Social determinants of health in relation to firearm-related homicides in the United States: A nationwide multilevel cross-sectional study.

backgroundGun violence has shortened the average life expectancy of Americans, and better knowledge about the root causes of gun violence is crucial to its prevention. While some empirical evidence exists regarding the impacts of social and economic factors on violence and firearm homicide rates, to the author's knowledge, there has yet to be a comprehensive and comparative lagged, multilevel investigation of major social determinants of health in relation to firearm homicides and mass shootings. METHODS AND

findingsThis study used negative binomial regression models and geolocated gun homicide incident data from January 1, 2015, to December 31, 2015, to explore and compare the independent associations of key state-, county-, and neighborhood-level social determinants of health-social mobility, social capital, income inequality, racial and economic segregation, and social spending-with neighborhood firearm-related homicides and mass shootings in the United States, accounting for relevant state firearm laws and a variety of state, county, and neighborhood (census tract [CT]) characteristics. Latitude and longitude coordinates on firearm-related deaths were previously collected by the Gun Violence Archive, and then linked by the British newspaper The Guardian to CTs according to 2010 Census geographies. The study population consisted of all 74,134 CTs as defined for the 2010 Census in the 48 states of the contiguous US. The final sample spanned 70,579 CTs, containing an estimated 314,247,908 individuals, or 98% of the total US population in 2015. The analyses were based on 13,060 firearm-related deaths in 2015, with 11,244 non-mass shootings taking place in 8,673 CTs and 141 mass shootings occurring in 138 CTs. For area-level social determinants, lag periods of 3 to 17 years were examined based on existing theory, empirical evidence, and data availability. County-level institutional social capital (levels of trust in institutions), social mobility, income inequality, and public welfare spending exhibited robust relationships with CT-level gun homicide rates and the total numbers of combined non-mass and mass shooting homicide incidents and non-mass shooting homicide incidents alone. A 1-standard deviation (SD) increase in institutional social capital was linked to a 19% reduction in the homicide rate (incidence rate ratio [IRR] = 0.81, 95% CI 0.73-0.91, p < 0.001) and a 17% decrease in the number of firearm homicide incidents (IRR = 0.83, 95% CI 0.73-0.95, p = 0.01). Upward social mobility was related to a 25% reduction in the gun homicide rate (IRR = 0.75, 95% CI 0.66-0.86, p < 0.001) and a 24% decrease in the number of homicide incidents (IRR = 0.76, 95% CI 0.67-0.87, p < 0.001). Meanwhile, 1-SD increases in the neighborhood percentages of residents in poverty and males living alone were associated with 26%-27% and 12% higher homicide rates, respectively. Study limitations include possible residual confounding by factors at the individual/household level, and lack of disaggregation of gun homicide data by gender and race/ethnicity.

conclusionsThis study finds that the rich-poor gap, level of citizens' trust in institutions, economic opportunity, and public welfare spending are all related to firearm homicide rates in the US. Further establishing the causal nature of these associations and modifying these social determinants may help to address the growing gun violence epidemic and reverse recent life expectancy declines among Americans.