Firearm violence is often framed as a problem of the inner cities and of the criminal justice system. However, this focus may direct attention away from smaller communities that also face firearm violence, including suicide. Ten years ago, the Firearm and Injury Center at Penn (FICAP) developed and implemented a model program in three smaller cities, using trauma centers to spearhead community partnerships. This Issue Brief describes the development and implementation of these partnerships, and highlights one community’s ongoing activities to reduce firearm injury

Branas, Charles

Richmond, Therese S

Schwab, C William

English

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics10-25-2004Trauma Center-Community Partnerships toAddress Firearm Injury: It can be DoneTherese S. RichmondUniversity of Pennsylvania, terryr@nursing.upenn.eduCharles BranasUniversity of Pennsylvania, cbranas@upenn.eduC William SchwabFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/46For more information, please contact repository@pobox.upenn.edu.Richmond, Therese S.; Branas, Charles; and Schwab, C William. Trauma Center-Community Partnerships to Address Firearm Injury:It can be Done. LDI Issue Briefs. 2004; 10 (1). http://ldi.upenn.edu/brief/trauma-center-community-partnerships-address-firearm-injury-it-can-be-doneTrauma Center-Community Partnerships to Address Firearm Injury: It canbe DoneAbstractFirearm violence is often framed as a problem of the inner cities and of the criminal justice system. However,this focus may direct attention away from smaller communities that also face firearm violence, includingsuicide. Ten years ago, the Firearm and Injury Center at Penn (FICAP) developed and implemented a modelprogram in three smaller cities, using trauma centers to spearhead community partnerships. This Issue Briefdescribes the development and implementation of these partnerships, and highlights one community’songoing activities to reduce firearm injury.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/46Leonard Davis Institute of Health EconomicsLDI Issue BriefVolume 10, Number 1October 2004Therese S. Richmond, PhD,CRNP, FAANLDI Senior FellowAssociate Professor of Trauma andCritical Care NursingSchool of NursingResearch Director, Firearm &Injury Center at Penn (FICAP)Charles C. Branas, PhDLDI Senior FellowAssistant Professor, Biostatistics &EpidemiologyC. William Schwab, MD, FACSProfessor of SurgerySchool of MedicineDirector, FICAPUniversity of PennsylvaniaDespite the impact offirearm injury, smallercommunities do notrecognize firearm violence astheir problemContinued on next page.Trauma Center-Community Partnerships toAddress Firearm Injury: It Can Be DoneEditor’s Note:  Firearm violence is often framed as a problem of the innercities and of the criminal justice system.  However, this focus may directattention away from smaller communities that also face firearm violence,including suicide. Ten years ago, the Firearm and Injury Center at Penn(FICAP) developed and implemented a model program in three smallercities, using trauma centers to spearhead community partnerships.  ThisIssue Brief describes the development and implementation of thesepartnerships, and highlights one community’s ongoing activities to reducefirearm injury.Firearm injury is the second leading cause of injury-related death, accounting forroughly 30,000 deaths each year in the U.S.  Although these deaths are preventable,many barriers exist to launching and sustaining prevention efforts, especially outsideof urban areas.• A highly politicized debate about gun rights has polarized individuals andcommunities.  Although all sides in this debate should be interested in reducingfirearm violence, the debate itself often overshadows and complicates efforts tounderstand the nature of firearm injury and possible interventions.• Progress has been hampered by the lack of comprehensive data sources atnational, state, and local levels.  Firearm injury surveillance lags behind well-established data systems applied to motor vehicle crashes.• Media attention is focused on firearms and urban crime.  However, firearmviolence is not restricted to urban areas, and no community or trauma center isuntouched by firearm injury. Gun suicides disproportionately affect Americansoutside of major cities and have managed to outnumber gun murders every yearfor the past two decades in the U.S.Academic trauma researchcenter develops model oftrauma center-communitypartnershipsModel calls for datacollection, communitycoalitions, and communityprofiles of firearm violenceTo overcome some of these obstacles, the Firearm & Injury Center at Penn (FICAP)developed a model of collaboration with smaller communities to help themunderstand firearm violence at the local level and begin to reach consensus onpossible interventions. Known as the Medical Professionals as Advocates Program(MPAP), it features active partnerships between health professionals and communitymembers to address local firearm violence.• This project drew conceptually on the World Health Organization’s SafeCommunities model, which advocates the value of building on structures andorganizations that already exist in communities.• The model used local trauma centers as lead organizations in their communities.Trauma centers were selected because of their clinical focus, and becauseaccreditation guidelines require trauma centers to lead injury prevention activities.• The trauma centers spearheaded efforts to acquire community-specificinformation on firearm injury, and worked with community leaders to framefirearm violence as a public health problem.• Three sites were selected, in counties containing and surrounding three smallcities: Bethlehem, Pennsylvania; Youngstown, Ohio; and Cedar Rapids, Iowa.Each trauma center-based team included a physician director and coordinator whoestablished a local advisory board, collected data, built community coalitions, anddeveloped local plans and initiatives.• The advisory board created a cadre of regional leaders who provided guidance,sought additional advisory board members, identified local funding sources, anddeveloped interventions.• Each site implemented a data collection system by working with medicalexaminers/coroners, law enforcement agencies, and crime laboratories. Linkeddata provided information about the victim, the shooter, the type and source offirearm and bullets, and the context in which the shooting occurred.  For suicides,the data included narratives of suicide notes, family interviews, and policeinvestigations.• The project featured close working relationships among the site teams and FICAPpersonnel to standardize processes.  FICAP provided training in injury preventionand intellectual resources from a variety of academic disciplines (such asepidemiology, nursing, criminology, and public health) to complement thecommunity expertise of the site teams.  FICAP analyzed the data and providedeach site with community-specific profiles of firearm violence.In the first five years (1994-1998), the project collected data from a total of 468neighborhoods that experienced 1,025 intentional deaths from firearms (396 firearmhomicides and 629 firearm suicides).• Profiles showed distinct difference among communities. The Ohio siteexperienced a firearm homicide rate of 12.5 per 100,000 population (farsurpassing the national rate), compared to 2.0 in Pennsylvania and 1.1 in Iowa.Firearm suicide rates among the three sites were virtually identical: between 6.5and 6.8 per 100,000 population (about the same as the national average).Five-year profiles highlightcommunity-specific dataSpotlight on one community:  Bethlehem-Allentown, PennsylvaniaContinued on back.• Detailed mortality data revealed that firearm homicide was consistently associatedwith out-of-home, nighttime activity in neighborhoods where many people werelikely to be coming and going. Conversely, firearm suicide was consistentlyassociated with in-home, daytime activity in out-of-the-way neighborhoods.• Consistent with national data, the handgun was the most common weapon in allfirearm deaths, with semiautomatic pistols being the predominant handgun inhomicides.  Revolvers (a second type of handgun) were the most frequently usedweapon for suicide in Ohio and Pennsylvania, while long guns (rifles andshotguns) were the main weapons used for suicide in Iowa.POLICY IMPLICATIONSLed by St. Luke’s Regional Trauma Center in Bethlehem, PA, this MPAP site exemplifies the results of aneffective trauma center-community partnership.  The program is directed by a trauma surgeon and a sitecoordinator, with the guidance of a 22-member advisory board of community leaders.  Although formalMPAP funding ended in 2004, St. Luke’s continues to fund the site coordinator and the advisory boardremains committed to continuing its efforts.• Local data revealed that half of all homicides occurred in 8% of neighborhoods.  This geographic detailallowed FICAP to map homicide “hotspots.”  These maps guided the advisory board’s strategies forhomicide reduction, including targeted policing, restructured housing policy, and development ofyouth programs.  These strategies have been endorsed by Allentown city officials, and included in afunding proposal to the State’s “Weed & Seed” program (a federal crime-fighting and neighborhoodrevitalization initiative).• Data also corrected community misperceptions and redirected efforts.  For example, at the beginningof the project, local officials assumed the major cause of firearm death in the community was drug-related homicide. Instead, the data showed that suicide was a much larger community problem, with afirearm suicide rate that was more than three times as great as the firearm homicide rate.  The boardidentified a need for an educational campaign focused on suicide prevention, and charged asubcommittee with devising a campaign strategy, starting with adolescent suicide.• Board discussions about suicide prevention highlighted a need to learn more about the effectiveness ofpossible interventions. In response, FICAP analyzed the suicide narratives and identified six majorthemes of suicide risk (mental illness, physical illness, substance abuse, relationship problems,psychosocial factors, and previous attempts).  This “typology of risk” model was used to improve acollective understanding of modifiable risks for suicide, to identify potential points of intervention, andto guide community decision-making.These community case studies demonstrate that trauma centers, when providedresources and support, can function as local firearm injury prevention centers. TheMPAP sites served as catalysts in addressing the politically sensitive issue of firearminjury.  The project underscores the need for detailed data at the neighborhood levelto help communities understand the nature and scope of their firearm injuryproblem.This Issue Brief is based on the following articles: T.S. Richmond, C.W. Schwab, J. Riely, C.C. Branas, R. Cheney, M. Dunfey.Effective Trauma Center Partnerships to Address Firearm Injury: A New Paradigm.  Journal of Trauma, June 2004, Vol. 56, pp.1197-1205; C.C. Branas, T.S. Richmond, C.W. Schwab.  Firearm Homicide and Firearm Suicide: Opposite but Equal.  PublicHealth Reports, March-April 2004, Vol. 119, pp. 114-124.Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104-6218.Janet Weiner, MPH, Associate Director for Health Policy, EditorDavid A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, andsocial and ethical issues that influence how health care is organized, financed, managed, and delivered in the United States andinternationally. The LDI is a cooperative venture among Penn schools including Dental Medicine, Medicine, Nursing and Wharton,and the Children’s Hospital of Philadelphia. For additional information on this or other Issue Briefs, contact Janet Weiner (e-mail:weinerja@mail.med.upenn.edu; 215-573-9374).Nonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue Brief Published by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTED© 2004 Leonard Davis InstituteVisit us on the web at www.upenn.edu/ldi• Local advisory boards are key partners in prevention efforts.  The boards arecrucial to building political support and reflecting community values and beliefs.Advisors can leverage limited resources, enhance community buy-in, reach targetpopulations, and sustain community ownership of firearm injury preventionprograms.• Establishing community partnerships is essential to move from the acquisition ofdata to a broader understanding of firearm injury as a public health problem.Initiatives cannot be imposed on communities that are unaware of a problem orunprepared for change.• The task of data acquisition would be made easier by the implementation of acomprehensive National Violent Death Reporting System (NVDRS). The federalgovernment has funded 13 states to jump-start development of NVDRS, andestimates that it will cost $20 million a year to fully implement the system in allstates. Given the importance of this information in guiding prevention efforts,and the demonstrated ability of communities to use the data, Congress shouldmove quickly to allocate this funding.POLICY IMPLICATIONSContinued

Trauma Center-Community Partnerships to Address Firearm Injury: It can be Done

Kosmopolis

University of Pennsylvania
ScholarlyCommons
Issue Briefs Leonard Davis Institute of Health Economics
10-25-2004
Trauma Center-Community Partnerships to
Address Firearm Injury: It can be Done
Therese S. Richmond
University of Pennsylvania, terryr@nursing.upenn.edu
Charles Branas
University of Pennsylvania, cbranas@upenn.edu
C William Schwab
Follow this and additional works at: http://repository.upenn.edu/ldi_issuebriefs
This paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/46
For more information, please contact repository@pobox.upenn.edu.
Richmond, Therese S.; Branas, Charles; and Schwab, C William. Trauma Center-Community Partnerships to Address Firearm Injury:
It can be Done. LDI Issue Briefs. 2004; 10 (1). http://ldi.upenn.edu/brief/trauma-center-community-partnerships-address-firearm-
injury-it-can-be-done
Trauma Center-Community Partnerships to Address Firearm Injury: It can
be Done
Abstract
Firearm violence is often framed as a problem of the inner cities and of the criminal justice system. However,
this focus may direct attention away from smaller communities that also face firearm violence, including
suicide. Ten years ago, the Firearm and Injury Center at Penn (FICAP) developed and implemented a model
program in three smaller cities, using trauma centers to spearhead community partnerships. This Issue Brief
describes the development and implementation of these partnerships, and highlights one community’s
ongoing activities to reduce firearm injury.
License
This work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.
This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/46
Leonard Davis Institute of Health Economics
LDI Issue Brief
Volume 10, Number 1
October 2004
Therese S. Richmond, PhD,
CRNP, FAAN
LDI Senior Fellow
Associate Professor of Trauma and
Critical Care Nursing
School of Nursing
Research Director, Firearm &
Injury Center at Penn (FICAP)
Charles C. Branas, PhD
LDI Senior Fellow
Assistant Professor, Biostatistics &
Epidemiology
C. William Schwab, MD, FACS
Professor of Surgery
School of Medicine
Director, FICAP
University of Pennsylvania
Despite the impact of
firearm injury, smaller
communities do not
recognize firearm violence as
their problem
Continued on next page.
Trauma Center-Community Partnerships to
Address Firearm Injury: It Can Be Done
Editor’s Note:  Firearm violence is often framed as a problem of the inner
cities and of the criminal justice system.  However, this focus may direct
attention away from smaller communities that also face firearm violence,
including suicide. Ten years ago, the Firearm and Injury Center at Penn
(FICAP) developed and implemented a model program in three smaller
cities, using trauma centers to spearhead community partnerships.  This
Issue Brief describes the development and implementation of these
partnerships, and highlights one community’s ongoing activities to reduce
firearm injury.
Firearm injury is the second leading cause of injury-related death, accounting for
roughly 30,000 deaths each year in the U.S.  Although these deaths are preventable,
many barriers exist to launching and sustaining prevention efforts, especially outside
of urban areas.
• A highly politicized debate about gun rights has polarized individuals and
communities.  Although all sides in this debate should be interested in reducing
firearm violence, the debate itself often overshadows and complicates efforts to
understand the nature of firearm injury and possible interventions.
• Progress has been hampered by the lack of comprehensive data sources at
national, state, and local levels.  Firearm injury surveillance lags behind well-
established data systems applied to motor vehicle crashes.
• Media attention is focused on firearms and urban crime.  However, firearm
violence is not restricted to urban areas, and no community or trauma center is
untouched by firearm injury. Gun suicides disproportionately affect Americans
outside of major cities and have managed to outnumber gun murders every year
for the past two decades in the U.S.
Academic trauma research
center develops model of
trauma center-community
partnerships
Model calls for data
collection, community
coalitions, and community
profiles of firearm violence
To overcome some of these obstacles, the Firearm & Injury Center at Penn (FICAP)
developed a model of collaboration with smaller communities to help them
understand firearm violence at the local level and begin to reach consensus on
possible interventions. Known as the Medical Professionals as Advocates Program
(MPAP), it features active partnerships between health professionals and community
members to address local firearm violence.
• This project drew conceptually on the World Health Organization’s Safe
Communities model, which advocates the value of building on structures and
organizations that already exist in communities.
• The model used local trauma centers as lead organizations in their communities.
Trauma centers were selected because of their clinical focus, and because
accreditation guidelines require trauma centers to lead injury prevention activities.
• The trauma centers spearheaded efforts to acquire community-specific
information on firearm injury, and worked with community leaders to frame
firearm violence as a public health problem.
• Three sites were selected, in counties containing and surrounding three small
cities: Bethlehem, Pennsylvania; Youngstown, Ohio; and Cedar Rapids, Iowa.
Each trauma center-based team included a physician director and coordinator who
established a local advisory board, collected data, built community coalitions, and
developed local plans and initiatives.
• The advisory board created a cadre of regional leaders who provided guidance,
sought additional advisory board members, identified local funding sources, and
developed interventions.
• Each site implemented a data collection system by working with medical
examiners/coroners, law enforcement agencies, and crime laboratories. Linked
data provided information about the victim, the shooter, the type and source of
firearm and bullets, and the context in which the shooting occurred.  For suicides,
the data included narratives of suicide notes, family interviews, and police
investigations.
• The project featured close working relationships among the site teams and FICAP
personnel to standardize processes.  FICAP provided training in injury prevention
and intellectual resources from a variety of academic disciplines (such as
epidemiology, nursing, criminology, and public health) to complement the
community expertise of the site teams.  FICAP analyzed the data and provided
each site with community-specific profiles of firearm violence.
In the first five years (1994-1998), the project collected data from a total of 468
neighborhoods that experienced 1,025 intentional deaths from firearms (396 firearm
homicides and 629 firearm suicides).
• Profiles showed distinct difference among communities. The Ohio site
experienced a firearm homicide rate of 12.5 per 100,000 population (far
surpassing the national rate), compared to 2.0 in Pennsylvania and 1.1 in Iowa.
Firearm suicide rates among the three sites were virtually identical: between 6.5
and 6.8 per 100,000 population (about the same as the national average).
Five-year profiles highlight
community-specific data
Spotlight on one community:  Bethlehem-Allentown, Pennsylvania
Continued on back.
• Detailed mortality data revealed that firearm homicide was consistently associated
with out-of-home, nighttime activity in neighborhoods where many people were
likely to be coming and going. Conversely, firearm suicide was consistently
associated with in-home, daytime activity in out-of-the-way neighborhoods.
• Consistent with national data, the handgun was the most common weapon in all
firearm deaths, with semiautomatic pistols being the predominant handgun in
homicides.  Revolvers (a second type of handgun) were the most frequently used
weapon for suicide in Ohio and Pennsylvania, while long guns (rifles and
shotguns) were the main weapons used for suicide in Iowa.
POLICY IMPLICATIONS
Led by St. Luke’s Regional Trauma Center in Bethlehem, PA, this MPAP site exemplifies the results of an
effective trauma center-community partnership.  The program is directed by a trauma surgeon and a site
coordinator, with the guidance of a 22-member advisory board of community leaders.  Although formal
MPAP funding ended in 2004, St. Luke’s continues to fund the site coordinator and the advisory board
remains committed to continuing its efforts.
• Local data revealed that half of all homicides occurred in 8% of neighborhoods.  This geographic detail
allowed FICAP to map homicide “hotspots.”  These maps guided the advisory board’s strategies for
homicide reduction, including targeted policing, restructured housing policy, and development of
youth programs.  These strategies have been endorsed by Allentown city officials, and included in a
funding proposal to the State’s “Weed & Seed” program (a federal crime-fighting and neighborhood
revitalization initiative).
• Data also corrected community misperceptions and redirected efforts.  For example, at the beginning
of the project, local officials assumed the major cause of firearm death in the community was drug-
related homicide. Instead, the data showed that suicide was a much larger community problem, with a
firearm suicide rate that was more than three times as great as the firearm homicide rate.  The board
identified a need for an educational campaign focused on suicide prevention, and charged a
subcommittee with devising a campaign strategy, starting with adolescent suicide.
• Board discussions about suicide prevention highlighted a need to learn more about the effectiveness of
possible interventions. In response, FICAP analyzed the suicide narratives and identified six major
themes of suicide risk (mental illness, physical illness, substance abuse, relationship problems,
psychosocial factors, and previous attempts).  This “typology of risk” model was used to improve a
collective understanding of modifiable risks for suicide, to identify potential points of intervention, and
to guide community decision-making.
These community case studies demonstrate that trauma centers, when provided
resources and support, can function as local firearm injury prevention centers. The
MPAP sites served as catalysts in addressing the politically sensitive issue of firearm
injury.  The project underscores the need for detailed data at the neighborhood level
to help communities understand the nature and scope of their firearm injury
problem.
This Issue Brief is based on the following articles: T.S. Richmond, C.W. Schwab, J. Riely, C.C. Branas, R. Cheney, M. Dunfey.
Effective Trauma Center Partnerships to Address Firearm Injury: A New Paradigm.  Journal of Trauma, June 2004, Vol. 56, pp.
1197-1205; C.C. Branas, T.S. Richmond, C.W. Schwab.  Firearm Homicide and Firearm Suicide: Opposite but Equal.  Public
Health Reports, March-April 2004, Vol. 119, pp. 114-124.
Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104-
6218.
Janet Weiner, MPH, Associate Director for Health Policy, Editor
David A. Asch, MD, MBA, Executive Director
Issue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, and
social and ethical issues that influence how health care is organized, financed, managed, and delivered in the United States and
internationally. The LDI is a cooperative venture among Penn schools including Dental Medicine, Medicine, Nursing and Wharton,
and the Children’s Hospital of Philadelphia. For additional information on this or other Issue Briefs, contact Janet Weiner (e-mail:
weinerja@mail.med.upenn.edu; 215-573-9374).
Nonprofit Organization
U.S. Postage
P  A  I  D
Permit No. 2563
Philadelphia, PA 19104
Issue Brief
Published by the
Leonard Davis Institute
of Health Economics
University of Pennsylvania
3641 Locust Walk
Philadelphia, PA 19104-6218
215.898.5611
fax 215.898.0229
ADDRESS CORRECTION REQUESTED
© 2004 Leonard Davis Institute
Visit us on the web at www.upenn.edu/ldi
• Local advisory boards are key partners in prevention efforts.  The boards are
crucial to building political support and reflecting community values and beliefs.
Advisors can leverage limited resources, enhance community buy-in, reach target
populations, and sustain community ownership of firearm injury prevention
programs.
• Establishing community partnerships is essential to move from the acquisition of
data to a broader understanding of firearm injury as a public health problem.
Initiatives cannot be imposed on communities that are unaware of a problem or
unprepared for change.
• The task of data acquisition would be made easier by the implementation of a
comprehensive National Violent Death Reporting System (NVDRS). The federal
government has funded 13 states to jump-start development of NVDRS, and
estimates that it will cost $20 million a year to fully implement the system in all
states. Given the importance of this information in guiding prevention efforts,
and the demonstrated ability of communities to use the data, Congress should
move quickly to allocate this funding.
POLICY IMPLICATIONS
Continued


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Trauma Center-Community Partnerships to Address Firearm Injury: It can be Done

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