Higher poverty concentration at the county level significantly increased the risk of firearm-related deaths in children and youth aged 5-24 years in the United States, based on a review of approximately 67,000 fatalities.

Firearms are the second-leading cause of death in children and young adults in the United States, according to data from the Centers for Disease Control and Prevention, wrote Jefferson T. Barrett, MD, of The Children’s Hospital at Montefiore, New York, and colleagues. County-level poverty has been associated with increased injury mortality in children, but the association between county-level poverty and firearm-related mortality in particular has not been well studied.

In a cross-sectional study published in JAMA Pediatrics, 67,905 firearm-related deaths in children and youth aged 5-24 years that occurred between Jan. 1, 2007, and Dec. 31, 2016 were analyzed. The deaths included 42,512 homicides (62.6%), 23,034 suicides (33.9%), and 1,627 unintentional deaths (2.4%).

County poverty data were acquired from the U.S. Census Bureau. County-level poverty was divided into five categories based on percentage of the population living below the federal poverty level: 0%-4.9%, 5%-9.9%, 10%-14.9%, 15%-19.9%, and 20% or more.

Overall, 88.6% of the total deaths were in males. Notably, 44.8% of total firearm-related deaths and 63.9% of homicides occurred in non-Hispanic Blacks, who make up only 14% of the youth population in the United States, the researchers wrote.

The total number of firearm-related deaths was 248 in the lowest quintile of poverty concentration, followed by 6,841, 18,551, 27,305, and 14,960 in the remaining quintiles.

In a multivariate regression model that included demographics, urban versus rural, and statewide firearm prevalence, youth in counties with the highest quintile of poverty concentration had an increased rate of total firearm-related deaths (adjusted incidence rate ratio, 2.29), as well as increased rates of homicides, suicides, and unintentional deaths (aIRR, 3.55, 1.45, and 9.32, respectively), compared with those living in the lowest quintile of poverty concentration. Individuals in the highest poverty quintile accounted for 22.0% of total firearm-related deaths, 25.5% of homicides, 15.3% of suicides, and 25.1% of unintentional deaths.

The researchers also calculated the population-attributable fraction (PAF) and years of potential life lost. “The PAF represents the proportion of deaths associated with a particular exposure, which was concentrated county poverty in this study,” they explained. The PAF for all firearm-related deaths was 0.51, PAFs for homicides, suicides, and unintentional deaths were 0.66, 0.30, and 0.86, respectively. The PAF calculation translated to 34,292 firearm-related deaths that may not have occurred if youth in all counties had the same risk as those in counties with the lowest poverty concentration.

“Over the 10-year study period, we observed 3,833,105 years of potential life lost in youth aged 5-24 years from firearm-related deaths,” the researchers wrote.

The study findings were limited by several factors including the potential bias of a cross-section design, and inability to account for all the ways that county-level poverty might increase the risk of firearm-related death in children and teens, the researchers noted. Other potential limitations include possible misclassification of death, lack of data on individual family incomes, shifts in counties in the poverty categories over time, and the use of statewide, rather than countywide, estimates of firearm ownership.

However, the results are consistent with those of previous studies, and add that “mortality rates were consistent even after controlling for demographic variables, county urbanicity, and statewide firearm prevalence,” the researchers concluded.

Address Structural Racism to Reduce Disparities

“Firearm-related homicides among youth aged 5-24 years are among the causes of death with the greatest disparities,” based on CDC fatal injury reports, wrote Alice M. Ellyson, PhD, Frederick P. Rivara, MD, and Ali Rowhani-Rahbar, MD, all of the University of Washington, Seattle, in an accompanying editorial.

The current study builds on previous research, including studies showing an association between income inequality and firearm-related homicide, they said. More research is needed to determine how to intervene in the pathways between poverty and firearm-related death. For example, if access to high-quality health care is a factor, programs to increase access to health insurance, such as the Affordable Care Act and Children’s Health Insurance Program, or to increase access to high-quality trauma care may help reduce firearm-related death in youth.

“The study of where, how, and why racism operates as a factor in both poverty and firearm-related death must continue, especially considering the disparities consistently documented in Alaska Native or American Indian, Black, and Hispanic communities,” the editorialists wrote.

“Key potential mechanisms for reducing the consequences of poverty for firearm-related death are often denied to racial and ethnic minority groups through a variety of structures, policies, and systems in health care, employment, housing, transportation, and education,” they emphasized, and the impact of racism, not only on the pathways to poverty, but also on mediators between poverty and firearm-related death, must be explored.

Findings Spotlight Need for Poverty Programs

The study was an interesting look at the specific relationship between poverty and firearm-related deaths in people aged younger than 25 years in the United States, Tim Joos, MD, of Seattle said in an interview.

“Although America is not a poor country, the combination of poverty within America and its unique gun culture seems to prove deadly for its youth,” Joos said. “The strongest relationship is between firearm-related homicide and poverty, but unintentional firearm deaths and poverty also are clearly linked, whereas the link between firearm-related suicide and poverty appears to be present, but small.”.

In the current study, “the authors note that firearm deaths are the second-leading cause of death among all people ages 15-24 years,” said Joos. “Many of us have followed children from infancy just to have them meet this untimely end as adolescents, wishing we had a vaccine or other remedy in our toolbelt for this particular scourge.

“As our country currently debates the size of the social safety net, this study is one of many that suggests government programs aimed at poverty alleviation would substantially contribute to the health of American youth,” Joos added.

The study received no outside funding. Lead author Barrett had no financial conflicts to disclose. Ellyson disclosed funds from the CDC, the state of Washington, and the Grandmothers Against Gun Violence Foundation for research outside the submitted work. Rivara disclosed funds from the National Institutes of Health, the State of Washington, and the National Collaborative on Gun Violence Research for research outside the submitted work. Rowhani-Rahbar disclosed funds from the CDC, National Institutes of Health, National Collaborative on Gun Violence Research, Fund for a Safer Future, and state of Washington for research outside the submitted work. Joos had no financial conflicts to disclose, but serves on the editorial advisory board of Pediatric News.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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