Journal of the American College of Surgeons

All too often the community of firearm owners in the US are approached as part of the firearm injury problem, and less commonly as part of the solution.37 Many healthcare organizations have called for using a public health approach to address the epidemic of firearm-related violence, and a key element of this approach is broad community engagement.^38-40 The degree of community engagement can make a critical difference in the efficacy of a public health and/or a healthcare program. Although Americans may disagree about the role of firearms in our society, a significant majority agree that action should be taken to eliminate firearm injury. Developing an inclusive strategy that engages a broad set of stakeholders, including firearm owners, while approaching the issue with equipoise and pragmatism, is more likely to lead to effective community engagement, coalition building, and more effective programs and legislation.

The ACS Committee on Trauma has pursued a broadly inclusive strategy that takes in all points of view to develop a consensus-based approach within a public health framework.⁴¹ This strategy led to the development of a “common narrative” that acknowledges both the constitutional right to keep and bear firearms and the critical and significant problem of intentional firearm violence in the US. This approach focuses on working together to fully understand and address the underlying root causes of violence, while simultaneously working to make firearm ownership as safe as possible (for both firearm owners and those who do not own a firearm). This inclusive and comprehensive approach has led to a range of strategies, such as promoting responsible and safe firearm ownership, implementing community and hospital-based violence intervention strategies, increasing high-quality firearm injury prevention research, enhancing access to mental healthcare, and engaging in bipartisan advocacy and policy change. This approach is supported by a very large proportion of US ACS members, as evidenced by a survey of the entire US ACS membership and detailed analysis of the subset of ACS members who keep firearms in their homes (42%).⁴² Three-quarters of firearm-owning surgeons have handguns in their home and keep firearms for self-defense/protection.⁴³ The results of this survey demonstrated a diversity of views, but, in general, ACS members, including those who own firearms, support most initiatives and policies related to firearm injury prevention (eg federal funding for firearm injury research, implementing proven injury prevention programs, preserving healthcare workers’ right to counsel patients about firearm safety, and enhancing and strengthening mandatory background checks).

At the outset of the COVID-19 pandemic there was a surge in firearm sales, predominantly handguns, likely motivated by concerns about civil unrest and personal safety.⁴⁴ Americans who buy firearms for personal protection may do so to help manage psychological threats that come from a belief that the world is a dangerous place and society may not keep them safe.⁴⁵ A recent survey of firearm owners in the US demonstrated that a significant majority (81%) did not view physicians as a trustworthy source of information about firearm safety.⁴⁶ To overcome this barrier several public health scientists have developed innovative ways to create and study partnerships between health professionals and firearm retailers, instructors, and advocates, to implement measures to lower harm for individuals at increased risk of firearm injury. This model of collaboration using firearm owners as experts and as “trusted messengers” has been tried in several states and has been successful largely because firearm owners and the organizations to which they belong are particularly well-suited to delivering firearm and lethal means safety messages in a culturally and technically competent fashion.^37,47,48

One element of the ACS strategic action plan to address firearm violence was the creation of the Firearm Strategy Team (FAST) Workgroup in 2018. This workgroup was charged to develop effective and actionable strategies that, if implemented, could produce a significant and durable reduction in firearm injuries while preserving constitutional freedoms. The membership of this workgroup included a geographically representative sample of surgical leaders who owned firearms. These members had expertise and insight in hunting, competitive shooting, self-defense, law enforcement, and/or had a history of military service.

The FAST Workgroup deliberately focused the discussion on work that could reduce the burden of firearm injuries and preserve the ownership rights of law-abiding Americans. To be included as a recommendation, all 22 members of the group had to agree. Although not representing all firearm-owning surgeons, this group’s initial recommendations addressed ownership, registration, licensure, education and training, ownership responsibilities, mandatory reporting and risk mitigation, safety innovation and technology, research culture of violence, social isolation, and behavioral health in a meaningful way⁴⁹ (Fig. 1).

There was consensus from the participating organizations at the 2022 Medical Summit that engaging firearm owners broadly was an important approach, consonant with both community engagement and garnering bipartisan support for public policy approaches to lessen the burden of firearm injury. Several groups expressed interest in repeating the ACS survey of firearm injury prevention within their own organization to better understand member attitudes and behaviors surrounding firearms and to better inform organizational efforts on this topic. There was also strong support for creating a multidisciplinary FAST Workgroup with participation of firearm-owning members from each of the medical organizations that participated in the medical summit. This group could identify and endorse pragmatic prevention approaches based on the best available evidence, and then take these measures to others in firearm-owning communities for endorsement and dissemination.

SESSION 2: ADDRESSING COMMUNITY VIOLENCE

Social determinants of violence

Addressing the social determinants of health was cited as an important public health intervention during the 2019 Firearm Injury Prevention Summit.¹ After that first summit, the ACS established a multidisciplinary working group called Improving Social Determinants to Attenuate Violence (ISAVE) to develop strategies for firearm injury prevention in this context.

The social determinants of health are the nonmedical factors that influence health. The World Health Organization defines social determinants of health as the conditions in which we are born, grow, live, work, and age and the wider set of forces and systems shaping the conditions of daily life.⁵⁰ They represent significant root causes of health inequities. Included in the specific factors that have a positive or negative impact on health, depending on the community and individual, are income, employment, education, food insecurity, housing, and social inclusion.

The broad impact on violence and other chronic disease states can be illustrated by starting with an original redlining map of a particular city and overlaying maps of structural factors such as power plants along with the incidence of firearm violence and homicide, obesity, childhood asthma, food deserts, early cardiopulmonary disease, early sequelae of poorly controlled diabetes, and low life expectancy.⁵¹ This overlap, coupled with a high area deprivation index, demonstrates the impact of social and structural determinants of health at all stages in life and across communities.

Trauma centers and healthcare systems are essential in treating the downstream physical and psychosocial consequences of the social determinants of health. ISAVE’s charge was to outline strategies to move upstream, working in partnership with marginalized communities and municipalities, to address the root causes of violence. ISAVE identified 4 areas of opportunity to address social determinants of health: (1) develop and implement a Trauma Informed Care curriculum; (2) identify strategies for integration of psychosocial care into trauma care (such as hospital- and community-based violence intervention programs); (3) support investment by healthcare organizations in disenfranchised communities the organization serves; and (4) advocacy for support of the 3 strategies.⁵²

The Substance Abuse and Mental Health Services Administration has outlined the importance of a trauma-informed approach to the care of patients in general. This approach acknowledges that “trauma” includes both physical and psychosocial injury and requires an understanding that many injured by violence may have a life-long struggle with adverse childhood events,⁵³ previous trauma, living in unsafe environments, and toxic stress. Trauma Informed Care introduces an approach that acknowledges these life-long struggles and establishes a method that addresses implicit bias, creating an environment for our patients that promotes equity, sensitivity of broader needs, and empowerment. A curriculum has been developed that includes trauma-informed principles and segments that address specific community inequities along with the provider risk of secondary trauma. Pilots of the course will occur in 14 trauma centers across the US in late 2022 and 2023 and inform the development of a dedicated Trauma Informed Care chapter for the next edition of the Advanced Trauma Life Support Course.

The social care construct acknowledges that, alongside standard medical and surgical practice, the trauma center can serve an important role in addressing immediate and longer-term social and mental health needs. This construct has been developed to improve patient-reported outcome measures⁵⁴ by enhancing an individual’s life course after injury. An example would be hospital-based violence intervention programs (HVIPs) in which credible messengers, also referred to as lived experience experts, are incorporated into the trauma service as Violence Prevention Professionals. They develop long-term relationships with violently injured individuals and work to address unmet psychosocial and mental health needs long after discharge.^55-59 More than 40 programs now exist across the country. The Health Alliance for Violence Intervention (HAVI)⁶⁰ has developed Standards and Indicators for HVIPs to aid in maintaining the fidelity, best practices, and sustainability of these programs. Comprehensive care clinics and family justice centers are also models for addressing psychosocial care needs and may be implemented in conjunction with HVIPs.

Moving further upstream involves addressing socioeconomic inequities in communities plagued with violence. This includes closing the racial wealth gap as a key strategy in reducing health disparities.⁶¹ Trauma centers and health systems can play a role by investing in communities in a number of ways: sourcing consumables such as cafeteria food from disenfranchised local proprietors, offering vocational training and job opportunities to local community members, and investing in housing and other forms of infrastructure. Leveraging opportunities through community needs assessment can springboard efforts. Institutions can make earnest commitments by joining organizations such as the Healthcare Anchor Network (https://healthcareanchor.network).

These 3 ISAVE strategies are critical solutions requiring clear lines of stakeholder communication that ensure effective and inclusive advocacy. An example has been advocacy supporting bills at the state level that allow the Centers for Medicaid and Medicare Services to cover the fee for service of violence prevention professionals in HVIPs. Such legislation has been passed in 5 states to date.⁶² Advocacy for incorporating best practice in trauma-informed care is another critical area that ISAVE endorses.

ISAVE strategies are focused on the trauma center’s role in addressing root causes of violence to improve long-term outcomes and positively alter the life course of injured patients. The strategies provide excellent opportunities in developing more comprehensive care for our patients and ultimately the communities we serve.

Perspectives from the health alliance for violence intervention

The HAVI underscored the urgency of addressing community violence, discussed HVIPs as a core evidence-informed community violence intervention (CVI) strategy, and highlighted the broad support that CVI methods have recently received.⁶⁰ The HAVI is working to heal cycles of systemic and interpersonal violence through the advancement of HVIPs. HVIPs are multidisciplinary programs that combine the efforts of medical staff with trusted community-based partners to provide safety planning, case management services, and trauma-informed care to violently injured people to reduce re-injury and promote comprehensive recovery. The HAVI currently supports more than 85 cities with high rates of violence in building community and hospital partnerships.⁶⁰

There is a growing body of research that demonstrates the importance of CVI strategies guiding further research that leverages dynamic systems modeling to capture the impact of violence intervention ecosystems.⁶³ A single intervention cannot reverse group- and structural-level patterns of violence, but a constellation of effective interventions and policy change can. Recently, a national consortium of researchers serving as The John Jay College Research Advisory Group conducted a meta-analysis of the existing academic literature on community violence intervention. The advisory panel offered recommendations focused on strategies to reduce violence by using health approaches, including the deployment of CVI models, such as HVIPs, working in concert to address community violence.⁶⁴

Scientific inquiry, successful CVI demonstration, contemporary social forces, and current events have coalesced to create national interest in HVIPs and broader community violence interventions. Community violence intervention is covered by national media, included in bipartisan legislation at the federal and state level, and supported by the public based on recent HAVI/Data for Progress polling.⁶⁵ Healthcare organizations can capitalize on this momentum and collaborate across sectors to end community violence.

Advancing community place-based violence prevention strategies: the Cardiff Model

Urban communities have an opportunity to clearly define the scope and nature of violence prevention by breaking down the silos that exist within neighborhoods to make communities safer. It is essential to establish relationships that are grounded in trust and to promote collaboration across sectors. This multifaceted approach across sectors is predicated on developing a trusting partnership that results in healthcare systems, community organizations, public health departments, businesses, law enforcement, and other sectors of civil society. Such partnerships will position communities to identify and evaluate areas most in need of place-based intervention strategies through real-time geocoding of time, place, and day of violence occurrence.

The Cardiff Model⁶⁶ has demonstrated that partnering across sectors enables a comprehensive approach for tackling this public health burden through data sharing, collaboration, and effective implementation of solutions at the right time and the right place.⁶⁷ The Model originated in Cardiff, Wales, with leadership from Jonathan Shephard, MD, a maxillofacial surgeon. He recognized that by further informing when and where assault injuries occurred, there were opportunities for collaborating and developing place-based prevention strategies. He further recognized that law enforcement agencies do not know about all of the assault events that occur within their jurisdictions and that emergency department information from patients who present with assault injuries (de-identified to name/address) would further inform the community about when/where assaults occur.⁶⁸ By combining the 2 sets of information (law enforcement and emergency department), the community can develop and evaluate place-based interventions to prevent assaults.⁶⁹

Evaluation of this model has demonstrated a 30% to 40% reduction in violence related admissions compared with other cities during the same time period (2003 to 2007).^70,71 The CDC has developed a toolkit⁷² to help provide guidance in operationalizing this model throughout the US. Currently, it is being implemented in West Allis and Milwaukee, Wisconsin, as well as Atlanta, Georgia. Implementation is also being explored in St Louis, Denver, and Philadelphia.

Community engagement programs: the Temple University experience

Recognizing the role that young people play in both violent perpetration and victimization, there are numerous examples of how healthcare systems have engaged the surrounding community. One example in Philadelphia is the Cradle to Grave Program. Launched in 2006 from Temple University’s level 1 Trauma Center, the program used both hospital and medical school resources to educate at-risk youth about the physical, emotional, and social consequences of gun violence. At the same time, young people are provided a glimpse into the clinical aspects of the public health crisis we face. By bringing at-risk young people into the hospital as students, the program seeks to reduce the likelihood that they will return as patients. Since inception, more than 14,000 young people have participated in this program. Program evaluation has demonstrated effectiveness in improving young people’s attitudes toward reducing violence.⁷³

This program highlights the important role that hospitals play, particularly those in urban settings, in tackling firearm-related violence. Hospital–community partnerships that extend to schools, juvenile justice organizations, and local stakeholders have a unique ability to educate community members about firearm-related injury, similar to population-based education about other public health crises. Ensuring that there is both community input and consistent community member participation in developing solutions is critical for community buy-in and trust. Proactive healthcare organization community violence prevention programs complement hospital-based violence prevention and intervention programs. To address the issue in a meaningful and lasting way, healthcare institutions must ultimately take on the work of dismantling the inequity and injustice that lie at the heart of the structural violence that impacts communities across the nation.

Project Inspire: a model for mentorship for at-risk youth, University of South Alabama, Mobile

Project Inspire is a hospital-led, comprehensive intervention that focuses on juvenile’s delinquent of firearm-related crimes. The strategy is to curb firearm-related violence and reduce recidivism by providing at-risk youth with education, exposure, opportunity, and mentorship. This program was created through partnerships between the level 1 Trauma Center at the University of South Alabama hospital, juvenile gun court, Mobile Mayor’s office, and law enforcement. The juvenile gun court selects participants for this program who are first-time gun offenders, ages 13 to 18 years. The program is spearheaded by the level 1 Trauma Center, using the hospital as a venue to engage participants and build trusting relationships.

The goal of Project Inspire is to impact the positive life trajectory of young people who participate. It is well established that adverse childhood experiences are directly related to negative outcomes such as aggressive behavior, alcohol and substance use, and posttraumatic stress disorder.^74,75 Research has also shown that benevolent childhood experiences may counteract the effects of adverse childhood experiences.⁷⁶

The core curriculum consists of 5 pillars: trauma-informed training and confidence building, educational and professional development, financial literacy, entrepreneurship, and career-specific job shadowing and mentorship. The program is structured to run during a semester in concert with the public school system calendar schedule. Participants shadow healthcare professionals in several departments within the trauma center and participate on rounds in the trauma intensive care unit. Participants are trained and verified in Basic Life Support and Stop the Bleed. Additionally, they engage in community service projects, develop lived experiences, build resumes, and prepare for job interviews. A significant portion of their time is spent together as a cohort and with their mentors to create a “family environment.” Such comprehensive experience develops relationships that extend far beyond the formal part of the course.

Building a regional coalition, University of Washington, Harborview Medical Center

Firearm-related violence disproportionately impacts communities of color especially young men and those who are socioeconomically vulnerable.^77-79 Interpersonal violence is often concentrated in certain areas within communities, and this adversely affects the health and well-being of the those injured, families, and communities at large. It is vital that those living in the communities most impacted by firearm violence be engaged as partners in the development and implementation of solutions that impact their neighborhoods.

Successful hospital-based and hospital-linked violence intervention programs are deeply rooted in the communities these programs serve. These programs offer a comprehensive approach to treating survivors of violence by attempting to address the underlying risk factors for violent injury in a culturally competent fashion. One way to further sustain violence prevention work that cuts across sectors and leverages the talent within communities is to create “Regional Coalitions” within communities. Such coalitions enable a more unified approach to violence prevention by linking existing community organizations with trauma centers. Success will require us to work together and shatter the siloed approach that often exists.

An example of this type of coalition, the Regional Peacekeepers Collective in King County, Washington (https://rp-kc.com), launched in 2021. This collective brings 6 community organizations that work with high-risk youth in King County together with the only level 1 Trauma Center in the area. The goal of the collective is to “prevent and eliminate youth gun violence by ensuring sustainable conditions that allow young people to live and be healthy, happy, hopeful, and thriving.” This collective works collaboratively to: (1) prevent violence from occurring in the first place by engaging with high-risk youth through credible messengers in the community and creating opportunity and alternatives to violence for these youth; (2) provide rigorous intervention for survivors of firearm violence to improve outcomes after injury and to address underlying root causes that contributed to the violence with the ultimate goal of keeping these youth alive, safe, and ideally thriving; (3) providing secondary prevention services for younger siblings of youth injured or killed by gun violence; and (4) provide follow-up care and support for family restoration and community healing. Banding together as a regional collective has built fellowship across healthcare and community organizations; increased the capacity, skills and impact of those doing the work; and forged a deeper commitment to the surrounding region.

There are a number of challenges that exist in successfully executing these types of regional coalitions. Perhaps the most obvious are barriers in trying to operationalize and coordinate efforts across numerous entities that often have their own goals and objectives. These issues may ease over time as coalition relationships are built and trust is established. The other challenge is in consistent funding for violence intervention and prevention efforts. The collaborative approach may be more attractive to funding sources through demonstration of effective resource utilization and results.

Role of healthcare professionals and academic medical centers

All healthcare professionals have a role in firearm injury prevention across their main missions of patient care, education of future healthcare workers, research, and community engagement.⁸⁰ All clinicians who care for patients have the opportunity to identify those at risk of firearm injury and provide counseling to mitigate these risks. These clinical opportunities include, but are not limited to, secure firearm storage, lethal means safety counseling, and family support in the implementation of extreme risk protection programs (that temporarily remove firearms from the home of those at risk for suicide or domestic violence). Health professionals should incorporate firearm injury prevention into the training of the next generation of healthcare professionals.⁷³ Finally, healthcare professionals should advocate for policies and practices that reduce firearm injury and death. Academic medical centers can support a framework for healthcare professionals and their organization at large to engage in firearm injury prevention advocacy and advance research to define best practices for interventions and their implementation.^81,82

Investing in at-risk communities

In urban cities across the US, predictably and disproportionately, low educational attainment, low income, low health status, and higher rates of homicide and violent firearm injuries occur in black and brown neighborhoods. This is largely accepted as the status quo and often not questioned or explored to better understand why the root cause of these social issues impacting neighborhoods exist. These neighborhoods were created by policy-driven practices established in the 1930s that were intended to rebuild America after the economic crisis that followed the Great Depression of 1929. Some Americans were provided opportunities to build wealth, explicitly through home ownership, which remains one of the most common pathways to building generational wealth in America. Policies incentivized developers to build houses by subsidizing them with the caveat that they agreed not to sell or rent them to black people. Maps of cities that were created divided communities and neighborhoods according to property value. They were color coded into blue, green, yellow, and red labels ranging from “best” (blue) to “hazardous” (red). The majority of black people and immigrants lived in red areas and were unable to participate in the wealth-building pathway. They could not access financial services or get mortgages because their communities were deemed to be a risk. Those communities and residents were unable to reach their full potential to build thriving, robust, and sustainable local economies and attain the health and well-being that financial security creates for families.

The impact of redlining has perpetuated itself for decades.⁸³ In 2022, predictably, redlining maps demographically matched outcomes, because it relates to the impact of COVID-19, climate and environmental change, poor health and low income, and the distribution of firearm injury. Traditional interventions to address manifestations of redlining (such as food insecurity, public, or subsidized housing) primarily fill gaps of inequity vs eliminating the inequities. These subsidies are not designed to ensure that people and communities are empowered to gain independence, financial stability, and wealth creation. The lack of sustainability and capacity building inherent to the current design result in people always relying on these limited resources that can make them feel trapped (ie “cliff effect” or restrictions on allowable earned income).

Safety-net hospitals disproportionately treat residents from disinvested communities that have been historically redlined. These healthcare systems also receive a majority of violent firearm-related injuries and deaths. In 2018, Boston Medical Center (BMC) made a commitment to transform after asking the question “What is the role of a safety net hospital? Is it charity exclusively in perpetuity or is it equity?” In recognizing that charity does not change life course trajectory and outcomes, BMC decided to transform with intentionality. The actions aimed to change life course trajectory, enabling patients and communities to change economic lanes in their communities to reach full potential and well-being, including building generational wealth. The effort extends beyond BMC through collaborations with multisector partners, including other healthcare systems. The 4 primary areas of focus are: (1) economic mobility and wealth-building ecosystems, (2) community revitalization, (3) health equity accelerator, and (4) community engagement. Economic mobility projects include local workforce development and financial education, intentionality in decision making for hiring, investment and procurement, and active participation in gap funding for small businesses. Community revitalization is focused on investing in community land trusts and affordable housing. The health equity accelerator project seeks to proactively identify equity gaps within our institution and close them expeditiously. This includes establishing standard procedures and removing subjective decision making that data have shown to drive inequitable outcomes. Finally, BMC’s community engagement includes an equity partnership network that engages community groups to inform decision making in all pillars of this work.

Leveraging the resources of healthcare systems

The healthcare industry, and health systems, must take an active leadership role to reduce firearm deaths and injuries. Healthcare leaders must prioritize firearm-related violence prevention through organizational commitments similar to other leading causes of death, such as heart disease and cancer. After many years of relative silence, healthcare systems have reached a turning point as more and more leaders are acting to stem the tide of violence. Collectively, healthcare system leaders have been troubled by the reality that firearms surpassed motor vehicle crashes as the leading cause of death^84,85 among American children and adolescents. The horrific mass shootings in Uvalde, Texas, and Buffalo, New York, in May 2022 weighed heavily on our collective conscience—as well as members of Congress.

Healthcare professionals understand that “good health” goes beyond the delivery of acute healthcare services. Ensuring the health and well-being of communities means ensuring the ability for people to attain employment, being able to walk down the street without the fear of being shot, and living in neighborhoods where livelihood is not dependent on zip code. To tackle the social issues that marginalized communities face, we must define health more broadly than has traditionally been done.

Healthcare professionals can play a critical role to change the narrative around firearm-related violence and have demonstrated that it is possible to depolarize an issue traditionally viewed as a political controversy. Focusing on a public health and medical approach has shifted the narrative to prevention of firearm-related injury, death, and disability. This has transformed an issue once viewed as “radioactive” to one that is “attractive” for healthcare system engagement. Healthcare systems should capitalize on the power of dialogue and continue to re-frame and approach firearm-related violence as a public health issue. Healthcare systems can create a center or organized effort around firearm violence prevention through community partnerships. Many of these strategies are no different than what other corporations⁸⁶ across the US employ.

There are many positive examples of this approach. As part of an ongoing effort to advance firearm safety, education, violence prevention and research, numerous examples across the country have been mobilizing to incorporate a comprehensive approach to violence prevention through health system–community partnerships.

Health system leaders have the ability to focus on the science of injury prevention⁸⁷ and concentrate efforts to reduce the daily toll of firearm violence that is disproportionately impacting marginalized communities. It is critically important that our nation’s hospitals and health systems support and work collaboratively with leaders of violence intervention programs, who understand the root causes of firearm violence within their communities. This includes supporting local community-based organizations and violence intervention programs and prioritizing the development of systemwide hospital-based violence intervention grounded in trauma-informed care principles.

Another crucial area of support is advocating for well-supported and robust firearm injury prevention research, similar to how health systems have led the way in driving research funding for heart disease, cancer, and sepsis. This includes not only leveraging federal funding, but committing to bolster funding through health system resources, philanthropy, and other foundations that have supported firearm injury prevention research.

Healthcare organizations can also lead by implementing evidence-based strategies that reduce firearm injury at the system level. This includes empowering healthcare professionals with the knowledge and skills to counsel patients on firearm safety, while also facilitating partnerships with other trusted messengers. Other opportunities are to improve integration with health system community partners by providing gun locks, secure firearm storage recommendations, and other firearm injury prevention initiatives.

Several health systems have become actively engaged in firearm violence prevention efforts, appointing champions to lead efforts within their institutions and backing them with the necessary resources. By supporting these types of programs, health systems—and the business community in general—have the opportunity to demonstrate organizational commitment on this issue, empower staff and frontline healthcare workers to become agents of change, and emphasize to individuals, families, and organizations that healthcare systems are actively pursuing solutions to make communities safer.

SESSION 3: EFFECTIVE HEALTHCARE SECTOR COMMUNICATION ON FIREARM INJURY PREVENTION

The ability to communicate effectively with patients, colleagues, and communities is at the core of tackling the complex health problems. Although we recognize the importance of science as the foundation of evidence-based solutions, communicating the data and statistics alone is not enough. Effectively and accurately communicating the impact of firearm violence on our patients, families, and communities is critical to motivating action that reduced the burden of firearm-related injury and violence.

Elements of successful communication include the words, tone, nonverbal communication, and, perhaps most important, storytelling. This session was opened by Gita Pullapilly, a Hollywood writer and film director, who made the case for healthcare and injury prevention professionals being able to tap into their role as storytellers⁸⁸ and proposed a 7-step roadmap: (1) grab people’s attention from the start; (2) show them a new perspective; (3) do not judge or preach; (4) get personal; (5) endings matter; (6) leave them wanting more; and (7) prompt them to take action.

Using methods of message communication in a way that can be tailored to the audience (eg patients, policy makers, and community) facilitates a data-driven approach. Communication is an essential part to any aspect of the multifaceted strategy required to tackle any complex public health problem.

How the language of firearm injury influences injury prevention

Violence prevention interventions—whether one-on-one counseling or large-scale public campaigns—must consider the audience, messenger, and message. Firearm owners and families are heterogeneous, with varied demographics, reasons for firearm ownership, firearm handling and storage practices, cultural practices, and views about violence risk and prevention. Although firearm ownership is still highest among white heterosexual men, other demographic groups are also key audiences in the development and dissemination of firearm injury prevention interventions. These audiences may respond better to tailored messaging⁸⁹ and to relatable messengers. Communicating with broad audiences and demographic subsets at greater risk of injury are important strategies to effective injury prevention. Research on trusted messengers for firearm suicide prevention found that family members, law enforcement, and veterans/military service members were seen as the most credible messengers, with celebrities and physicians as the least credible^90,91 (acknowledging variation among owner subgroups).

The framing of messages—the words used can also affect how the content is received. For example, in firearm suicide prevention, work has found that the term “means safety” is preferred to “means restriction,” because restriction suggests punitive or legal action.⁹² Messaging to firearm owners may be better received if it appeals to an individual’s identity and core values as a firearm owner (eg culture of safety and responsibility) and uses neutral terms.⁹³ In 2022, a multidisciplinary group of experts suggested key terms to use (and avoid) for firearms, firearm suicide, and community violence.⁹⁴ Recommendations included: “secure firearm storage” (rather than “safe firearm storage”); “die by” rather than “commit” suicide; and “communities disproportionately affected by violence” rather than “inner cities” or “urban communities.” A full list of terminology is available online.⁹⁴ Additional research around communication, testing of varied messages, and those who might be the most effective messengers may help increase the likelihood of impactful interventions.

Counseling patients on firearm safety: closing the gap

Considering the role healthcare professionals have played in addressing numerous public health problems over the years, it is clear no single solution exists. Empowering clinicians with the knowledge and skills to discuss firearm safety has similar importance to clinician engagement in counseling for obesity, smoking, substance use, and preventive health. In 2015, 66% of 4,000 Americans surveyed indicated that it is at least sometimes appropriate for healthcare professionals to speak with their patients about firearm safety. Responses varied by firearm ownership status. Of those who believe a healthcare professional discussing firearm safety was at least sometimes appropriate, 54% were firearm owners.⁹⁵

Despite clinicians recognizing the importance of discussing firearm safety, when patients are asked whether any healthcare professional had ever discussed firearm safety, only 7.5% of adults who live in a home with a firearm had ever received safety advice from a clinician.⁹⁶ Among US veterans that percentage was only slightly higher at 9.2%.⁹⁷

To increase screening as a component of risk reduction from firearm-related injury, it is critical to close this practice gap. Several barriers to counseling exist, including lack of time in clinical encounters, discomfort on the part of those clinicians who are not knowledgeable about firearms, fear of offending or alienating patients, and inadequate resources to support counseling.⁹⁸ An additional barrier is lack of familiarity with legal protections for healthcare professionals. There are no state or federal statutes prohibiting healthcare professionals from asking about firearm access when the information is relevant to preserving the health of the patient or family.

Understanding existing resource and time constraints, there has been discussion about how best to screen patients. One option is to consider whether clinicians should use a risk-based screening tool for firearm safety or employ universal screening. Ongoing research regarding optimal counseling will provide guidance as to how best to proceed.

For clinicians who want to increase their knowledge and confidence, there are courses on effective counseling of patients on firearm safety, some of them providing free online continuing medical education. One example is the Bullet Points Project. Learners (n = 150) participated in a 45-minute video on firearm-related injury and death, and the proportion of learners who felt confident to counsel patients increased from 39% to 93%.⁹⁹ Similarly, after participating in a simulation-based educational program that trained psychiatry, internal medicine, and pediatric residents and fellows, only 4% responded at completion of being uncomfortable with counseling compared with 60% who initially stated discomfort with counseling patients on firearm safety.¹⁰⁰

Healthcare professionals can play an important role in screening and counseling patients on firearm safety and injury prevention. As trusted health professionals, we must gain cultural and technical competence and leverage that trust to reduce preventable firearm injury, death, and disability.

SUMMIT WORKGROUP REPORTS

Advocacy and health policy

The consensus of the Advocacy and Health Policy Workgroup at the second Summit was that the represented professional organizations should work to establish an ongoing coalition that would develop specific policy goals at both the state and federal level. This would leverage advocacy resources from multiple healthcare organizations to develop a clear strategy and remain consistent in message. A multidisciplinary firearm strategy team should be established with relevant stakeholders, including firearm owners, to advise the coalition on policy recommendations and the overarching communication strategy. In addition to promoting policy efforts that support firearm safety, there is a clear need to support policy implementation. For example, extreme risk protection orders are only effective if the public and those responsible for their activation are aware of these laws and how to apply them. A coordinated strategy at the state with the opportunity to engage the state chapters of the represented organizations will help move implementation of state laws that reduce firearm injury. The workgroup also recommended grass roots advocacy training for healthcare professionals specific to firearm injury prevention and establishing an online resource repository to support these efforts. Finally, this workgroup sees opportunities to expand the reach of firearm injury prevention activities through public–private partnerships, inclusive of businesses, healthcare organizations, and local governments.

Addressing community violence

The Community Violence Workgroup developed short-, medium-, and long-term goals for the widespread implementation of violence prevention programs (Table 6).