The Public Health
Approach to Gun
Violence Prevention
November 2020
Attachment A
The Public Health Approach to Gun Violence Prevention | 2 Table of Contents
3 Introduction
4 What is Public Health?
5 Why is Gun Violence a Public Health Epidemic?
7 What is the Public Health Approach?
10 Health Impact Pyramid
11 How Do We Address Gun Violence Through the
Public Health Approach?
13 Recommendations
14 Resources
3 Introduction
Each day more than 100 Americans die by firearms and nearly 200 are shot and injured. These deaths are preventable. A comprehensive public health approach is needed to address the gun violence epidemic. Public health is the science of reducing and preventing injury, disease, and death and promoting the health and well-being of populations through the use of data, research, and effective policies and practices. A public health approach to prevent gun violence is a population level approach that addresses both firearm access and the factors that contribute to and protect from gun violence. This approach brings together institutions and experts across disciplines in a common effort to:
1) define and monitor the problem, 2) identify risk and protective factors, 3) develop and test prevention strategies, and 4) ensure widespread adoption of effective strategies.
We have used the public health approach to successfully eradicate diseases, reduce smoking-related deaths, and decrease car crashes.
We can use this same approach to prevent gun violence in all its forms and strive towards a society where everyone can live free from gun violence.
The Public Health Approach to Gun Violence Prevention | 4 The Public Health Approach to Gun Violence Prevention | Public health is the science of reducing and preventing injury, disease, and death and promoting the health and well-being of populations through the use of data, research, and effective policies and practices. Public health works to address the underlying causes of a disease or injury before they occur, promote healthy behaviors, and control the spread of outbreaks.
Public health researchers and practitioners then work with communities and populations to implement and evaluate programs and policies that are based on research. Policymakers, researchers, and advocates have successfully used the public health approach in the United States to drastically decrease premature death rates, reduce injury, and improve the health and well-being of the population, including by eradicating diseases like polio, promoting widespread usage of vaccines, reducing smoking-related deaths, addressing environmental toxins, and decreasing motor vehicle crashes.
How Public Health differs from Healthcare
People often assume that public health is the same as healthcare. While both strive to improve health and well-being, they approach this goal differently. In healthcare, the focus is on improving the health of the individual. In contrast, public health focuses on improving the health of an entire population through large-scale interventions and prevention programs.
Public health works to address the many factors
that determine the health and well-being of
populations. These factors are often referred to as
risk and protective factors. They are characteristics
or behaviors in individuals, families, communities,
and the larger society that increase or decrease the
likelihood of premature death, injury, or poor health.
What is Public Health?
The Public Health Approach to Gun Violence Prevention | 5 Why is Gun Violence a
Public Health Epidemic?
Gun violence is a public health epidemic that affects the well- being and public safety of all Americans. In 2018, nearly 40,000 Americans were killed by gun violence, more than the number of Americans killed in car crashes.² An additional 71,000 Americans suffer nonfatal firearm injuries,³ and millions of Americans face the trauma of losing a loved one or living in fear of being shot.
The impacts of gun violence, both direct and indirect, inflict an enormous burden on American society. When a child is shot and killed, they lose decades of potential: the potential to grow up, have a family, contribute to society, and pursue their passions in life.
When compared to other communicable and infectious diseases, gun violence often poses a larger burden on society in terms of potential years of life lost. In 2018, firearm deaths accounted for 919,185 years of potential life lost before the age of 65 – more than diabetes, stroke, and liver disease combined.⁴
The Public Health Approach to Gun Violence Prevention | 6 1. Firearm Suicide:
• Each year, nearly 23,000 Americans die
by firearm suicide.⁵
• Half of all suicide deaths are by firearm.⁶
• Suicide attempts by firearm are almost
always deadly — 9 out of 10 firearm suicide
attempts result in death.⁷
• Access to a firearm in the home increases
the odds of suicide more than three-fold.⁸
2. Firearm Homicide:
• Each year, more than 13,000 Americans
die by firearm homicide.⁹
• Nearly three out of four homicides are
committed with a firearm.¹⁰
• Access to firearms — such as the presence
of a gun in the home — doubles the risk
for homicide victimization.¹¹,¹²
• The firearm homicide rate in the United
States is 25.2 times higher than other
industrialized countries.¹³
3. Domestic Violence:
• More than half of female intimate partner
homicides are committed with a gun.¹⁴
• There are about 4.5 million women in
America who have been threatened with
a gun and nearly 1 million women who
have been shot or shot at by an intimate
partner.¹⁵
• A woman is five times more likely to be
murdered when her abuser has access to
a gun.¹⁶
4. Police-Involved Shootings:
• 1,000 Americans are shot and killed by
police every year.¹⁷
• Black Americans are disproportionately
impacted by police-involved shootings
and are killed at more than twice the rate
of White Americans.¹⁸
5. Unintentional Shootings:
• Each year, nearly 500 people die from
unintentional firearm injuries — more
than one person every single day.
• More than 100 children and youth die each
year due to unintentional gun injuries.²⁰
• Americans are four times more likely
to die from an unintentional gun injury
than people living in other high-income
countries.²¹
6. Nonfatal Firearm Injuries:
• For every individual in the United States
who dies by firearm, more than two
individuals survive.²²
• Each year, there are over 71,000 nonfatal
gunshot injuries, costing hospitals an
estimated $2.8 billion annually.²³
• Each year, there are more than 7,100
emergency room visits for nonfatal
gunshot wounds among children under
the age of 18 and 36,000 visits among
those ages 18-29.²⁴
7. Exposure to Gun Violence:
• One-third of American adults say that
their fear of mass shootings prevents them
from going to certain places or events.²⁵
• An estimated 15% of American adults state
that they have witnessed a shooting and 15%
of American adults also state that someone
they care for has been killed with a gun.²⁶
• An estimated 25% of American adults
report being threatened or intimidated
with a gun.²⁷
Scope of Gun Violence
Americans are impacted by various
forms of gun violence – including sui -
cide, homicide, and unintentional deaths,
as well as nonfatal gunshot injuries,
threats, and exposure to gun violence
in communities and society.
The Public Health Approach to Gun Violence Prevention | 7 What is the Public
Health Approach?
The Centers for Disease Control and Prevention and World Health Organization outline a public health approach to violence prevention based on four steps: ²⁸
‚
²⁹
STEP 1 – DEFINE AND MONITOR THE PROBLEM
Researchers and policymakers need reliable data to understand the scope and complexity of gun violence. There are many different types of gun violence, and each type often requires different prevention strategies. Collecting and distributing reliable firearm data is essential to combating gun violence through a public health approach.
Gun violence prevention researchers need reliable and timely data around the number of firearm fatalities and nonfatal injuries that occur in the United States each year.
This data should include the demographics of the victim and shooter (if applicable), the location and time of the shooting, and the type of gun violence that occurred.
Databases should classify the types of gun violence (suicides, intimate partner violence, mass shootings, interpersonal violence, police shootings, unintentional injuries) based on clearly defined and standardized definitions. This data should be made widely available and easily accessible to the general public free of charge.
The Public Health Approach to Gun Violence Prevention | 8 STEP 2 – IDENTIFY RISK AND PROTECTIVE FACTORS
The public health approach focuses on prevention and addresses population level risk factors that lead to gun violence and protective factors that reduce gun violence. A thorough body of research has identified specific risk factors, both at the individual level and at the community and societal level, which increase the likelihood of engaging in gun violence. At an individual level, having access to guns is a risk factor for violence, increasing the likelihood that a dangerous situation will become fatal. Simply having a gun in one’s home doubles the chance of dying by homicide and increases the likelihood of suicide death by over three-fold.³⁰ Other individual risk factors closely linked to gun violence include: a history of violent behavior, exposure to violence, and risky alcohol and drug use.³¹ Community level factors also increase the likelihood of gun violence. Under-resourced neighborhoods with high concentrations of poverty, lack of economic opportunity, and social mobility are more likely to experience high rates of violence. These community level factors are often the result of deep structural inequities rooted in racism.³² ,³³ Policies and programs should mitigate risk factors and promote protective factors at the individual and community levels.
Applying the Public Health Approach
to Prevent Firearm Suicide
The social ecological model is a public health framework that is used to show the interplay between risk and protective factors for health outcomes and to develop parallel policies and programs that address these factors. The model spans four levels:
individual, relationship, community, and society.
Access to firearms is a significant risk factor
for firearm suicide, and addressing firearm
access is a critical component of any suicide
prevention strategy. Prevent Firearm
Suicide is a project of the Educational
Fund to Stop Gun Violence that applies
the social ecological model for firearm
suicide prevention, by sharing the available
programs and policies that reduce access
to firearms from individuals when they are at an elevated risk for suicide. These interventions span the four levels of the model and include safer firearm storage (individual), lethal means safety counseling (relationship), gun shop projects (community), and extreme risk laws (society).
To learn more, visit PreventFirearmSuicide.com
preventfirearmsuicide.efsgv.org/
Prevent Firearm
Suicide
Individual
Safer Storage
Relationship
Lethal Means
Safety Counseling
Community
Gun Shop
Project
Society
Extreme Risk
Laws
The Public Health Approach to Gun Violence Prevention | 9 STEP 3 – DEVELOP AND TEST PREVENTION STRATEGIES
Policymakers and practitioners must craft interventions that address the risk factors for gun violence. These interventions should be routinely tested to ensure they are effective and equitable; rigorous evaluations should be conducted on a routine basis. The foundation for effective gun violence prevention policy is a universal background check law, ensuring that each person who seeks to purchase or transfer a firearm undergoes a background check prior to purchase. Universal background checks should be supplemented by a firearm licensing system, which regulates and tracks the flow of firearms, to ensure that firearms do not make it into the hands of prohibited individuals. Building upon this, policymakers can create interventions that target behavioral risk-factors for gun violence (e.g. extreme risk laws) and they can push for policies that address community risk factors that lead to violence (e.g. investing in community based violence prevention programs). In addition to these gun violence prevention policies, there are a number of evidence-based strategies that can reduce gun violence within communities. For example, community based violence intervention programs work to de-escalate conflicts, interrupt cycles of retaliatory violence, and support those at elevated risk for violence.
STEP 4 – ENSURE WIDESPREAD ADOPTION OF EFFECTIVE STRATEGIES While it is essential to pass strong laws, it is equally important to enforce and implement these laws and to scale up evidence-based programs. Strong gun violence prevention policies are only effective if they are properly implemented and enforced in an equitable manner. A key focus of the public health approach is ensuring that these strategies are not only effective but that they also promote equity. Historically disenfranchised groups should be involved in the implementation process to ensure that public health strategies do not have unintended consequences. For example, gun violence prevention policies should be consistently evaluated to ensure that they do not stigmatize individuals living with mental illness or perpetuate the discriminatory and racist practices embedded in the criminal justice system. The public health approach includes a focus on allocating funds for implementation and evaluation of these gun violence prevention strategies at the federal, state, and local levels. Funds should be allocated to train the proper stakeholders to ensure that new policies and programs are properly adopted and achieve measurable and equitable outcomes.
The Public Health Approach to Gun Violence Prevention | 10 The goal of public health is to maximize the overall health and well-being of populations. Public health practitioners do this by developing a wide range of interventions. These interventions address risk and protective factors ranging from factors at the individual level to the societal level. The public health pyramid helps researchers conceptualize the many different levels of intervention needed to address a public health problem like gun violence.³⁴ At the top of the pyramid are narrowly tailored interventions that work with individuals at risk for gun violence. These interventions, like lethal means safety counseling and violence intervention programs, can have a tremendous impact in reducing gun violence. Yet, they also require individual action. These programs provide the tools and support to change behavior, but the individuals themselves must be willing to take action and change behavior.
The middle of the pyramid includes interventions that require less individual action. They are often laws and policies that change the environments within communities to mitigate risk factors. One such policy is universal background checks and firearm licensing. Research shows that when individuals are required to undergo a background check and obtain a license to purchase a firearm, far fewer firearms are diverted into illegal markets and used to perpetrate violence.
At the bottom of the public health pyramid are the conditions within society that lead to poor health outcomes like gun violence. These factors are often referred to as the root causes or social determinants of health. Socioeconomic factors, such as racial disparities, inequality, poverty, inadequate housing and education, are all risk factors for interpersonal gun violence. Policies that address these root causes have enormous potential to reduce gun violence and improve health. These policies, while requiring a broad collective effort to achieve, require minimal individual effort to be effective at reducing gun violence.
The health impact pyramid helps researchers
conceptualize the many different levels of
intervention needed to address a public
health problem like gun violence.
Source: Adapted from Frieden TR. (2010). A
framework for public health action: the health
impact pyramid. American Journal of Public Health.
Health Impact Pyramid
The Public Health Approach to Gun Violence Prevention | 11 By using a comprehensive public health
approach to car safety, the United States
reduced per-mile driving deaths by
nearly 80% from 1967 to 2017.
The public health approach is multifaceted and comprehensive and brings together institutions and experts across disciplines in a common effort to develop a variety of evidence-based interventions.³⁵ This comprehensive approach to tackling public health crises in America has been used over the last century to eradicate diseases like polio, reduce smoking deaths, and make cars safer. This public health approach has saved millions of lives. We can learn from public health successes – like car safety – and apply these lessons to preventing gun violence.
Applying the public health successes of car safety to prevent gun violence: One of the greatest American public health successes is our nation’s work to make cars safer.
By using a comprehensive public health approach to car safety, the United States reduced per-mile driving deaths by nearly 80% from 1967 to 2017.³⁶ This public health approach to car safety prevented more than 3.5 million deaths over these fifty years.³⁷ To reduce gun violence, we should apply this same time-tested public health approach.
How Do We Address Gun
Violence Through the
Public Health Approach?
Source: National Traffic Highway Safety
Administration (NTHSA). Motor Vehicle Traffic
Fatalities and Fatality Rates, 1899-2017.
ALLOCATE
REGULATE
LICENSING
REGISTRATION
PROHIBIT RISKY
PEOPLE
MANUFACTURING
STANDARDS
AGE
REQUIREMENTS
LICENSING
RENEWAL
ONGOING
MONITORING
AND REGULATION
LIABILITY
Preventing Car Crashes Preventing Gun Deaths
Allocate funds to study the
epidemic of motor vehicle crashes.
Federal agencies regulate car
manufacturers and ensure car
safety.
Drivers must submit an application
and pass a test to obtain a driver’s
license.
Car registration is required at each
point of sale.
Reckless and drunk driving laws
ensure that risky individuals do
not endanger others on the road.
Manufacturers are required to
make safer cars by installing seat
belts and airbags.
Age requirements for obtaining
a driver’s license, including a
graduated licensing system
(driver’s permit) for young drivers.
Drivers are required to renew their
license periodically.
New models of cars are monitored
and regulated, and recalls are
issued for unsafe models.
Manufacturers are held liable if
they sell a dangerous vehicle.
Allocate funds to the CDC and the NIH to research
gun violence.
Allow federal agencies to regulate firearm man -
ufacturers and ensure gun safety.
Require firearm purchasers to submit an applica-
tion, undergo a background check, and take safety
education to obtain a license to own a firearm.
Pass firearm registration laws to ensure that fire -
arms are registered at each point of sale.
Expand firearm prohibitions to include individuals
who are at elevated risk for violence.
Require manufacturers to make fireams safer,
including requiring that guns be outfitted with
microstamping technology.
Enact stronger age requirements for owning or
possessing all types of firearms.
Require gun owners to renew their license on a
routine basis.
Allow Consumer Product Safety Commission to
regulate safety of firearms and ensure industry
accountability.
Repeal the Protection of Lawful Commerce in
Arms Act (PLCAA) to hold firearm manufacturers
accountable for dangerous and reckless distribu -
tion of firearms.
Applying the Public Health Successes
of Auto Safety to Gun Violence Prevention
The Public Health Approach to Gun Violence Prevention | 13 1. Better Data Collection
2. Research Funding
3. Evidence-based policies and practices
4. Implementation and evaluation
Public health is the science of reducing and preventing injury, disease, and death and promoting the health and well-being of populations through the use of data, research, and effective policies and practices.
The public health approach has been successfully applied to tackle a wide variety of complex health problems at the population level. Gun violence is a public health epidemic that requires a public health solution. Based on the four steps of the public health approach to prevent gun violence, we recommend the following:
Recommendations
Federal, state, and local governments should collect more comprehensive gun violence data for fatal and nonfatal firearm injuries, shootings that may not involve physical injuries, and firearm-involved crimes where no shots were fired, including domestic violence-related threats. Federal, state, and local governments should make data publicly available where possible and particularly to researchers studying gun violence and its prevention.
Enhanced research funding is key for advancing knowledge and improving public health interventions and outcomes. Federal, state, and local governments, in addition to foundations and universities, should dedicate funding to research gun violence prevention.
Gun violence takes many forms and is a multifaceted problem that requires a multitude of data-driven solutions. Gun violence prevention policies and practices should be evidence-based.
Policies and practices should be continuously monitored and evaluated to ensure equitable implementation and ongoing effectiveness.
The Public Health Approach to Gun Violence Prevention | 14 Resources
Research
• Allchin A, Chaplin V, & Horwitz J. (2019). Limiting access to lethal means: applying the social ecological model for firearm suicide prevention. Injury Prevention. • Branas CC, Flescher A, Formica MK, Galea S, Hennig N, Liller KD ... & Ying J. (2017). Academic public health and the firearm crisis: an agenda for action.
American Journal of Public Health.
• Decker MR, Wilcox HC, Holliday CN, & Webster DW. (2018). An integrated public health approach to interpersonal violence and suicide prevention and response. Public Health Reports.
• Cook PJ. Expanding the public health approach to gun violence prevention. (2018). Annals of Internal Medicine.
• Hemenway D & Miller M. (2013). Public health approach to the prevention of gun violence. New England Journal of Medicine.
• McGinty EE, Siddiqi S, Linden S, Horwitz J, & Frattaroli S. (2019). Improving the use of evidence in public health policy development, enactment and implementation: a multiple-case study. Health Education Research. • Mozaffarian D, Hemenway D, & Ludwig DS. (2013). Curbing gun violence: lessons from public health successes. Journal of the American Medical Association. • Maa J & Darzi A. (2018). Firearm injuries and violence prevention—The potential power of a Surgeon General’s report. New England Journal of Medicine. • Rajan S, Branas CC, Hargarten S, & Allegrante JP. (2018). Funding for gun violence research is key to the health and safety of the nation. American Journal of Public Health.
• Zeoli AM & Webster DW. (2019). Firearm policies that work. Journal of the American Medical Association.
Resources
• AFFIRM
• American Psychological Association: Gun Violence
• American Public Health Association: Gun Violence
• CDC Infographic: The Public Health Approach to Violence Prevention • FACTS Consortium
• Harborview Injury Prevention & Research Center
• Johns Hopkins Center for Gun Policy and Research
• Reducing Gun Violence in America: Informing Policy with Evidence and Analysis • Robert Wood Johnson Foundation: Gun Violence, a Public Health Epidemic • Rutgers Center on Gun Violence Research
• Society for Advancement of Violence and Injury Research (SAVIR) • Society for Public Health Education: Gun Violence Resolution • University of California Firearms Violence Research Center (UCFC) and BulletPoints Project
The Public Health Approach to Gun Violence Prevention | 15 About the
Educational Fund
to Stop Gun Violence
The Educational Fund to Stop Gun Violence (Ed Fund) seeks to make gun violence rare and abnormal. Founded in 1978, the Ed Fund is a nonprofit organization that makes communities safer by translating research into policy to prevent gun violence and engaging impacted communities in the policy making process. The Ed Fund is the gun violence prevention movement’s premier research intermediary and founder of the Consortium for Risk-Based Firearm Policy, a group of researchers and experts who collaborate to develop innovative recommendations for policymakers.
The Ed Fund’s affiliate organization, the Coalition to Stop Gun Violence, has advocated for stronger gun laws since 1974. Together, they have paved the way for the gun violence prevention movement to advance research and support evidence- based gun violence prevention programs and policies.
Contributors
Suggested Citation
The Ed Fund would like to thank Ari Davis, Dakota Jablon, Lisa Geller, Vicka Chaplin, Adelyn Allchin, Bryan Barks, Lauren Footman, and Josh Horwitz for their contributions to the development of this report.
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⁹ Centers for Disease Control and Prevention, National
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Citations