Gun Deaths in Rural and Urban Settings: Recommendations for Prevention

Lee T. Dresang, MD, Department of Family Medicine, University of Wisconsin Medical School, and the St. Luke's Family Practice Residency, Mitchell Point Family Health Center, Milwaukee.

J Am Board Fam Med. 2001;14(2) 

In This Article

Abstract and Introduction

Background: Family physicians can play a vital role in preventing gun violence, and better data on which to base their interventions might result in more effective prevention efforts. Using Washington State data, two assumptions on which interventions can be based were tested: compared with urban areas, rural areas have (1) a higher percentage of gun deaths from shotguns and rifles, and (2) a higher percentage of gun deaths from suicides and accidents.
Methods: From 1990 to 1996, 4,271 gun deaths on Washington death certificates were classified as rural or urban. The data were retrospectively sorted and analyzed by gun type (handguns, rifles, shotguns, or other) and by intent (suicide, homicide, or accidental death).
Results: Compared with urban settings, rural areas had a higher percentage of gun deaths from shotguns and rifles and a higher percentage from suicides and accidents (P < .01). Two similarities, however, stand out as more important than the confirmed hypothesized differences: handguns accounted for more than 50% of gun deaths, and suicides accounted for nearly 70% of gun deaths in both urban and rural areas.
Conclusions: Family physicians might want to focus their firearm safety efforts on preventing handgun deaths and suicides, which accounted for most gun deaths in rural and urban areas. Also, data from this study suggest that deaths from shotguns and rifles as well as accidental and suicide gun deaths deserve special attention in rural areas.

Gun violence in the United States is a public health epidemic. In a study of firearm deaths from 1968 to 1991, the number of firearm-related deaths in 1991 exceeded the number of motor-vehicle-related deaths in 7 states and Washington, DC.[1] For male teenagers, firearm-related deaths exceed the number of deaths from all natural causes combined.[2] Recent school shootings in Littleton, Colo, and Conyers, Ga, have intensified US public awareness of tragedies associated with gun violence in general and have focused attention on issues specific to rural and urban areas.

According to a 1996 study, "few patients report that their physician has ever discussed firearm safety with them, and only 30% of physicians surveyed report ever counseling patients about firearm safety."[3] In another study, 80% of physicians believed they should counsel on firearm safety, but only 38% did so. Of those who did counsel, only 20% counseled more than 10% of the families they saw.[4] Parents "indicate that they would acknowledge gun ownership if their pediatrician asked about guns in the home."[5] This finding suggests that family physicians can play a bigger role in combating the epidemic of gun violence.

Better data on which to base interventions could result in more effective efforts. "Our knowledge about firearm injury in rural areas is limited compared with urban settings. Yet rural areas have high levels of firearm access and mortality."[6] Nationally, rates of firearm violence have been declining since 1993. The so-called Boston miracle has received much attention: "a combination of gang-based interventions, identification and prosecution of firearms traffickers, and other measures has been associated in a preliminary evaluation with a more than 60% decrease in juvenile and youth homicide and a reduction in weapon carrying."[7] Some legislation has been effective. For example, background checks under the Brady Handgun Violence Prevention Act and related statutes prevent the sale of firearms to 70,000 to 80,000 felons per year.[7] Still, more work needs to be done. "The homicide rate for persons aged 15 through 24 years remains high; the rate in 1995 was 71% higher than a decade earlier."[8] More information comparing and contrasting rural and urban gun deaths might make it possible to develop more effective interventions.

Nationally, studies to date generally support the hypothesis that the greater number of rural gun deaths are from rifles or shotguns, whereas the greater number of urban gun deaths are from handguns. Among 122 gunshot wounds in a rural Wisconsin trauma center between 1981 and 1991, 39% were inflicted by rifles, 21% by shotguns, and 20% by handguns (16% were not specified, and 4% were inflicted by other).[9] In contrast, among guns used for homicides and suicides in Milwaukee between 1990 and 1994, 85% were handguns, 7% were shotguns, and 6% were rifles.[10] In Tennessee between 1978 and 1988, 59% of deaths in urban areas and 33% in rural areas involved handguns.[11] During a 5-year period in Philadelphia, a handgun was used in more than 90% of homicides.[12] An exception to the above pattern is a rural North Carolina county, where between 1990 and 1991, 51% of gun deaths were inflicted by handguns, 26% by rifles, and 23% by shotguns.[6]

This study also categorized gun deaths by suicide, homicide, and accidental shootings. According to statistics from the Centers for Disease Control and Prevention (CDC), suicides, homicides, and unintentional shootings accounted for 49%, 45%, and 1% of gun deaths, respectively, in the United States in 1994.[13] That year, firearms were responsible for 70% of all homicides and 60% of all suicides.[14] Washington State had the 19th highest suicide rate in the United States in 1990.[15]

In general, homicide gun deaths in the United States are more of an urban than a rural problem. "Half of all homicides occurred in 63 cities with 16% of the nation's population; within those cities, homicides were largely clustered in certain neighborhoods."[7] For example, in Milwaukee, two inner-city zip codes, 53204 and 53215, have homicide rates of 89.1 per 100,000 and 38.8 per 100,000, respectively, compared with a homicide rate of 10.5 per 100,000 for the state in general.[16]

Just as regionally comparative studies suggest that firearm homicides are more of an urban problem, they generally show that firearm-related suicides and accidents are a bigger problem in rural areas. In rural Kentucky, between 1988 and 1993 the relative risk and confidence intervals (CIs) for pediatric gun deaths by suicide and unintentional injuries were 3.07 (1.85-4.29) and 1.66 (1.04-2.27), respectively.[17] In Oklahoma, between 1982 and 1983 the pediatric unintentional gun death rate was four times higher in rural counties.[18] In Texas, between 1984 and 1988 the pediatric death rate for unintentional shootings was 2.9 times greater in rural counties, whereas the pediatric death rate for homicides was 2.4 times greater in metropolitan areas.[19] In a rural North Carolina county, between 1990 and 1991, 59% of gun deaths were suicides, and none was unintentional.[6]

This study has two hypotheses: (1) compared with urban Washington, rural Washington has a higher percentage of gun deaths from shotguns and rifles; and (2) compared with urban Washington, rural Washington has a higher percentage of gun deaths from suicides and accidents. The former focuses on gun type, whereas the latter focuses on intent. This study does not investigate why certain types of gun deaths are more common.

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