 (0.99–1.07) 1.00 (0.92–1.09) 1.02 (1.01–1.03) 1.03 (1.01–1.05)
0.4924 0.0292 0.0950 0.9508 0.0081 0.0044
Table 5 Variable importance in projection scores of distressed community index metrics.
Adults without High School Diploma Poverty Rate Adults not Working Housing Vacancy Rate Median Income Ratio Change in Employment Change in Establishments
All Firearm Events
Assaults
Violent Firearm Events
1.0767* 1.1050* 0.9110 1.0512* 1.2091* 0.7442 0.8179
1.0829* 1.0532* 0.8676 1.713* 1.0096* 0.9534 0.8158
1.0449* 1.1088* 0.9088 1.2372* 1.0449* 0.7317 0.8335
Asterisk (*) denotes a highly relevant variable (VIP N 1).
factors that predispose a neighborhood and more importantly, its youth, to gun violence.
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Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
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Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Community distress predicts youth gun violence☆,☆☆ Brett M. Tracy a,⁎, Randi N. Smith a, Krista Miller b, Eric Clayton b, Kathryn Bailey b, Carrol Gerrin b, Tatiana Eversley-Kelso b, David Carney b, Heather MacNew b a b
Department of Surgery, Emory University School of Medicine, Atlanta, Georgia Department of Surgery, Memorial University Medical Center, Savannah, Georgia
a r t i c l e
i n f o
Article history: Received 31 December 2018 Received in revised form 14 February 2019 Accepted 25 March 2019 Available online xxxx Key words: Pediatric trauma Youth gun violence Firearm violence Distressed community index Socioeconomic distress
a b s t r a c t Background: The purpose of this study was to investigate our institution's experience with pediatric firearm events. We sought to determine the relationship between a community's level of socioeconomic distress and the incidence of youth gun violence. Methods: We performed a retrospective review of children b18 years involved in firearm events. Using visual cluster analysis, we portrayed all firearm events and violent firearm events (assaults + homicides). Distressed community indices (DCIs) were obtained from an interface that uses US Census Bureau data. Incident rate ratios (IRRs) were calculated for firearm circumstances (i.e. assault, homicide, suicide) using a DCI. Significant IRRs were analyzed to discern which DCI metrics contributed most to gun violence. Results: There were 114 children involved in firearm events; 66 were county residents. The DCI of injury location significantly predicted total firearm events (IRR 1.02, 95% CI 1.01–1.03), assaults (IRR 1.02, 95% CI 1.01–1.05), and violent firearm events (IRR 1.03, 95% CI 1.01–1.05). The proportion of adults without a high school diploma, poverty rate, median income ratio, and housing vacancy rate were highly predictive of gun violence (VIP N 1). Conclusion: Community distress significantly predicts pediatric firearm violence. Local interventions should target neighborhoods with high levels of distress to prevent further youth gun violence. Level of evidence: Retrospective study, IV. © 2019 Elsevier Inc. All rights reserved.
In 2016, there were 1,637 firearm fatalities nationwide in children aged 17 years and younger in the US. The corresponding crude death rate was 2.22 per 100,000 and has been steadily increasing since 2013 [1]. In the Southern region of the country, the death rate is even higher at 2.66 per 100,000, which makes it the census region with the most youth killed by firearms [1,2]. Several explanations have been offered for this geographic variability. For example, higher levels of firearms ownership typically seen in the South have been shown to positively correlate with increasing gun assaults
☆ Conflicts disclosure: The authors have no conflicts of interest to disclose. ☆☆ Funding disclosure: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author at: 69 Jesse Hill Jr Dr SE, Glenn Memorial Bldg 3rd Floor, Atlanta, GA 30303. E-mail addresses: [email protected] (B.M. Tracy), [email protected] (R.N. Smith), [email protected] (K. Miller), [email protected] (E. Clayton), [email protected] (K. Bailey), [email protected] (C. Gerrin), [email protected] (T. Eversley-Kelso), [email protected] (D. Carney), [email protected] (H. MacNew).
and homicides [3,4]. Additionally, Fleeger and colleagues found a significant association between the laxity of Southern states' firearm legislation and a higher rate of firearm fatalities [5]. Another plausible explanation for the discrepancy in regional firearm deaths is the concept of distressed communities created by the Economic Innovation Group (EIG). Using the US Census Bureau's American Community Survey, the EIG found that the South has the largest portion of its population living in distressed geographic areas. Further analysis revealed that mortality rates and violent deaths are higher in economically distressed areas by 25% and 52%, respectively [6]. These precarious Southern neighborhoods teeter with poverty, which according to Charles Bruner, PhD, afflicts young children more than any other American age group [7]. The purpose of this study was to investigate our institution's experience with pediatric firearm-related injuries. We sought to determine the relationship between a region's level of socioeconomic distress and the incidence of firearm-related events. We hypothesize that youth gun violence accounts for a significant portion of the overall pediatric firearm-related traumas in our county and that individual distressed communities harbor greater rates of pediatric gun violence.
https://doi.org/10.1016/j.jpedsurg.2019.03.021 0022-3468/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
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B.M. Tracy et al. / Journal of Pediatric Surgery xxx (2019) xxx–xxx
1. Methods We performed a retrospective chart review from January 2010 to March 2017 after obtaining approval from our institutional review board. The trauma registry was queried for all pediatric patients b 18 years involved in a firearm-related event. We extracted patient age, gender, race, injury severity score (ISS), Glasgow coma scale (GCS) score, and hospital length of stay (LOS). We identified the zip code of the patient's home residence as well as the zip code of the location where the injury occurred. Using the home zip code, we divided the group into Chatham county residents and nonresidents. The patients were further classified by circumstance of injury: accidental, assault, homicide, attempted suicide, suicide, or unknown. 1.1. Visual cluster analysis Nonresidents were compared with residents of Chatham County for differences in demographic data. Using only residents of the county, visual cluster analysis (i.e. heat maps) was created using patient home zip codes and injury location zip codes to reflect (A) all firearm events, and (B) violent firearm events (assaults & homicides). 1.2. Distressed community index To classify a zip code's level of economic distress, we obtained a Distressed Communities Index (DCI) using the interactive mapping feature on the Economic Innovation Group's website. The DCI is calculated using seven economic indicators extracted from the US Census Bureau's American Community Survey 5-Year Estimates and Business Patterns dataset (2012–2016). The components include: 1. Percentage of adults aged 25 years and older without a high school diploma (or the equivalent). 2. Percentage of habitable housing that is unoccupied. 3. Percentage of adults aged 25 to 64 years not working. 4. Percentage of the population living beneath the poverty line. 5. Median household income as a percentage of the state's median household income. 6. Percent change in the number of jobs. 7. Percent change in the number of business establishments. Each metric is weighted equally in calculating a DCI, which ranges from 0 (most prosperous) to 100 (most distressed). Of note, zip codes for a DCI reflect United States Postal Service lines and routes.
than 1 impart the most relevant variables, a VIP value below 0.5 is considered an irrelevant variable in a model [9]. Data analyses were performed with JMP® Pro software, Version 13 of the SAS® System for Windows®. Copyright © 2016 SAS Institute Inc., SAS Campus Drive, Cary, North Carolina, 27513, USA. 2. Results During the study period, 1,937 pediatric traumas presented to our institution. Of this number, there were 114 children involved in firearm-related events of which 66 children were residents of Chatham County and 48 were not. The mean age for residents and non-residents was 12 years. There was no significant difference in mean GCS, ISS, or hospital LOS between groups (Table 1). The majority of patients were male and black in both groups. Homicide occurred significantly more often among residents than nonresidents of the county (19.7% vs 2.1%, p = 0.0018), which made the overall mortality rate for residents 24.2% (n = 16) and 8.3% (n = 4) for nonresidents (p = 0.0275) (Table 1). 2.1. Temporal trends Most gunshot incidents transpired in August for county residents; however, this finding was not significant among individual months (p = 0.1394). Nonresidents experienced the most firearm trauma in December, which was significant compared to the remaining months (p = 0.0316). Years 2015 and 2016 saw the highest incidence of firearm events for residents and nonresidents (Fig. 1). 2.2. Visual cluster analysis Regarding all firearm events, home zip codes 31404 and 31405 each accounted for a quarter of all the events in the county. Location of injury zip code 31401 and 31404 had the highest frequency of firearm events at 30.3% (n = 17) and 23.2% (n = 13), respectively (Table 2, Fig. 2). In terms of violent firearm events, home zip code 31405 was also found to house the highest number of residents who were victims of a violent firearm event (Table 2, Fig. 2). The most violence transpired in injury zip code 31401 (n = 12, 21.4%) and 31404 (n = 9, 16.1%) (Table 2, Fig. 3). Significantly more overall firearm events and violent firearm events occurred in injury zip code 31401 compared to home zip code 31401 (p = 0.0259, p = 0.0396).
1.3. Distressed community index metrics Using linear regression, the DCI for each Chatham County zip code was used to determine incident rate ratios for each injury circumstance. These ratios were calculated for both the patient's home zip code and the injury location zip code. Any significant incident rate ratios were further analyzed to determine which of the seven DCI metrics contributed most to the variance explanation amongst these ratios. 1.4. Statistical analyses Student t-tests were used to discern differences in continuous variables among groups and chi-square tests were used to calculate differences in categorical variables. Generalized regression using a Poisson distribution was performed to predict incidence rate ratios. All results were deemed significant if a p-value was b0.05. In addition, partial least squares analysis was utilized to generate variable importance (or influence) on projection (VIP) scores for each DCI metric. VIP is a parameter used for determining the overall measure of the importance/influence of each unique independent variable on a model. The average of the squared VIP scores equals 1; thus, a VIP N1 is used for selecting the most important variables in the model [8]. While values greater
Table 1 Demographics for Chatham County residents and nonresidents. Continuous values represent means.
Age, years (±SD) Circumstance Accidental (%) Assault (%) Homicide (%) Attempted suicide (%) Suicide (%) Unknown (%) GCS (±SD) Gender, male (%) ISS (±SD) LOS, days (±SD) Mortality (%) Race Black (%) White (%) Hispanic (%) Unknown (%)
Residents n = 66
Nonresidents n = 48
P value
12.7 (5.5)
12.8 (4.7)
0.8540
20 (30.3) 30 (45.5) 13 (19.7) 1 (1.5) 2 (3.0) 0 (0.0) 11.8 (5.1) 55 (83.3) 15.3 (14.8) 5.2 (6.4) 16 (24.2)
16 (33.3) 26 (54.2) 1 (2.1) 3 (6.3) 1 (2.1) 1 (2.1) 13.1 (4.2) 39 (81.3) 11.6 (13.2) 6.1 (7.9) 4 (8.3)
0.7314 0.3580 0.0018 0.1739 0.7523 0.1869 0.1528 0.7728 0.1781 0.5009 0.0275
46 (69.7) 17 (25.8) 1 (1.5) 2 (3.0)
28 (58.3) 15 (31.3) 4 (8.3) 1 (2.1)
0.2104 0.5204 0.0762 0.7523
GCS Glasgow coma scale, ISS injury severity score, LOS length of stay, SD standard deviation.
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
B.M. Tracy et al. / Journal of Pediatric Surgery xxx (2019) xxx–xxx
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Fig. 1. Temporal trends for Chatham County residents and non-residents by (A) month and (B) year. Year 2017 data excluded owing to study's completion before year's end.
2.3. Distressed community index metrics The DCI was lowest for zip code 31322 and highest for 31401 (Fig. 4). The percentage of adults older than 25 years without a diploma, percentage of adults not working, poverty rate, and housing vacancy rate were the lowest in 31322 compared to any other zip code in Chatham County. Meanwhile, the percent change in employment, percent change
in establishments, and median income ratio were the highest in 31322 (Table 3). Using Poisson regression, the DCI was used to predict the circumstances of firearm injury for home and injury location zip codes. The DCI did not significantly correlate with any circumstance based on a patient's home zip code. However, using the location of injury zip codes, the DCI significantly correlated with firearm events (IRR 1.02, 95% CI 1.01–1.03), assaults (IRR 1.02, 95% CI 1.01–1.05), and violent
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
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Table 2 Firearm events and violent firearm events by home and injury location zip codes. All Firearm Events
31322 31401 31404 31405 31406 31408 31415 31419
Violent Firearm Events
Home n = 66 (%)
Injury n = 56 (%)
P value
Home n = 66 (%)
Injury n = 56 (%)
P value
3 (4.6) 8 (12.1) 16 (24.2) 17 (25.8) 4 (6.1) 2 (3.0) 10 (15.1) 6 (9.1)
2 (3.6) 17 (30.3) 13 (23.2) 10 (17.9) 0 (0) 1 (1.8) 7 (12.5) 6 (10.7)
0.7902 0.0259 0.9075 0.3516 0.6582 0.6948 0.7761
1 (1.5) 5 (7.6) 9 (13.6) 10 (15.2) 4 (6.1) 2 (3.0) 9 (13.6) 3 (4.5)
0 (0.0) 12 (21.4) 9 (16.1) 5 (8.9) 0 (0.0) 1 (1.8) 6 (10.7) 5 (8.9)
0.0396 0.7276 0.3225 0.6582 0.6450 0.3461
firearm events (IRR 1.03, 95% CI 1.01–1.05) (Table 4). We selected these three significant event categories and determined the VIP for each of the DCI metrics (Table 5). The percentage of adults without a high school diploma, poverty rate, housing vacancy rate, and median income ratio were found to strongly predict all three firearm event categories (VIP N 1). 3. Discussion The youth firearm mortality rate at our institution was 24% for Chatham County residents and significantly lower at 8% for nonresidents. Interestingly, the Pediatric National Trauma Database reports a 12.4% firearm mortality rate [10]. We investigated this mortality discrepancy using the CDC's WISQARS™ and confirmed that Chatham County has a much higher youth firearm-related death rate (4.63 per 100,000 children) compared to the nation and most parts of Georgia [1]. While our hospital does serve a large volume of rural patients, Chatham County is defined as a medium metropolitan area, rendering the county urban [11]. Nance and colleagues explain that rural counties have higher rates of pediatric firearm-related suicide while urban counties have significantly higher rates of homicide [12]. Furthermore, assaults accounted for almost half of all firearm events among our sample of Chatham County's children. Kalesan and colleagues report that for each pediatric fatality from firearms, there are seven to eight nonfatal firearm-related injuries [13]. Thus, this geographic predilection helps to explain why we witnessed more assaults than homicides as well as more homicides than suicides. In congruence with national trends, the frequency of firearm-related traumas in our study is increasing and these traumas were noted to occur most frequently in August for county residents. This temporal finding is consistent with work by Veenstra and colleagues who identified June and August as the most likely time for children to incur a firearm injury [14]. Children often have less supervision in summer, placing them at increased risk for gun-related events. Regardless of this discovery, gun violence can still occur at any time during the year. Specifically, in 2011, the CDC surveyed high school students for violent and risky behaviors and received 15,425 completed questionnaires from 43 states. Georgia was found to be one of the most violent states with 23% of the state's students carrying a knife or gun compared to the 16.6% national average. During the 12-months prior to the survey, 11.7% of Georgia high school students reported being threatened or injured by a weapon at school, making Georgia schools again the most dangerous surveyed in this category [15]. Regarding weapon type, research by Anderson shows that violence in disadvantaged communities is more likely to involve guns compared to other weapons, further explaining Chatham County's high firearm violence rates. Our data show that victims of gun violence are black, adolescent males, which are supported by numerous studies [2,14,16,17]. Similarly, racial minority groups also account for more than half of the population living in distressed communities in the US and the majority of the nation's black population resides in distressed communities [6]. Felson et al. explain that young black children with no innate violent
tendencies adopt aggressive postures and begin carrying guns to protect themselves. Consequently, a neighborhood arms race ensues and Griffiths and colleagues describe that firearm homicides spread from the most violent areas to adjacent ones [18]. This dispersion is true in Chatham County where zip codes 31401 and 31404 are the epicenter of firearm violence. Using heat mapping analysis, a shift of gun violence toward adjacent zip codes 31415 and 31408 is seen. In addition to these zip codes being geographically proximate, 31401, 31415, and 31408 also have DCIs that are within mere points of each other and are all notably distressed (N80). Based on regression analysis using injury location zip codes, the DCI significantly predicted total firearm events, firearm assaults, and violent firearm events. Of note, the DCI did not significantly predict any firearm-related event based on a patient's home zip code. This finding is supported by Graif et al. who argue that the neighborhood of home residence is not typically the place of crime or being victimized because much of the time is spent inside the home. In fact, up to 70% of crimes are committed outside the neighborhood of residence [19]. Wikstrӧm and colleagues add that urban youth routinely travel outside their home and/or school zone and those children with a higher crime propensity spend more time in these central, but still outside-the-home areas. These locations ultimately become criminogenic [20]. Consequently, while most children lived in 31404 and 31405, the most firearm trauma actually occurred in 31401. This zip code is the downtown region of Chatham County where there are not only a plethora of bars and clubs, but also the highest poverty rate, highest housing vacancy rate, and second lowest median income ration in all of the county. We determined that of the DCI metrics, the poverty rate, rate of adults without a diploma, median income ratio, and the housing vacancy rate were the most important variables predicting firearmrelated events. Bushman et al. support that most youth gun violence, excluding school shooters, occurs in densely populated areas where poverty rates approach 40% [21]. Bushman and colleagues also suggest that academic achievement predicts lower rates of urban youth violence [21]. This notion is in line with work by Kodjo and associates who demonstrate that academic achievement is protective against gun carrying at school. They additionally believe that adolescents with school connectedness are more likely to make positive choices and not engage in violent behavior [22]. Unfortunately, the odds of graduating are not favorable in a distressed community where 7.4 million adults have not completed high school compared to prosperous zip codes where only 3.3 million people have not [6]. High school dropouts are estimated to earn $300,000 less than high school graduates throughout their lifetime and $1,300,000 less than college graduates with a 4-year degree [23]. The margins are steeper for higher educational attainment and reinforce the close relationship between education and financial income. The median income ratio nadir for the average distressed community in America is 68.2%. However, zip code 31401 is much lower at 53% and is where the most pediatric firearm injuries transpired in Chatham County. It is no surprise that Kalesan et al. found that
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
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Fig. 2. All firearm events by (A) home zip code (n = 66) and (B) injury zip code (n = 56).
injury-related hospitalizations and fatalities in children are more likely to occur in low-income households [13]. While the relationship between low income and youth gun violence is striking, the relationship between the housing vacancy rate and firearm-events is stronger. According to the EIG, the housing vacancy rate is the best predictor of a zip code's DCI and a rising vacancy rate suggests socioeconomic disinvestment and decline [6]. It is estimated that 1.12 million vacant housing units are located in distressed zip
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Fig. 3. Violent firearm events by (A) home zip code (n = 66) and (B) injury zip code (n = 56).
codes while only 0.5 million are located in prosperous ones. Furthermore, the nationwide average vacancy rate for a distressed community is 14.7%, yet the rate in 31401 was 18.9%. Accordingly, our results show that the highest VIP scores for youth gun violence were in the housing vacancy category but were lowest for overall firearm events, which include suicide and accidental injuries. Therefore, we believe that of the seven metrics comprising the DCI score, the housing vacancy rate is the best predictor of violent youth firearm events.
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
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Fig. 4. Distressed community index map of Chatham County by zip code.
This study does have inherent limitations. While we saw no differences in our county cohort when compared to all-comers, our findings may not be unequivocally generalizable to all parts of the US given our geographic location in the South. Furthermore, our analysis centered on zip codes, which can change over time and did not account for individual zones within a zip code. Therefore, our findings represent estimates for a region without definite geographic lines. Our analysis was also limited by power and we were unable to find the injury location zip code for 10 patients in the Chatham County cohort. This issue may have led to an over or underestimation of firearm violence patterns for the zip codes. Lastly, though each individual chart was reviewed for specific details regarding the circumstances of the firearm event, we did not have access to formal police reports. Thus, our determination
of intent of injury relied on details provided by emergency medical personnel and any law enforcement present during the initial trauma resuscitation as documented in the medical record. 4. Conclusion Youth firearm violence most often affects adolescent, black males and occurs in our Southern communities that are most economically distressed. An increasing DCI significantly correlates with a greater volume of pediatric firearm violence and a community's housing vacancy rate is the strongest predictive metric that comprises the index. Armed with this information, local outreach efforts and violence intervention programs can be better tailored to address the socioeconomic
Table 3 Distressed community index with individual metrics for each zip code. Values represent percentages.
31322 31401 31404 31405 31406 31408 31415 31419
DCI
Adults without Diploma
Poverty Rate
Adults not Working
Housing Vacancy Rate
Median Income Ratio
Change in Employment
Change in Establishments
2.2 83.8 67.4 61.6 51.6 82.2 82.1 49.4
6.3 13.0 14.6 11.4 11.5 22.6 25.6 10.1
7.5 39.4 26.2 22.9 19.0 25.6 35.2 13.9
20.8 34.1 29.2 33.5 25.1 44.3 38.6 28.1
4.4 18.9 12.5 10.1 9.1 10.3 18.6 9.5
140.2 53.0 65.6 87.4 91.2 75.5 47.7 101.0
54.6 5.6 19.4 10.9 9.6 27.1 43.6 4.2
37.1 9.0 8.6 6.2 3.3 −0.8 11.9 4.1
DCI distressed community index.
Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021
B.M. Tracy et al. / Journal of Pediatric Surgery xxx (2019) xxx–xxx Table 4 Incident rate ratio of firearm circumstances using distressed community indices.
Home Zip Code Accidental Assault Homicide Suicide & Self-Injury Total Firearm Events Violent Firearm Events Injury Zip Code Accidental Assault Homicide Suicide & Self-Injury Total Firearm Events Violent Firearm Events
Incident Rate Ratio (95% CI)
P value
1.00 (0.98–1.02) 1.02 (0.99–1.03) 1.01 (0.98–1.04) 0.99 (0.95–1.03) 1.01 (0.99–1.02) 1.01 (0.99–1.03)
0.8051 0.0927 0.3656 0.6557 0.1125 0.0571
1.01 (0.99–1.03) 1.02 (1.00–1.05) 1.04 (0.99–1.07) 1.00 (0.92–1.09) 1.02 (1.01–1.03) 1.03 (1.01–1.05)
0.4924 0.0292 0.0950 0.9508 0.0081 0.0044
Table 5 Variable importance in projection scores of distressed community index metrics.
Adults without High School Diploma Poverty Rate Adults not Working Housing Vacancy Rate Median Income Ratio Change in Employment Change in Establishments
All Firearm Events
Assaults
Violent Firearm Events
1.0767* 1.1050* 0.9110 1.0512* 1.2091* 0.7442 0.8179
1.0829* 1.0532* 0.8676 1.713* 1.0096* 0.9534 0.8158
1.0449* 1.1088* 0.9088 1.2372* 1.0449* 0.7317 0.8335
Asterisk (*) denotes a highly relevant variable (VIP N 1).
factors that predispose a neighborhood and more importantly, its youth, to gun violence.
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Please cite this article as: B.M. Tracy, R.N. Smith, K. Miller, et al., Community distress predicts youth gun violence, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.03.021