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Background: Participant recruitment is a central aspect of human sciences research. Barriers to participant recruitment can be categorised into participant, recruiter and institutional factors. Firearm injury research poses unique barriers to recruitment. This is especially true for rural adolescents, who are at high risk for firearm-related injury and death, and whose voice is often absent in firearms research. In particular, recruitment strategies targeting adolescents should align with developmental changes occurring during this life stage. Identifying strategies to address recruitment barriers tailored to firearm-related research can help future researchers engage rural adolescents in injury prevention efforts., Purpose: The purpose of the current methodology paper is to outline barriers and provide strategies for recruiting rural adolescents in firearms research informed by the Youth Experiences in Rural Washington: Research on Firearm Safety project, a mixed-methods, community-based participatory research study of 13-18 year-olds residing in rural Washington., Strategies: Recruitment barriers and related strategies were organised by participant-related and recruiter-related/institutional-related factors. While carrying out the study, key considerations or strategies which addressed multiple participant and recruiter/institutional factors, emerged with potential to enhance firearm-related research with rural adolescents more broadly. Key considerations included logistics (ie, scheduling flexibility, adequate and aligned incentives), use of a community-based participatory research approach and accounting for developmental stage., Conclusion: Reducing the burden of firearm injury and death for rural adolescents and developing effective interventions requires understanding and navigating recruitment barriers. Strategies used in the current project can guide future qualitative or mixed methods data collection informing firearm injury prevention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Firearm-related injuries in the U.S. have risen 37% since 2015. Understanding how the association between firearm incidents and state-level firearm restrictiveness is modified by community-level distress and economic connectedness (EC) may inform upstream injury prevention efforts., Methods: A national cross-sectional study of firearm incidents (interpersonal and unintentional firearm events) occurring between 1/2015 and 12/2021 was performed using the Gun Violence Archive. The exposures were community distress (Distressed Communities Index, DCI), EC, and year-state-level firearm restrictiveness. The primary outcome was mean annual urban firearm incidence rate per ZIP Code Tabulation Area. Generalized linear mixed models were fit to evaluate the modification of the firearm law-firearm incident association by DCI and EC. Data analyses took place in 2022., Results: About 266,020 firearm incidents were included. The mean rate was higher with each DCI tertile, with a RR of 3.18 (95% CI: 3.06, 3.30) in high versus low distress communities. Low EC was associated with over 1.8 times greater rate of firearm-related injury. The least restrictive firearm laws were associated with 1.20 times higher risk of firearm incidents (95% CI: 1.12, 1.28). The association between restrictive laws and lower incidence rates was strongest in low and medium distress and high EC communities., Conclusions: Stricter firearm laws are associated with lower rate of firearm incidents. The magnitude of this association is smallest for communities experiencing the greatest economic disadvantage., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Firearms account for the majority of suicide deaths in the USA. A recommended approach for suicide prevention is reducing access to firearms by temporarily removing them from the home. We sought to understand how firearm owners and those who reside with them view and might use voluntary, temporary out-of-home firearm storage., Methods: From July to November 2021, we interviewed English-speaking adults in Colorado and Washington who own firearms or reside with them, using semistructured interviews. We used a team-based mixed deductive and inductive approach to code transcripts and identify themes., Results: Half of the 38 interviewees were men (53%) aged 35-54 years (40%); 92% identified as white. The average age that participants reported first having a firearm was 20.4 years; 16% reported never owning a firearm themselves, only living in homes with firearms. Qualitative findings fell into broad themes: (1) storage with family members/friends, (2) concerns/challenges with storing a firearm with a business/organization, (3) importance of trust (4) outreach methods for out-of-home storage programmes., Conclusion: Programmes for voluntary, temporary out-of-home firearm storage will not be impactful unless such storage is desired and used. Understanding views of potential storage users can help support development of acceptable and feasible programmes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The annual number of firearm injuries in Portland, Oregon has been higher in the years since 2020 than in any prior year in the city's history. This descriptive study analyzed data from Gun Violence Archives (GVA) from January 1, 2018, to December 31, 2021. All incidents in GVA of interpersonal firearm injury that occurred in Portland during this period were analyzed for location, number of people injured or killed, and demographic information for those injured or killed. Comparisons in firearm injury rates were made with Seattle and San Francisco. Interpersonal firearm injuries began to rise after the first COVID-19 case in Oregon; July 2020 had the most injuries in the four-year period. Black men suffered the highest rate of interpersonal fatalities, with more than 11-fold higher rate per 100,000 than White men in every year studied. Portland had a higher rate of total interpersonal firearm injuries and a higher rate of firearm fatalities from 2018 through 2021 compared to Seattle and San Francisco. Neighborhoods near Downtown and those on the Eastside of the city had the highest rates of interpersonal injuries and deaths from firearms, whereas those in the Southwest had the lowest. Defining the burden of disease from interpersonal firearm injuries is a fundamental step in designing future public health research and implementing interventions to curb the trauma brought by interpersonal firearm injury., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: Firearm-related injuries are the leading cause of death among children and adolescents in the US. For youths aged 10 to 19 years, 64% of firearm-related deaths are due to assault. Understanding the association between the rate of death due to assault-related firearm injury and both community-level vulnerability and state-level gun laws may inform prevention efforts and public health policy., Objective: To assess the rate of death due to assault-related firearm injury stratified by community-level social vulnerability and state-level gun laws in a national cohort of youths aged 10 to 19 years., Design, Setting, and Participants: This national cross-sectional study used the Gun Violence Archive to identify all assault-related firearm deaths among youths aged 10 to 19 years occurring in the US between January 1, 2020, and June 30, 2022., Exposure: Census tract-level social vulnerability (measured by the Centers for Disease Control and Prevention social vulnerability index [SVI]; categorized in quartiles as low [<25th percentile], moderate [25th-50th percentile], high [51st-75th percentile], or very high [>75th percentile]) and state-level gun laws (measured by the Giffords Law Center gun law scorecard rating; categorized as restrictive, moderate, or permissive)., Main Outcomes and Measures: Youth death rate (per 100 000 person-years) due to assault-related firearm injury., Results: Among 5813 youths aged 10 to 19 years who died of an assault-related firearm injury over the 2.5-year study period, the mean (SD) age was 17.1 (1.9) years, and 4979 (85.7%) were male. The death rate per 100 000 person-years in the low SVI cohort was 1.2 compared with 2.5 in the moderate SVI cohort, 5.2 in the high SVI cohort, and 13.3 in the very high SVI cohort. The mortality rate ratio of the very high SVI cohort compared with the low SVI cohort was 11.43 (95% CI, 10.17-12.88). When further stratifying deaths by the Giffords Law Center state-level gun law scorecard rating, the stepwise increase in death rate (per 100 000 person-years) with increasing SVI persisted, regardless of whether the Census tract was in a state with restrictive gun laws (0.83 in the low SVI cohort vs 10.11 in the very high SVI cohort), moderate gun laws (0.81 in the low SVI cohort vs 13.18 in the very high SVI cohort), or permissive gun laws (1.68 in the low SVI cohort vs 16.03 in the very high SVI cohort). The death rate per 100 000 person-years was higher for each SVI category in states with permissive compared with restrictive gun laws (eg, moderate SVI: 3.37 vs 1.71; high SVI: 6.33 vs 3.78)., Conclusions and Relevance: In this study, socially vulnerable communities in the US experienced a disproportionate number of assault-related firearm deaths among youths. Although stricter gun laws were associated with lower death rates in all communities, these gun laws did not equalize the consequences on a relative scale, and disadvantaged communities remained disproportionately impacted. While legislation is necessary, it may not be sufficient to solve the problem of assault-related firearm deaths among children and adolescents.

Importance: International Classification of Diseases-coded hospital discharge data do not accurately reflect whether firearm injuries were caused by assault, unintentional injury, self-harm, legal intervention, or were of undetermined intent. Applying natural language processing (NLP) and machine learning (ML) techniques to electronic health record (EHR) narrative text could be associated with improved accuracy of firearm injury intent data., Objective: To assess the accuracy with which an ML model identified firearm injury intent., Design, Setting, and Participants: A cross-sectional retrospective EHR review was conducted at 3 level I trauma centers, 2 from health care institutions in Boston, Massachusetts, and 1 from Seattle, Washington, between January 1, 2000, and December 31, 2019; data analysis was performed from January 18, 2021, to August 22, 2022. A total of 1915 incident cases of firearm injury in patients presenting to emergency departments at the model development institution and 769 from the external validation institution with a firearm injury code assigned according to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM), in discharge data were included., Exposures: Classification of firearm injury intent., Main Outcomes and Measures: Intent classification accuracy by the NLP model was compared with ICD codes assigned by medical record coders in discharge data. The NLP model extracted intent-relevant features from narrative text that were then used by a gradient-boosting classifier to determine the intent of each firearm injury. Classification accuracy was evaluated against intent assigned by the research team. The model was further validated using an external data set., Results: The NLP model was evaluated in 381 patients presenting with firearm injury at the model development site (mean [SD] age, 39.2 [13.0] years; 348 [91.3%] men) and 304 patients at the external development site (mean [SD] age, 31.8 [14.8] years; 263 [86.5%] men). The model proved more accurate than medical record coders in assigning intent to firearm injuries at the model development site (accident F-score, 0.78 vs 0.40; assault F-score, 0.90 vs 0.78). The model maintained this improvement on an external validation set from a second institution (accident F-score, 0.64 vs 0.58; assault F-score, 0.88 vs 0.81). While the model showed some degradation between institutions, retraining the model using data from the second institution further improved performance on that site's records (accident F-score, 0.75; assault F-score, 0.92)., Conclusions and Relevance: The findings of this study suggest that NLP ML can be used to improve the accuracy of firearm injury intent classification compared with ICD-coded discharge data, particularly for cases of accident and assault intents (the most prevalent and commonly misclassified intent types). Future research could refine this model using larger and more diverse data sets.

Importance: The absence of reliable hospital discharge data regarding the intent of firearm injuries (ie, whether caused by assault, accident, self-harm, legal intervention, or an act of unknown intent) has been characterized as a glaring gap in the US firearms data infrastructure., Objective: To use incident-level information to assess the accuracy of intent coding in hospital data used for firearm injury surveillance., Design, Setting, and Participants: This cross-sectional retrospective medical review study was conducted using case-level data from 3 level I US trauma centers (for 2008-2019) for patients presenting to the emergency department with an incident firearm injury of any severity., Exposures: Classification of firearm injury intent., Main Outcomes and Measures: Researchers reviewed electronic health records for all firearm injuries and compared intent adjudicated by team members (the gold standard) with International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) codes for firearm injury intent assigned by medical records coders (in discharge data) and by trauma registrars. Accuracy was assessed using intent-specific sensitivity and positive predictive value (PPV)., Results: Of the 1227 cases of firearm injury incidents seen during the ICD-10-CM study period (October 1, 2015, to December 31, 2019), the majority of patients (1090 [88.8%]) were male and 547 (44.6%) were White. The research team adjudicated 837 (68.2%) to be assaults. Of these assault incidents, 234 (28.0%) were ICD coded as unintentional injuries in hospital discharge data. These miscoded patient cases largely accounted for why discharge data had low sensitivity for assaults (66.3%) and low PPV for unintentional injuries (34.3%). Misclassification was substantial even for patient cases described explicitly as assaults in clinical notes (sensitivity of 74.3%), as well as in the ICD-9-CM study period (sensitivity of 77.0% for assaults and PPV of 38.0% for unintentional firearm injuries). By contrast, intent coded by trauma registrars differed minimally from researcher-adjudicated intent (eg, sensitivity for assault of 96.0% and PPV for unintentional firearm injury of 93.0%)., Conclusions and Relevance: The findings of this cross-sectional study underscore questions raised by prior work using aggregate count data regarding the accuracy of ICD-coded discharge data as a source of firearm injury intent. Based on our observations, researchers and policy makers should be aware that databases drawn from hospital discharge data (most notably, the Nationwide Emergency Department Sample) cannot be used to reliably count or characterize intent-specific firearm injuries.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Firearm violence is a major threat to global public health and safety. Several individual, family, peer, community, and societal risk and protective factors determine or modify the risk of firearm violence. Specifically, there is a strong relationship between poverty, income inequality, and firearm violence; as such, interventions that influence upstream determinants of health by providing income support may hold much promise in affecting multiple domains of risk that are on the causal pathway to firearm violence. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we conducted a scoping review to examine the current state of evidence on the relationship between income support policies and risk of firearm violence. We searched 8 databases related to health and social sciences from inception through March 30, 2022, and placed no time, language, setting, or other publication restrictions on our search, as long as the study was quantitative or mixed-methods and addressed firearm violence specifically, rather than violence more broadly, as an outcome in relation to income support policies. We found 4 studies; of those, 3 were conducted in the United States and 1 in Brazil. All 4 found associations of policy-relevant magnitude between income support policies and reductions in risk of inter-personal firearm violence. We propose future opportunities to enhance the substantive scope and methodologic rigor of this field of research and inform policy and practice for greater impact., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ali Rowhani-Rahbar reports funds outside of this work for research on firearms from the Centers for Disease Control and Prevention, National Institutes of Health, National Collaborative on Gun Violence Research, Fund for Safer Future, and State of Washington. Frederick Rivara reports funds outside of this work for research on firearms from the National Institutes of Health, National Collaborative on Gun Violence Research, and State of Washington. Julia Schleimer, Caitlin Moe, and Heather Hill do not report any potential competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Qualitative exploration into the risk, experiences, and outcomes of victims of firearm injury is imperative to informing not only further research, but prevention and intervention strategies. The purpose of this study was to explore prior violent exposures, risks, recovery, supportive services, outcomes, and views of firearms and violence among survivors of firearm assaults and unintentional injuries. Adults treated at a level 1 trauma center in Seattle, WA, for assault and unintentional firearm injuries were interviewed utilizing a semistructured instrument. Interview responses were coded to identify common themes and representative quotes are reported. Sixteen participants were interviewed. Notable themes included the following: (a) prior violent exposures were experienced by half of survivors, mostly through community violence; (b) risk for firearm injury was felt to be related to general societal violence, unsafe communities, and firearm practices; (c) important aspects of recovery included family/social support, mental health care and financial support services; (d) notable outcomes included psychological problems such as PTSD and anxiety, changes in relationships, and developing a new sense of purpose or mission in life; (e) generally negative views toward firearms, supporting restricted access and firearm safety practices; (f) acknowledgement of the complexity of firearm violence in society with prevention geared toward equitable education, economic opportunities and safety net programs to reduce community violence; and (g) disappointment in the criminal justice system. These findings demonstrate the varied experiences, needs, and outcomes after injury, but highlight the significance of community and societal violence, and need for improved mental health services. Integration of mental health services and victim assistance programs into trauma centers and hospital-based violence intervention programs is imperative for all survivors. Encouraging survivors to engage in new aspirations after injury can be empowering, and there is an unmet need for victim support and advocacy within the criminal justice system.

Introduction: Child Access Prevention Negligent Storage (CAP-NS) laws seek to reduce pediatric firearm injury by imposing sanctions on gun owners if children gain access to unlocked guns. Whether these laws affect the storage behavior they aim to encourage is not known because historical panel data on firearm storage do not exist. As a result, assessing how much, if at all, firearm storage changed because of CAP-NS laws requires an indirect approach., Methods: Data for this study came from a web-based survey conducted by the research firm Ipsos from July 30, 2019 to August 11, 2019. Respondents were adult gun owners drawn from an online sampling frame comprising approximately 55,000 U.S. adults recruited using address-based sampling methods to be representative of the U.S., Population: The primary outcome was the proportion of gun owners in CAP-NS versus non-CAP-NS states who had ≥1 unlocked firearm. Estimates are presented by CAP-NS status, for gun owners overall and for those who live with children, before and after adjusting for potential confounders. Data were analyzed in 2021., Results: In adjusted analyses, gun owners in CAP-NS states were no more likely to lock firearms than were those in states without these laws. In addition, most gun owners reported not knowing whether they lived in a state with a CAP-NS law., Conclusions: CAP-NS laws have at best modest effects on firearm storage. If the storage effect is as small as this study indicates, the mortality benefits previously attributed to CAP-NS laws are overstated. As such, developing interventions that effectively reduce firearm mortality by reducing access to firearms remains an urgent clinical and public policy priority., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Decision-making on having firearms at home may be contingent on perceptions of the likelihood of their negative and positive outcomes. Using data from a nationally representative survey (n=4030) conducted during 30 July 2019 to 11 August 2019, we described how US adults living in firearm-owning households perceived the relative likelihood of firearm-related harm by injury intent ('accidentally harm self or someone else with a gun', 'injure self on purpose with a gun' and 'injure someone else on purpose with a gun') for groups at risk of compromised decision-making (children; adolescents and individuals with mental health issues, substance use disorders or cognitive impairment). We found that US adults living in firearm-owning households believe that unintentional firearm injuries are more likely than intentional self-inflicted or assault-related firearm injuries, despite evidence to the contrary. Prior evidence indicates that communicating risk in relative terms can motivate behaviour change; therefore, findings from this study might helpfully inform health communications around firearm safety., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To determine if an association exists between the number of driving under the influence (DUI) convictions required to activate federal firearms prohibitions and annual firearm homicide and suicide rates by state., Methods: Ecological cross-sectional study of all US states from 2013 to 2017. We collected DUI law data from Thomson Reuters Westlaw database and firearm mortality data from the Centers for Disease Control and Prevention Vital Statistics programme., Results: Five states had laws such that one or two DUI convictions could result in prohibitions to firearms access according to federal law. Four states had no legal framework that would restrict firearms access because of DUI convictions; the remaining states could activate federal restrictions at three or more DUI convictions. Firearm-specific homicide (victimisations) rates were 19% lower among women in states where federal restrictions of firearms access occurred after one or two DUI offences (incidence rate ratio (IRR) 0.81; 95% CI 0.64 to 1.01) and 18% lower in states with firearm prohibitions after three or more offences (IRR 0.82; 95% CI 0.71 to 0.95) compared with the states with no legal framework for prohibiting firearms after DUI convictions. There was no association between number of DUI activations and overall, or firearm-specific, suicide among the entire population (men and women) or among only women, or only men., Conclusions: DUI penalties that activate federal firearms prohibitions may be one pathway to reduce firearm homicide of female victims., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe life experiences associated with patterns of medically treated and documented self-directed violence among youth who attempted suicide using highly lethal means to understand precipitating factors among youth using such lethal means., Method: Using data from a regional, level 1 Trauma center, we identified all youth suicide attempt survivors who received treatment from 2010 to 2018 for a suicide attempt with a firearm, hanging, or jump from height injury (n = 42). We described differences in patient demographics and life experiences associated with patterns of self-directed violence by suicide attempt mechanism. We additionally assessed mechanisms used in any prior suicide attempts to identify potential increasing lethality of mechanism selection., Results: There were 42 eligible patients included, of whom 40.5% attempted suicide with a firearm, 26.2% with hanging, 33.3% with jumping injury. A greater proportion of patients with firearm injuries endorsed social support and had fewer preparatory acts, history of self-harming behavior, prior suicide behaviors, and fewer prior attempts compared to patients who attempted suicide with other mechanisms., Conclusions: Given our findings, means safety should remain a key strategy to prevent highly lethal suicidal behavior among adolescents, especially with firearms, given that such attempts may occur prior to formal contact with mental health services., (© 2021 The American Association of Suicidology.)

Background: Rates of firearm homicide and suicide have varied over time. These variations are due to a number of factors including temporal trends, age, birth year and gender. We sought to conduct an age-period-cohort analysis to understand the intersection of these factors with firearm homicide and suicide., Methods: We used data on firearm homicide and suicide for the years 1983-2017 from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System for this analysis. We restricted our analysis on firearm homicide to persons aged 10-44 years and our analysis on firearm suicide to persons aged 50-84 years, as these age groups are most at risk of each outcome. We calculated annual incidence rates for both outcomes per 100 000 population, overall and by gender., Results: Across all age groups, rates of firearm homicide increased dramatically in the late 1980s and early 1990s. The peak age for firearm homicide varied across cohorts, although it was generally between ages 15 and 29 years. Rates of firearm homicide were substantially higher among men than women, regardless of age, period or cohort. Firearm suicide rates varied significantly by gender. Among men, older cohorts had higher firearm suicide rates, although the rate of firearm suicide increased with age across all cohorts. Among women, firearm suicide rates were also highest among older cohorts; however, firearm suicide rates decreased or remained relatively constant with age., Conclusion: There are important differences in rates of firearm homicide and suicide with respect to gender, age, period and cohort., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Childhood and adolescent firearm injury and death rates have increased over the past decade and remain major public health concerns in the United States. Safe firearm storage has proven to be an effective measure to prevent firearm injury and death among youth. Social media has been used as an avenue to promote safe firearm storage, but perceptions of this tool remain unknown., Objective: The aim of this study was to determine receptiveness and responsiveness in promoting firearm lock box and trigger lock giveaway events on social media, and to describe the characteristics of participants who learned of these events through social media., Methods: We performed a mixed methods study combining a content analysis of Facebook event post comments, quantitative analysis of positive and negative feedback on social media, and a descriptive analysis of event participant characteristics. Through a qualitative content analysis approach, we thematically coded comments from each event's social media page posting. Interrater reliability and κ statistics were calculated. We calculated the prevalence of positive and negative feedback data. Further, we calculated descriptive statistics for demographic characteristics gathered from day-of-event intake surveys. Differences between collected measures were analyzed with χ 2 and t tests according to how the participant found out about the event (social media vs other means). Using concurrent analysis, we synthesized the results from both the qualitative and quantitative aims., Results: Through qualitative content analysis, 414 comments from 13 events were coded. Seven themes emerged through the comment coding process with the most common being "positive receptiveness" (294/414, 71.0%). From quantitative analysis of the social media content, we found higher levels of positive feedback compared to negative feedback. The average number of event post "likes" was 1271.3 per event, whereas the average count in which "hide post" was clicked was 72.3 times per event. Overall, 35.9% (1457/4054) of participants found out about the event through social media. The participants who learned about the event through social media were on average significantly younger than those who learned about the event through other means (-6.4 years, 95% CI -5.5 to -7.3). Among the group that learned of the event through social media, 43.9% (629/1433) identified as female, whereas 35.5% (860/2420) identified as female among the group that learned of the event through other means., Conclusions: There was overall positive receptiveness and responsiveness toward firearm lock box and trigger lock giveaway events when promoted on social media. Compared with other promotional tools, social media has the ability to reach those who are younger and those who identify as female. Future studies should extend this research to determine whether there is a difference between rural and urban settings, and consider other social media platforms in the analysis., (©Esther Lam, Megan Moreno, Elizabeth Bennett, Ali Rowhani-Rahbar. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 18.06.2021.)

Background: Patients with firearm injuries are at high risk of subsequent arrest and injury following hospital discharge. We sought to evaluate the effect of a 6-month joint hospital- and community-based low-intensity intervention on risk of arrest and injury among patients with firearm injuries., Methods: We conducted a cluster randomized controlled trial, enrolling patients with firearm injuries who received treatment at Harborview Medical Center, the level 1 trauma center in Seattle, Washington, were 18 years or older at the time of injury, spoke English, were able to provide consent and a method of contact, and lived in one of the five study counties. The intervention consisted of hospital-based motivational interviewing, followed by a 6-month community-based intervention, and multiagency support. The primary outcome was the risk of subsequent arrest. The main secondary outcome was the risk of death or subsequent injury requiring treatment in the emergency department or hospitalization., Results: Neither assignment to or engagement with the intervention, defined as having at least 1 contact point with the support specialist, was associated with risk of arrest at 2 years post-hospital discharge (relative risk for intervention assignment, 1.15; 95% confidence interval, 0.90-1.48; relative risk for intervention engagement, 1.07; 95% confidence interval, 0.74-2.19). There was similarly no association observed for subsequent injury., Conclusions: This study represents one of the first randomized controlled trials of a joint hospital- and community-based intervention delivered exclusively among patients with firearm injuries. The intervention was not associated with changes in risk of arrest or injury, a finding most likely due to the low intensity of the program., Level of Evidence: Care management, level II., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The incidence of firearm injury and death in the United States is increasing. Although the health care-related effect of firearm injury is estimated to be high, existing data are largely cross-sectional, do not include data on preinjury and postinjury health care visits and related costs, and use hospital charges rather than actual monetary payments., Objective: To compare actual health care costs (that is, actual monetary payments) and utilizations within the 6 months before and after an incident (index) firearm injury., Design: Before-after study., Setting: Blue Cross Blue Shield plans of Illinois, Texas, Oklahoma, New Mexico, and Montana., Participants: Plan members continuously enrolled for at least 12 months before and after an index firearm injury sustained between 1 January 2015 and 31 December 2017., Measurements: Eligible costs, out-of-pocket costs, and firearm injury-related International Classification of Diseases, Ninth or 10th Revision, codes., Results: Total initial (emergency department [ED]) health care costs for persons with index firearm injuries who were discharged from the ED were $8 158 786 ($5686 per member). Total initial (hospital admission) costs for persons with index firearm injuries who required hospitalization were $41 255 916 ($70 644 per member). Compared with the 6 months before the index firearm injury, in the 6 months after, per-member costs increased by 347% (from $3984 to $17 806 per member) for those discharged from the ED and 2138% (from $4118 to $92 151 per member) for those who were hospitalized. The number of claims increased by 187% for patients discharged from the ED and 608% for those who were hospitalized., Limitation: Firearm injury intent was not specified because of misclassification concerns., Conclusion: In the 6 months after a firearm injury, patient-level health care visits and costs increased by 3 to 20 times compared with the 6 months prior. The burden of firearm injury on the health care system is large and quantifiable., Primary Funding Source: None.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Individuals with a firearm injury are at high risk of subsequent firearm victimization, but characteristics associated with sustaining recurrent firearm injuries are not well understood. In this retrospective cohort study, we sought to quantify the hazards of sustaining subsequent assaultive firearm injuries among people with an initial firearm assault injury and to identify characteristics associated with recurrent victimization. Using hospital discharge, emergency department, and mortality records, we identified and followed all individuals aged ≥15 years with a nonfatal firearm assault injury resulting in an emergency department visit or hospital admission in California, 2005-2013. We model transitions from one injury to the next and from injury to death, accounting for event history, covariates, and competing risks using multistate models. 29,156 people had an index nonfatal firearm assault injury. Among individuals with 1 such injury, 3.1% had additional nonfatal firearm assault injuries and 1.0% subsequently died from firearm homicide. Among individuals with 2+ nonfatal firearm assaults, 2.0% died from firearm homicide. The estimated transition probability for 1 to 2+ nonfatal injuries reached 10% by 8.5 years post-index injury. The rate of subsequent nonfatal firearm assault injury was highest among men (hazard ratio [HR]: 3.87; 95% confidence interval [CI]: 2.63-5.69) and Blacks (vs. whites) (HR: 2.69; 95% CI: 1.99-3.64). Identification of additional risk markers will require more detailed individual-level data; nonetheless, this study supports the generalizability of findings from smaller studies, provides broad guidance for allocating scarce resources, and suggests that interventions on root causes of violence disparities may have downstream effects on recurrence., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Pediatric firearm injuries are a serious and growing public health problem, constituting the second leading cause of death in children and adolescents in the United States. Firearm injuries have a high case fatality, but knowledge is limited to date regarding their injury severity and health care utilization burden compared with those of other penetrating injuries, especially among children with critical injury., Objective: To describe and compare the resource utilization, injury severity, and short-term clinical outcomes associated with pediatric firearm injuries and other penetrating trauma., Design, Setting, and Participants: This retrospective cohort study used data from the National Trauma Data Bank, an encounter-level registry of trauma data in the United States, from January 1, 2007, to December 31, 2016. Encounters for firearm injury (n = 25 155) or cut or pierce injury (21 270) in children 17 years or younger were analyzed. Statistical analysis was conducted from July 15, 2018, to June 5, 2019., Exposures: Firearm injury compared with cut or pierce injury encounters., Main Outcomes and Measures: Intensive care unit (ICU) admission, hospital and ICU length of stay (LOS), and Injury Severity Score (ISS)., Results: A total of 25 155 firearm injury encounters and 21 270 cut or pierce injury encounters were analyzed. Most firearm and cut or pierce injuries occurred among boys (21 573 [85.8%] and 15 864 [74.6%]) and adolescents aged 15 to 17 years (18 807 [74.8%] and 10 895 [51.2%]). A greater proportion of those with firearm injuries were African American children compared with those with cut or pierce injuries (15 019 [61.3%] vs 6397 [31.2%]). A greater proportion of those with firearm injuries compared with cut or pierce injuries were admitted to the ICU (7682 [30.5%] vs 2712 [12.8%]). Compared with cut or pierce injuries, firearm injuries were associated with a higher mean (SD) ISS (4.6 [6.8] vs 10.9 [12.7] points), longer mean (SD) hospital LOS (2.8 [4.1] vs 5.0 [8.4] days), and longer mean (SD) ICU LOS (3.1 [4.5] vs 5.1 [7.7] days). Firearm injuries accounted for 126 027 hospital days and 39 255 ICU days, whereas cut or pierce injuries accounted for 58 705 hospital days and 8353 ICU days. After adjustments for age, sex, year, and hospital, those with firearm injuries were more likely to require ICU admission (relative risk [RR], 2.3; 95% CI, 2.1-2.5; P < .001) and to have higher ISS scores (6.7 points higher for all injuries; 95% CI, 6.1-7.2) compared with those with cut or pierce injuries, even among critical injuries. Multinomial logistic regression demonstrated higher risk of prolonged hospital LOS (RR ratio, 4.11; 95% CI, 3.46-4.89; P < .001) and ICU LOS (RR ratio, 2.2; 95% CI, 1.9-2.3) for firearm injuries compared with cut or pierce injuries., Conclusions and Relevance: This study found that pediatric firearm injuries were associated with greater severity and health care utilization compared with penetrating trauma from other mechanisms, suggesting that the mechanism of injury is an important consideration in penetrating sharp force trauma in children and adolescents. Public health measures, legislative efforts, and safe storage practices are among the interventions needed to reduce pediatric firearm injuries.

Research on spatial injury patterns is limited by a lack of precise injury occurrence location data. Using linked hospital and death records, we examined residence and injury locations for firearm assaults and homicides in or among residents of King County, Washington, USA from 1 January 2010 to 31 December 2014. In total, 670 injuries were identified, 586 with geocoded residence and injury locations. Three-quarters of injuries occurred outside the census tract where the victim resided. Median distance between locations was 3.9 miles, with victims 18-34 having the greatest distances between residence and injury location. 40 of 398 tracts had a ratio of injury incidents to injured residents of >1. Routine collection of injury location data and homelessness status could decrease misclassification and bias. Researchers should consider whether residential address is an appropriate proxy for injury location, based on data quality and their specific research question., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Firearm carriage is a key risk factor for interpersonal firearm violence, a leading cause of adolescent (age < 18) mortality. However, the epidemiology of adolescent firearm carriage has not been well characterized. This scoping review examined four databases (PubMed; Scopus; EMBASE; Criminal Justice Abstracts) to summarize research on patterns, motives, and underlying risk/protective factors for adolescent firearm carriage. Of 6156 unique titles, 53 peer-reviewed articles met inclusion criteria and were reviewed. These studies mostly examined urban Black youth, finding that adolescents typically carry firearms intermittently throughout adolescence and primarily for self-defense/protection. Seven future research priorities were identified, including: (1) examining adolescent carriage across age, gender, and racial/ethnic subgroups; (2) improving on methodological limitations of prior research, including disaggregating firearm from other weapon carriage and using more rigorous methodology (e.g., random/systematic sampling; broader population samples); (3) conducting longitudinal analyses that establish temporal causality for patterns, motives, and risk/protective factors; (4) capitalizing on m-health to develop more nuanced characterizations of underlying motives; (5) increasing the study of precursors for first-time carriage; (6) examining risk and protective factors beyond the individual-level; and, (7) enhancing the theoretical foundation for firearm carriage within future investigations.

Individuals who sustain nonfatal gunshot wound (GSW) injuries are at substantially increased risk of subsequent firearm injury. There is a dearth of literature examining what, if any, firearm-related behavior changes occur among adults as a result of GSW injuries. Using survey data on firearm-related behaviors from an ongoing randomized controlled trial, we sought to describe changes in reported firearm-related behaviors among GSW patients following their injury. Our results suggest that patients with a GSW, especially firearm owners, may change their firearm-related behaviors following injury, some by increasing firearm-related safety and others by increasing frequency of behaviors that may place them at increased risk of subsequent injury. This study highlights the need for further examination of firearm-related behavior change among GSW patients and development of interventions to promote firearm safety among this population.

Introduction: Interventions that reduce access to highly lethal and commonly used methods of suicide (e.g., limiting firearm access) are considered essential elements of effective suicide prevention programs. Scant epidemiologic data are available to inform such efforts among Veterans. The aim of this study is to describe firearm storage practices and correlates of those practices among a nationally representative sample of U.S. Veteran firearm owners., Methods: The authors used a probability-based online survey of Veteran firearm owners in 2015 (data analyzed in 2017; 54.6% response rate). The primary outcome was firearm storage practices. Additional items assessed individual and household-level sociodemographic characteristics, firearm-related characteristics, and risk perceptions related to firearm ownership., Results: One in three (33.3%, 95% CI=28.6%, 38.4%) Veteran firearm owners stores at least one firearm loaded and unlocked. The prevalence of this practice ranges substantially (9%-65%) across individual, household, and firearm ownership characteristics, and is strongly related to other firearm-related behaviors (e.g., carrying handguns); reasons for firearm ownership (e.g., protection versus other); number of firearms owned; and perceptions about the utility of guns stored safely and whether guns make homes safer., Conclusions: Storing a firearm loaded and unlocked is common among Veterans. Storage practices are strongly related to reasons for ownership and potentially malleable perceptions including beliefs about firearm-related risks. Suicide prevention initiatives among Veterans should incorporate communication strategies that address common misperceptions about household firearm risk and whether safe storage practices may better align with reasons most Veterans own firearms (i.e., safety)-especially when someone in their home is at increased risk for suicide., (Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Substance use, mental disorders, and arrest are markers of increased firearm injury risk. It is unclear how these markers vary by intent. Examining these interrelated factors together can clarify their associations with assault-related, self-inflicted, unintentional, and legal intervention firearm injuries, informing intent-specific interventions., Methods: In 2017-2018, 2-year diagnosis and arrest histories of intent-specific firearm injury cases were compared with those of unintentionally injured motor vehicle collision passenger controls. Fatal and nonfatal firearm and motor vehicle collision injury records in Seattle (2010-2014) were linked to statewide hospitalization and arrest records. Multinomial logistic regression models compared odds of prior arrest, substance use, and mental disorder diagnoses among intent-specific firearm injury cases relative to controls, adjusting for age, race, and gender., Results: A total of 763 cases and 335 controls were identified. Unintentional and self-inflicted cases did not differ significantly from controls in arrest history. Legal intervention cases resembled assault-related cases in their arrest history, and self-inflicted cases in their hospitalization history. The legal intervention cases were more likely than controls to have a prior felony arrest (OR=7.72, 95% CI=2.63, 20.97), and diagnoses involving alcohol (OR=4.06, 95% CI=1.04, 15.84); cannabis (OR=11.00, 95% CI=1.01, 119.36); depression/anxiety (OR=7.22, 95% CI=1.89, 27.67); psychosis (OR=6.99, 95% CI=1.35, 36.24); or conduct disorder (OR=22.01, 95% CI=1.44, 335.93)., Conclusions: Individuals with intent-specific firearm injuries have distinct patterns of prior substance use, mental disorder, and arrest. Many injuries occur after a series of encounters with institutions meant to help individuals during crises that can fail to provide longer-term solutions., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Importance: Understanding global variation in firearm mortality rates could guide prevention policies and interventions., Objective: To estimate mortality due to firearm injury deaths from 1990 to 2016 in 195 countries and territories., Design, Setting, and Participants: This study used deidentified aggregated data including 13 812 location-years of vital registration data to generate estimates of levels and rates of death by age-sex-year-location. The proportion of suicides in which a firearm was the lethal means was combined with an estimate of per capita gun ownership in a revised proxy measure used to evaluate the relationship between availability or access to firearms and firearm injury deaths., Exposures: Firearm ownership and access., Main Outcomes and Measures: Cause-specific deaths by age, sex, location, and year., Results: Worldwide, it was estimated that 251 000 (95% uncertainty interval [UI], 195 000-276 000) people died from firearm injuries in 2016, with 6 countries (Brazil, United States, Mexico, Colombia, Venezuela, and Guatemala) accounting for 50.5% (95% UI, 42.2%-54.8%) of those deaths. In 1990, there were an estimated 209 000 (95% UI, 172 000 to 235 000) deaths from firearm injuries. Globally, the majority of firearm injury deaths in 2016 were homicides (64.0% [95% UI, 54.2%-68.0%]; absolute value, 161 000 deaths [95% UI, 107 000-182 000]); additionally, 27% were firearm suicide deaths (67 500 [95% UI, 55 400-84 100]) and 9% were unintentional firearm deaths (23 000 [95% UI, 18 200-24 800]). From 1990 to 2016, there was no significant decrease in the estimated global age-standardized firearm homicide rate (-0.2% [95% UI, -0.8% to 0.2%]). Firearm suicide rates decreased globally at an annualized rate of 1.6% (95% UI, 1.1-2.0), but in 124 of 195 countries and territories included in this study, these levels were either constant or significant increases were estimated. There was an annualized decrease of 0.9% (95% UI, 0.5%-1.3%) in the global rate of age-standardized firearm deaths from 1990 to 2016. Aggregate firearm injury deaths in 2016 were highest among persons aged 20 to 24 years (for men, an estimated 34 700 deaths [95% UI, 24 900-39 700] and for women, an estimated 3580 deaths [95% UI, 2810-4210]). Estimates of the number of firearms by country were associated with higher rates of firearm suicide (P < .001; R2 = 0.21) and homicide (P < .001; R2 = 0.35)., Conclusions and Relevance: This study estimated between 195 000 and 276 000 firearm injury deaths globally in 2016, the majority of which were firearm homicides. Despite an overall decrease in rates of firearm injury death since 1990, there was variation among countries and across demographic subgroups.

Background: Safe firearm storage practices are associated with a lower risk of unintentional and self-inflicted firearm injuries among household members, though many firearms remain unlocked and/or loaded., Objectives: Conduct a preliminary evaluation of a community-based firearm safety intervention and assess participants' preferences for firearm locking devices and their comfort with potential firearm safety counsellors., Design/methods: Baseline event and follow-up surveys among adult participants to assess changes in firearm storage practices, including whether all household firearms were stored locked, all were unloaded, all ammunition was locked, and a composite measure assessing whether all firearms were locked and unloaded and all ammunition was stored locked., Results: A total of 206 out of 415 participants completed both surveys and were included. Nearly 9 in 10 respondents preferred the firearm lock box rather than a trigger lock. At follow-up, a significantly greater proportion reported that all household firearms were locked (+13.7%) and unloaded (+8.5%) and a non-significantly greater proportion reported that all ammunition was locked (+6.3%). A significantly greater proportion reported practising all three safe firearm and ammunition storage practices at follow-up (+12.6%). A majority reported they would be comfortable or very comfortable discussing firearm safety with various safety counsellors, though women were less likely to do so than men., Conclusion: This intervention that included distribution of a free, participant-selected locking device improved safe firearm storage practices among participants. Differences in participant preferences for devices and safety counsellors suggest that a 'one size fits all' approach may be inadequate in affecting population-level storage practices., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Study Objective: To identify critical emergency medicine-focused firearm injury research questions and develop an evidence-based research agenda., Methods: National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine-relevant research questions. In-person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated., Results: Fifty-nine final emergency medicine-relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self-directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional ("accidental") injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings., Conclusion: The technical advisory group identified key emergency medicine-relevant firearm injury research questions. Emergency medicine-specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas., (Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Hospital-based violence intervention programs typically focus on patients whose firearm injury occurred through interpersonal violence (assault). Knowledge of violence perpetration by victims of unintentional (accidental) firearm injury is limited., Objective: To examine violence perpetration before and after a patient becomes hospitalized for firearm injury according to injury intent (intentional [assault] or unintentional [accidental])., Design: A case-control study and a retrospective cohort study., Setting: Hospitals in Washington., Patients: Persons aged 15 years or older hospitalized for a firearm injury, other injuries, or a noninjury reason from 2006 to 2007., Measurements: In the case-control study, the odds of violence-related arrest from 2001 through hospitalization by injury intent among 3 groups were compared. In the cohort study, the rates of violence-related arrest from hospitalization through 2011 by injury intent among 3 groups were compared., Results: Patients with unintentional firearm injuries (n = 180) were more likely than those with other unintentional injuries (n = 62 795; odds ratio [OR], 2.01 [95% CI, 1.31 to 3.09]) and no injuries (n = 172 830; OR, 3.43 [CI, 2.22 to 5.32]) to have been arrested for a violent crime before hospitalization. Prior violence-related arrest did not differ between patients with assault-related firearm injuries (n = 339) and those with other assault-related injuries (n = 2342; OR, 1.10 [CI, 0.84 to 1.46]). During follow-up, the cumulative incidence of violence-related arrest for patients with unintentional and assault-related firearm injuries was 10% and 15% (subhazard ratio, 1.88 [CI, 1.11 to 3.17] and 1.61 [CI, 1.08 to 2.44]), respectively, compared with 1% for those without injuries., Limitation: Exclusion of self-inflicted injuries, misclassification of intent, and ascertainment bias., Conclusion: Some firearm injuries classified as accidental may indicate involvement in the cycle of violence and present an opportunity for intervention., Primary Funding Source: City of Seattle and the University of Washington Royalty Research Fund.

Objectives: We investigated whether stricter state-level firearm legislation was associated with lower hospital discharge rates for nonfatal firearm injuries., Methods: We estimated discharge rates for hospitalized and emergency department-treated nonfatal firearm injuries in 18 states in 2010 and used negative binomial regression to determine whether strength of state firearm legislation was independently associated with total nonfatal firearm injury discharge rates., Results: We identified 26 744 discharges for nonfatal firearm injuries. The overall age-adjusted discharge rate was 19.0 per 100 000 person-years (state range = 3.3-36.6), including 7.9 and 11.1 discharges per 100 000 for hospitalized and emergency department-treated injuries, respectively. In models adjusting for differences in state sociodemographic characteristics and economic conditions, states in the strictest tertile of legislative strength had lower discharge rates for total (incidence rate ratio [IRR] = 0.60; 95% confidence interval [CI] = 0.44, 0.82), assault-related (IRR = 0.58; 95% CI = 0.34, 0.99), self-inflicted (IRR = 0.18; 95% CI = 0.14, 0.24), and unintentional (IRR = 0.53; 95% CI = 0.34, 0.84) nonfatal firearm injuries., Conclusions: There is significant variation in state-level hospital discharge rates for nonfatal firearm injuries, and stricter state firearm legislation is associated with lower discharge rates for such injuries.

Background: Risk for violent victimization or crime perpetration after firearm-related hospitalization (FRH) must be determined to inform the need for future interventions., Objective: To compare the risk for subsequent violent injury, death, or crime perpetration among patients with an FRH, those hospitalized for noninjury reasons, and the general population., Design: Retrospective cohort study., Setting: All hospitals in Washington., Patients: Patients with an FRH and a random sample of those with a non-injury-related hospitalization in 2006 to 2007 (index hospitalization)., Measurements: Primary outcomes included subsequent FRH, firearm-related death, and the combined outcome of firearm- or violence-related arrest ascertained through 2011., Results: Among patients with an index FRH (n = 613), rates of subsequent FRH, firearm-related death, and firearm- or violence-related arrest were 329 (95% CI, 142 to 649), 100 (CI, 21 to 293), and 4221 (CI, 3352 to 5246) per 100 000 person-years, respectively. Compared with the general population, standardized incidence ratios among patients with an index FRH were 30.1 (CI, 14.9 to 61.0) for a subsequent FRH and 7.3 (CI, 2.4 to 22.9) for firearm-related death. In survival analyses that accounted for competing risks, patients with an index FRH were at greater risk for subsequent FRH (subhazard ratio [sHR], 21.2 [CI, 7.0 to 64.0]), firearm-related death (sHR, 4.3 [CI, 1.3 to 14.1]), and firearm- or violence-related arrest (sHR, 2.7 [CI, 2.0 to 3.5]) than those with a non-injury-related index hospitalization., Limitation: Lack of information on whether patients continued to reside in Washington during follow-up may have introduced outcome misclassification., Conclusion: Hospitalization for a firearm-related injury is associated with a heightened risk for subsequent violent victimization or crime perpetration. Further research at the intersection of clinical care, the criminal justice system, and public health to evaluate the effectiveness of interventions delivered to survivors of firearm-related injury is warranted., Primary Funding Source: Seattle City Council and University of Washington Royalty Research Fund.