Three-tiered exposure framework

Mounting evidence shows that people exposed to gun violence face worse health outcomes than those who have not been exposed.14–17 Direct, indirect and community-level GVE contributes to greater subsequent medical spending,18 increased psychiatric and substance use disorders,19 poorer self-rated health,20 worse sleep21 and heightened risk for suicidal ideation and behaviours.22 The present-day structural determinants of community gun violence are deeply intertwined with historical systems of oppression and have concentrated the very conditions that contribute to violence and its health-related consequences within a small number of communities.23 As a result, the burden of community gun violence and its consequences for health are not distributed evenly, imparting a much heavier toll on structurally disadvantaged Black, Indigenous and Latinx communities. The diffusion of violence-related harm in the most affected neighbourhoods means that whole communities are likely to suffer in ways that more structurally advantaged places simply do not. Recognising these upstream factors that fundamentally shape rates of gun violence in local areas, we argue that GVE operates as a critical social determinant of health uniquely tied to intersectional inequality in well-being across racial, ethnic and socioeconomic lines.24

We present a three-tiered exposure (TTE) framework to illustrate how three forms of GVE—direct, secondary and community exposure—converge within local communities to shape population health outcomes (see figure 1). Depicted by the downward arrow on the left, social proximity or personal involvement increases when moving from community exposure (ie, witnessing, hearing or living near an incident of gun violence) to direct victimisation. As social and relational proximity increase, the likelihood of a traumatic stress response to exposure increases with more substantial implications for mental, physical and behavioural well-being.25 26 Depicted by the upward arrow on the right side of the figure, the prevalence of a particular form of exposure within a given neighbourhood increases when moving upwards from direct exposure to community-level exposure. The inverted pyramid design does not imply a hierarchy where one type of exposure is more traumatic or harmful to well-being than another. Rather, it reflects the population-based reality that in any given community, the most prevalent type of exposure is indirect via community exposure (witnessing, hearing or living near an incident of gun violence), followed by secondary and then direct exposure. These dynamics are patterned by structural imbalances in access to economic resources, educational opportunities and quality of life that broadly influence levels of violence and resources for response.23 Ultimately, the impact of GVE across all three tiers exceeds individual health harms and results in broad damages to collective well-being generated by widespread traumatic exposure that courses throughout entire communities.27

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Figure 1

Three-tiered exposure framework.

Direct exposure entails being the survivor of a shooting. This means someone is shot by another person and lives, often with lasting injuries and psychological trauma. We align with researchers like Dr. John Rich and Dr. Bessel van der Kolk in defining trauma as experiences or situations that are emotionally painful and distressing while overwhelming an individual’s capacity to cope.28 29 Being a gun violence victim alters the daily functions that many people take for granted including walking, holding down a job and maintaining healthy relationships.30 A recent nationally representative study of GVE among Black and Indigenous adults indicates about 3% of Black adults and 6% of AIAN adults have been shot at some point in their lifetime.20 Shooting survivors can become paralysed, require walking aids or have ongoing medical problems that include post-traumatic arthritis and chronic venous insufficiency.31 Victims are also more likely to be reinjured; a systematic review found the median rate of violent re-injury was 27%, with rates as high as 62%.32 Those who have been shot contend with a range of mental health issues including depression, anxiety and post-traumatic stress alongside substance misuse to cope with recurrent trauma and assist with chronic pain management.33–35

Secondary exposure characterises those indirectly impacted by the fatal or non-fatal shooting of someone they know personally. This tier includes not only family and friends but also individuals working as part of violence prevention organisations such as CureViolence and Safe Streets that employ community-based outreach workers and anti-violence community-building efforts to defuse conflicts before they erupt into shootings.36 The burden of secondary exposure is particularly intense in minoritised communities experiencing high levels of structural disadvantage where rates of gun violence are elevated. In fact, one estimate suggests that young Black men will personally know, on average, three homicide victims by the age of 24.37 Those who are secondarily exposed to gun violence often know the victim well, suffering extensive trauma and experiencing persistent feelings of betrayal, alienation and loneliness.38 Black survivors of homicide victims, in particular, are at disproportionate risk of compromised psychological health due to habitual, cumulative experiences of violence and limited culturally responsive resources for coping with traumatic grief.39 These hardships also extend to the loved ones of non-fatal shooting survivors.18 19 Over time, persistent mental health challenges among secondary survivors can influence health behaviours related to substance use, diet and exercise as well as physical outcomes like chronic illness and functional well-being.40 41

The third and final tier of the framework encompasses those who experience community exposure to gun violence, including people who live and spend time in neighbourhoods where shootings are pervasive as well as residents who witness a shooting or hear gunshots but may not know the victim well. This broad form of vicarious exposure contributes to feelings of anxiety, fear and traumatic stress but does not entail direct injury or the victimisation of a close loved one. In a meta-analysis of 114 studies on the mental health effects of community violence exposure, witnessing or hearing about community violence was associated with externalising and internalising behaviours as well as risk for post-traumatic stress among children and adolescents.16 More recent studies have similarly determined that the occurrence of a past-year gun homicide near the homes of adolescents is associated with symptoms of anxiety and depression,42 43 particularly among socioeconomically disadvantaged Black male youth.44 Community GVE has also been linked to greater risk for suicidal ideation, psychotic experiences and higher levels of distress and depression.22 45 46

In general, researchers have paid greatest attention to the extensive psychosocial consequences of GVE, particularly fallout resulting from secondary and community tiers of exposure.47 Yet, the consequences of GVE on the mind have significant implications for the body as well. Chronic physiological stress as a result of GVE generates psychosocial harms that include recurring fear and anxiety, post-traumatic stress and constant vigilance to threat, leading to an overexposure of stress hormones like cortisol. This generates wear-and-tear on the body called allostatic load that impacts all major systems of the body including cardiovascular, neuroendocrine, metabolic and immune functions.48 Allostatic load exacerbates pre-existing illnesses and generates further harms to long-term and short-term mental and physical health.49 50 The impacts of GVE and the resultant physiological stress response are especially consequential for well-being among children and adolescents during critical periods of development.51 Traumatic stress is linked to permanent changes in brain structure, heightened inflammation throughout the body and biological imprinting across generations through epigenetic mechanisms like DNA methylation.52–54 Further, fear of victimisation can limit a person’s capacity to engage in everyday health-promoting activities like spending time outdoors, exercising, running errands, sleeping well or going to the doctor.55 Those exposed to gun violence may use or misuse substances to cope with the resultant stress and fear, including tobacco, alcohol, marijuana and other hard drugs.56 Constraints on health-promoting behaviours combined with the inability to regularly access preventive healthcare can further exacerbate stress-responsive physical conditions such as obesity, diabetes and asthma.57

Depicted by the dashed circle encompassing the inverted pyramid in figure 1 and as discussed previously, structural inequity is a critical environmental factor that shapes the complex dynamics of GVE in local communities. We specifically use the term ‘inequity’ to highlight the unjust nature of the distribution of resources that exacerbate risk of violence of a given place. Structural inequity entails a broad collection of historical and systemic factors that create and concentrate local conditions conducive to high levels of gun violence including poverty, unemployment, family disruption, youth disengagement, inadequate housing and racial segregation.58 Black, Latinx and Indigenous people are far more likely to live in areas characterised by structural inequity than their White counterparts.12 Any consideration of the population health impacts of GVE must account for the structurally rooted conditions of the local community in question. Neighbourhoods most harmed by structural inequities are likely to experience greater GVE at all three tiers, thereby generating greater damages to population health.59

The three exposure tiers in our framework are not mutually exclusive but rather interrelated and often overlapping. Since gun violence is highly concentrated in places and within social networks, exposure overlap is likely among individuals and throughout neighbourhoods. Among individuals, it is likely that frequency, recency and variation of exposure all matter for differing health outcomes. For instance, experiencing repeated direct exposure (eg, being shot or threatened in multiple instances) may impact health differently than being directly exposed in a single instance. Repeated exposure may be especially consequential for post-traumatic stress, hypervigilance and chronic stress with implications for long-term health.

Studies demonstrate that cumulative exposure to multiple types of gun violence is especially damaging to both mental and physical health,20–22 underscoring the importance of considering overlap, recency and frequency in research on GVE. Since those most affected by gun violence often have strong ties to place and fewer resources to relocate,60 exposures are likely to proliferate in local spaces and compound over time, affecting more people as shootings occur throughout the community. This means that structurally disadvantaged neighbourhoods with high levels of gun violence are far more likely to be comprised of people who experience cumulative GVE, contributing to poorer community health outcomes when compared with more advantaged communities with less gun violence. The intense concentration of gun violence in these disadvantaged places thus serves to perpetuate the structural and socioeconomic conditions that lead to GVE accumulation, resulting in compounding consequences for inequalities in health and well-being.59

Implications for data and research

Within the context of our TTE framework, the social ecology of GVE and its implications for population health offer insight for data collection and research. One of the primary barriers to comprehensively addressing gun violence and reducing related health disparities lies in the inability to measure the problem at each tier of the TTE framework using timely and accurate data. The problem extends beyond the challenge of accurately tracking gun injuries; the absence of detailed data on gun-related injuries severely hampers the ability to assess the full scope of trauma and health consequences resulting from gun violence across the country. Even when focused on the most directly impacted victims, reliable estimates of the number of non-fatal gun injuries by intent (eg, due to assault) cannot properly be derived from either of the main surveillance systems that collect this information. The Healthcare Cost and Utilisation Project Nationwide Emergency Department Sample (HCUP-NEDS) provides an estimate of the total number of non-fatal gun injuries in the USA, but it is subject to the misclassification of intent indicated by the International Classification of Diseases code assigned by hospital medical records coders, particularly in the case of assaults and unintentional shootings.61

The Centres for Disease Control and Prevention’s (CDC) National Electronic Injury Surveillance System–Gun Injury Surveillance Study records injury circumstances and intent in more depth but relies on a sample too small and variable to produce stable estimates nationally or over time.62 Other systems like Trauma Quality Improvement Programme suffer from extensive missing data.63 The Gun Violence Archive (GVA) was developed to overcome barriers to understanding non-fatal gun injuries and has been used to proxy for national and regionally representative estimates.64 However, the database relies in part on media accounts of shooting incidents rather than official data sources and is managed by a small group of private individuals rather than a publicly funded entity, generating potential concerns about data fidelity and long-term management. Even the existence of a relatively high-quality data source like the GVA should not preclude the development and maintenance of a comprehensive data source managed by an appropriately funded public health agency like the CDC.

To date, there remains no single, validated national database of intentional gun violence incidents in the USA, a crucial tool for population-level violence prevention research efforts. Some municipalities have begun to publicly release incident-level shooting data, but no harmonised database exists for the country as a whole. Other sources of small area gun violence data lack the temporal and spatial precision of incident-level crime data. For example, the Federal Bureau of Investigation’s (FBI) National Incident-Based Reporting System (NIBRS) reports data on gun-related incidents down to the police agency level, but these data cannot be reported at the incident level or even for specific neighbourhoods. A small but meaningful portion of police agencies still do not submit data to NIBRS and the FBI cannot compel non-reporting agencies to do so.65 The dearth of granular data on gun violence incidents greatly limits the capacity to build local violence reduction strategies in real time and substantially hinders efforts to develop evidence of the population health consequences related to GVE beyond direct victimisation.

Research to fully capture the health burdens associated with GVE will require vastly improved data sources that enable reliable, longitudinal and incident-level surveillance of fatal and non-fatal gun injuries. These efforts can be supported by multisector violent injury surveillance partnerships to link data from health systems, law enforcement and other agencies that provide information from, among others, Medicaid claims, medical examiners, emergency call systems and community violence intervention organisations. Continued development of innovative imputation, machine learning and data linkage methods can advance the efficacy of multisector gun injury databases for population health surveillance.66

Self-report surveys can also provide estimates of direct, secondary and community exposures to gun violence alongside personal health outcomes. However, large-scale surveys can be prohibitively expensive to administer and the most affected populations—those with limited resources and who tend to be more disconnected from mainstream institutions—may be systematically under-represented among respondents. Intentional surveying efforts are needed to understand collateral trauma and related health impacts due to GVE, even when violence is not experienced firsthand. Data should include not only whether someone is touched by community gun violence, but in what forms the exposure occurred and with what particular health consequences. A coordinated data strategy that includes officially validated sources at local and national levels alongside far more granular data about experiences of gun violence at all exposure tiers is essential moving forward.

Enhanced epidemiological surveillance systems and related quantitative information should be further paired with in-depth, qualitative data that enriches and humanises the adverse health impacts of GVE while explicating strength-based protective factors to improve prevention and treatment opportunities among those exposed across all three tiers.30 35 39 Qualitative research is particularly vital to helping unearth mechanisms and pathways related to GVE and well-being that have been overlooked in more deductively oriented quantitative studies. Indeed, research to capture the burden and consequences of GVE must be intentional in avoiding solely deficit-based metrics for measuring this expansive public health problem. Such metrics and resultant narratives risk pathologising the environmentally responsive safety and survival strategies of the most affected populations, too often leading to reductionist explanations that do not confront the very real structural and institutional arrangements that govern the pervasiveness of multiple forms of GVE.67

Accordingly, the field of gun violence prevention research will benefit from additional emphasis on the perspectives of healers and peacemakers in communities most impacted across the broad spectrum of GVE, while understanding their capacities to reshape local structures as key leverage points for transformational change. Researchers should work to better understand and authentically engage with how individuals and groups within local communities respond to the trauma of gun violence and support one another in the face of exposure across all three tiers. This means taking a holistic approach to examining healing processes that include aspects of the healthcare system, kinship networks and diverse social supports while understanding that traditional therapy or grief counselling may not be adequate to address long-standing health concerns in the face of such substantial and repeated violence.68

There is thus a need for mixed-methods scholarship that challenges conventional, hierarchical conceptions of rigour and evidence that is led, conducted and disseminated by a more diverse cadre of scholars who represent and are accountable to affected communities. For example, the newly formed Black and Brown Collective was developed to address long-standing inequities in gun violence research and aims to change the landscape of research in the field.69 The work of those in the Collective and other like-minded researchers can uplift and centre the perspectives and lived experience of those most impacted to understand not only the harms of community gun violence but also the assets that nurture healing, safety and well-being.

Implications for practice and policy

Our multitiered conceptualisation of GVE in local communities and its consequences for population health supports large-scale investments in gun violence prevention practice and policy. In this paper, we have focused on the direct impacts of GVE for population health, but GVE also shapes many additional outcomes related to education, income, housing and state engagement that have implications for collective well-being.70 71 The extensive scope of the population health burden imparted by gun violence necessitates transformational efforts and the development of new institutions to coordinate resources for gun violence prevention and services to those that have been harmed. These institutions must have the capacity to address GVE and the associated consequences for health at the individual, secondary and community exposure tiers outlined here. Some of the most effective unifying efforts can be accomplished by developing collaborative state-level or local-level offices of violence prevention and neighbourhood safety tasked with synthesising public safety strategies that combine victim services with prevention programming. There are now 48 individual city-level or county-level offices of violence prevention throughout the country and more than half of these have been established since 2020. Additionally, there are state-level offices in California, Colorado, Illinois, Maryland, Michigan, New Jersey, New York, North Carolina, Oregon, Pennsylvania, South Carolina and Washington.72

Violence prevention offices should work to coordinate community violence prevention groups, victim services agencies and law enforcement personnel to serve as a single resource centre for violence prevention and victim support. Any office of violence prevention will only be as effective as the organisations and community-led initiatives which it supports. Offices must centralise services under a single division with consistent funding and stable leadership supported in the state or city budget. In theory, each state and many major cities could establish similar offices to generate an interlocking network of violence prevention institutions across the country.72 Whether through a state office or alternative institutional mechanism, stable financial and political backing is needed for the following three ‘buckets’ of efforts to address GVE and related health disparities: (1) evidence-based prevention and intervention programmes to reduce shootings and killings, (2) support services for those that experience gun violence at all three tiers of exposure and (3) interventions to address structural and systemic risk factors for gun violence in local neighbourhoods.

First, targeted prevention efforts to reduce shootings can decrease the risk of exposure across all tiers within local neighbourhoods. To optimise prevention capacity, it is necessary to invest in solutions that demonstrate the greatest promise for sustained change.73 Community violence intervention (CVI) strategies are an increasingly popular alternative to law enforcement-dominant responses to violence that empower local community members to lead violence reduction efforts (eg, community-based outreach workers).74 These programmes have long operated in under-resourced communities and have shown success at reducing violence when adequately funded and supported. However, continued evaluation is needed to determine how to best fund and manage these programmes as well as how they might be optimally situated within larger violence reduction efforts.

For example, outreach workers have been shown to operate as critical connectors to cognitive behavioural therapy and jobs programmes in partnerships like the Rapid Employment and Development Initiative in Chicago.75 Violence interrupters have also been shown to play an important role within community, social service and criminal justice coalitions geared towards focused deterrence like Project Safe Neighbourhoods in places like Chicago and the Eastern District of Missouri, as well as Operation Ceasefire in Newark, New Jersey.76 Regardless of the programme in question, community-based outreach workers are likely to be most effective when systems are in place for them to successfully connect people with the culturally relevant supports they need to address an array of needs, including those related to health and well-being.77 There remains tremendous opportunity for public health practitioners, criminal justice agencies and social service providers to collaborate and synthesise the most scientifically promising aspects of diverse prevention efforts while abiding by critical principles of procedural justice and community equity.

Second, it is critical to invest in addressing the harms of GVE when shootings are not prevented to reduce health consequences and related inequities across all three tiers of exposure. Research on the coping strategies of minoritised and disadvantaged communities underscores relational approaches to healing rooted in communal spiritual traditions and meaning making while acknowledging structurally rooted cultural trauma and responses to it.67 Oftentimes, this means offering culturally congruent support services that do not necessarily rely solely on formalised systems like therapeutic counselling services in clinical settings.68 Support can manifest in myriad ways including highly localised mutual aid groups, collective chapters to promote collective healing through organisations like the Crime Survivors for Safety and Justice (CSSJ), and wraparound trauma recovery centres (TRCSs). For example, CSSJ currently operates chapters across 10 states to promote collective healing support for more than 187 000 members while there are 52 TRCs throughout 12 states as part of the National Alliance of Trauma Recovery Centres (NATRC). TRCs offer non-siloed, survivor-centred services to facilitate recovery while providing practical assistance with the complex web of legal, financial and housing needs experienced by many survivors. It is notable that CSSJ chapters and TRCs remain absent in many of the states that have historically experienced the highest rates of gun violence in the USA like Alabama, Mississippi, Arkansas and Missouri. Together, CSSJ and the NATRC contribute to a broadening network of community-driven, survivor-centric opportunities for aid and recovery, but these resources must be expanded across more states and made easily accessible to those who need them.

Expansion efforts to support those who experience gun violence should also include local educational campaigns to make victims aware of compensation and resources available via the Victim of Crime Act while reducing barriers to accessing these funds. Yet, it is important to recognise that victim assistance offices can potentially serve as sources of additional trauma for survivors and their loved ones, especially when they are forced to jump through bureaucratic hoops to justify assistance such as providing burdensome evidence to cover funeral expenses. Campaigns to enhance awareness of resources to victims of violence and their families should be directly informed and implemented by local community members with clear guidance and support from state-level or city-level offices tasked with violence prevention.

Hospital-based violence intervention programmes (HVIPs) can play a crucial role in mitigating the health-related harms of gun violence across all levels of exposure. HVIPs rely on credible messengers to work with violence victims starting at the patient’s hospital bedside, discouraging retaliation while connecting them with social support services such as housing assistance, employment opportunities and access to counselling and substance use resources. There remains a lack of robust evaluations and mixed evidence on HVIP capacity to reduce gun violence offending,78 but many programmes have demonstrated positive outcomes related to reduced criminal legal system involvement, improved attitudinal changes and decreased reinjury.79 HVIPs can offer support to acquaintances of victims and residents of violence-prone communities, acknowledging the various ways violence exposure occurs as outlined in our TTE framework. There is a need for enhanced social services that cater to the wider circle of individuals touched by such violence that includes providing medical and therapeutic support tailored to specific exposure levels. Integrating HVIPs with CVI programmes can strengthen their outreach, ensuring support extends beyond the immediate victims that come into the hospital with an injury to encompass the wider community. Coordinating HVIP services through a single statewide office alongside survivor support networks, victim compensation and educational campaigns can ensure all efforts are geared towards the shared goal of mitigating the harms of GVE to collective well-being.

Third, the enduring challenge of gun violence in the USA should be met with a wide variety of evidence-based interventions that go beyond direct programming for community prevention strategies and victim service provision. The true scope of the problem and broad implications for health equity outlined here demand the use of every viable tool in the policy toolkit. For instance, place-based solutions associated with decreases in community gun violence and improvements in collective well-being should be scaled to include public investments in vacant lot remediation, dilapidated building demolition, home façade renovation, and even lighting and tree planting.80 Evidence-based policing strategies that address small, high-risk networks of shooters like focused deterrence have been shown to decrease gun violence,81 though consistent attention to any related harms of punitive approaches to individuals and broader communities is necessary. Adoption of these programmes in law enforcement agencies alongside community and place-based interventions may be especially impactful, though they must be employed in a manner that supports neighbourhoods affected by gun violence rather than criminalises them. These diverse efforts should be centralised within a single office to ensure that all communities in a given state or city receive appropriate interventions while enabling the flexibility to tailor solutions to specific areas and innovate in response to changing conditions.

Additionally, research shows that income support policies can decrease gun assaults and, by extension, their broader population-level consequences.82 The Earned Income Tax Credit, for example, has led to reductions in gun violence and increased economic security and stability. Similarly, reductions in violent crime were seen after passage of the federal Low-Income Housing Tax Credit Programme, which incentivised affordable housing in low-income areas. Significant gun violence reduction requires a combination of structural changes and more immediate programmatic efforts that synthesise the strongest efforts of local communities, law enforcement and policymakers. Efforts to reduce gun violence not rooted in broader structural and economic change will be doomed to fail at the whims of political change, fleeting budgetary priorities and flagging media attention. An effective policy agenda thus requires efforts at both the macro (structural) and micro (programmatic) levels with support from reliable data and consistent investment over time.