Modifiable Risk Factors for Youth Firearm Violence Prevention: A Baseline Descriptive Analysis from a Hospital Violence Intervention Program Evaluation

Abstract

Individuals who have experienced a violent injury are at an increased risk of subsequent reinjury. The traumatic event may increase one’s motivation to change the modifiable factors that are associated with violence risk. The current paper describes the assessment of potentially modifiable risk factors in a recently developed hospital-based violence intervention program (HVIP) for youth. Individuals aged 17–24 who sought hospital treatment for violent injury at a Level 1 Trauma Center enrolled to participate in a quasi-experimental study designed to evaluate a motivational-interviewing-informed case management HVIP (N = 48). Descriptive analyses of modifiable risk factors assessed at baseline for participants, including substance use, employment, housing, mental health issues, and firearm-related beliefs and behaviors, were conducted. Participants identified primarily as male (85%) and Black (87%). Commonly acknowledged risk factors included: PTSD (38%), unemployment or marginal employment (73%), low educational attainment (44% < high school equivalency), and daily marijuana use (55%). Participants’ acknowledgement of unsafe firearm behaviors was highly variable, with 50% denying any firearm carriage in the past 12 months. Nevertheless, participants reported neutral-to-moderate firearm beliefs, with moderate endorsement of needing a firearm for protection (M = 3.77, SD = 2.2) and acknowledgment that most people they knew carry a firearm (M = 3.6, SD = 2.0). However, there was mild disagreement with the idea that firearm carriage would reduce the likelihood of being victimized (M = 2.67, SD = 2.2). Given the variability in the reporting of unsafe firearm behaviors, HVIPs overly focused on firearm behaviors may not be appropriate for youth.

1. Introduction

Youth firearm violence is a critical and ongoing public health crisis in the United States. Firearms are among the leading cause of death for children (ages 1–17), and the third leading cause of death amongst youth (ages 15–25) (Center for Disease Control and Prevention, 2024a). In 2023, the US recorded the fifth highest death record by firearm homicide, despite firearm homicide rates decreasing by 8.6% the previous year (Kim et al., 2025). Beyond mortality, nonfatal firearm injuries impose substantial physical, psychological, and economic burdens, including long-term disability, trauma exposure, educational attainment barriers, and increased risk for reinjury or perpetration (D. B. Lee et al., 2020; E. Lee et al., 2024; Rosenfeld et al., 2015; Vella et al., 2020). Further, there are significant disparities amongst youth, with males and marginalized youth of color being the most likely to experience community firearm violence (E. J. Kaufman et al., 2021; Nguyen & Drane, 2025). Additionally, communities affected by structural disadvantage, such as concentrated disadvantage, racialized economic residential segregation, and over-policing (Fleckman et al., 2025; Ghio et al., 2023; Gobaud et al., 2024; Houghton et al., 2021; Jay, 2023; Mehranbod et al., 2022), are disproportionately affected by firearm violence.

Hospital-based violence intervention programs (HVIPs) have emerged as a promising, evidence-informed approach aiming to interrupt cycles of firearm violence. HVIPs are grounded in trauma-informed and social support frameworks, with growing but heterogeneous evidence demonstrating potential benefits for reducing reinjury and improving psychosocial outcomes. HVIPs occur in hospitals following a violent injury, when a participant may be more receptive to intervention, to engage individuals in trauma-informed wraparound services. These programs typically include bedside engagement, intensive case management, and sustained linkage to community-based resources such as mental health care, educational and employment support, housing assistance, and legal advocacy, with the aim of reducing the risk of reinjury and improving recovery for individuals who have been violently injured. Prior evaluations suggest that HVIPs may reduce violence reinjury and criminal justice involvement (Bell et al., 2018; Nofi et al., 2023; Romo et al., 2023; Snider et al., 2020), supporting their potential as a public health-oriented intervention to reduce firearm violence.

HVIPs are designed to address modifiable risk factors that contribute to youths’ increased risk for firearm violence. Prior research identifies a range of factors associated with recurrent injury and continued involvement in violence, including psychological trauma, economic instability, school disengagement, unemployment, substance use, and experiencing housing instability (R. M. Cunningham et al., 2015; E. Kaufman et al., 2016; Laytin et al., 2018; Loe et al., 2025; Mueller et al., 2023; Rowhani-Rahbar et al., 2015; Strauss et al., 2022). However, much of the existing HVIP literature has focused on the downstream outcomes, such as reinjury, arrest or hospital utilization, paying less attention to the broader social determinants and behavioral mechanisms through which programs intervene and reduce the risk of such outcomes (Bell et al., 2018; Juillard et al., 2015, 2016). While research on HVIP implementation and evaluation have largely focused on adult populations, a recent scoping review identified 36 studies, spanning 23 pediatric-focused HVIPs, and highlighted substantial gaps (Nofi et al., 2023). The review included studies if the HVIP enrolled any participants under the age of 18; however, there was no upper age limit for program inclusion. Despite aiming to characterize programs serving children and youth, the review found that most HVIPs primarily enroll older adolescents and adults. The reported mean ages frequently exceeded 18 years, with several programs documenting mean ages in the early-to-late twenties, underscoring a predominance of young adult-focused interventions (Nofi et al., 2023). Notably the youngest reported mean age across programs was 13 years, and only four programs included children younger than ten, revealing a critical lack of developmentally tailored interventions targeting early intervention timepoints. Furthermore, relatively few studies have examined whether HVIPs influence youths’ firearm-related beliefs, behaviors, or perceived need for firearms, despite growing evidence that these factors are shaped by social context and violence exposure and are demonstrated risk factors for injury and reinjury (Nofi et al., 2023; Puppalla et al., 2024).

Youth is defined as a developmental period that encompasses both older adolescents and emerging adults. This approach aligns with public health definitions, including those from the Centers for Disease Control and Prevention, which commonly define youth violence as occurring among individuals aged 10–24 (Center for Disease Control and Prevention, 2024b). It also reflects evidence that key neurodevelopmental and psychosocial processes, including identity formation, emotional regulation, and risk appraisal, continue across this transition period into the mid-twenties (Branje, 2022; Monahan et al., 2009). Exposure to firearm violence during this period may disrupt these developmental milestones in several ways. Neurodevelopmental models suggest that heightened sensitivity to threat, coupled with still-developing prefrontal regulatory systems, may increase reactivity to violence exposure and impair adaptive decision-making (Steinberg, 2010). Concurrently, trauma frameworks indicate that repeated exposure to violence is associated with dysregulated emotional responses, hypervigilance, and altered perceptions of safety, which may shape how youth interpret and respond to risk (Fowler et al., 2017; Leibbrand et al., 2020; E. Lee et al., 2024). Grouping adolescents and emerging adults together is therefore consistent with developmental science and aligns with prior violence prevention research that conceptualizes this age range as a critical window for intervention, particularly for individuals at elevated risk of violent injury and reinjury (Walsh et al., 2025).

This study aims to examine the baseline characteristics and potentially modifiable factors of youth enrolled in an evaluation study of a hospital-based violence intervention program. Specifically, we assessed baseline social determinants and needs for participants (i.e., income, educational attainment, employment, housing security, substance use, etc.) as well as other potentially modifiable risk factors, including firearm beliefs and firearm carrying behaviors. By focusing on modifiable risk factors during a critical intervention window, this study contributes to a growing body of public health research by identifying emerging patterns related to actionable risk factors in order to inform intervention development.

2. Materials and Methods

2.1. Study Sample

The current descriptive study included a sample of youth (N = 48) enrolled in an evaluation study of an HVIP. Participants were recruited from a Level 1 Trauma Center in New Orleans, Louisiana, where they were receiving treatment for an assault-related gunshot injury, stab wound, or blunt force trauma. The eligibility criteria included: being between the ages of 16 and 24 years of age, a resident of Louisiana, and English language proficiency. Individuals were ineligible if they were deemed physically or mentally incapable by a medical professional, currently in police custody, and/or a victim of domestic violence. Enrollment began in the summer of 2022 and closed in the summer of 2025. It is important to note that although the study was developed with the intention of enrolling participants as young as 16, only individuals aged 17 and older consented to participate in the study.

2.2. Study Design

We analyzed baseline data from the Supportive Hospital-based Intervention for Firearm Trauma (SHIFT) study (NCT06712940), a six-month quasi-experimental evaluation study of a motivational-interviewing (MI)-informed case management HVIP in the greater New Orleans area. The study utilized a non-randomized controlled design that involved alternating recruitment days to assign study conditions, which allowed participants to know upfront whether they would be in the MI/case management or treatment-as-usual (TAU) arm (Mathe et al., 2015). All potentially eligible individuals were met at bedside after confirming with their medical care team that it was appropriate. Participants in the MI arm (n = 22) were paired with a licensed clinical social worker for six monthly MI sessions, case management services tailored to the needs of the participant, a firearm safety training course, and optional biometric lock box giveaway, whereas TAU participants (n = 26) were provided resource referrals by a case manager. Examples of case management and resource referrals included financial assistance, supplemental educational attainment, employment opportunities, and mental and physical health services. MI sessions were on average one hour. Sessions with minor participants were developmentally adapted, and mandatory reporter status was enforced. All participants (N = 48) completed surveys at three timepoints: baseline, three months, and six months. A total of 263 youths were identified as potentially eligible. The study team was able to confirm eligibility of 124 individuals after meeting with them, and 48 youths agreed to enroll in the study, resulting in an enrollment rate of 38.71%. For minors to enroll in the study, their parent(s) had to provide parental permission in addition to assent. Surveys were similar to the adult sample, with a few modifications to ensure that all data could be provided by the youths (i.e., self-reported and not requiring parental completion of data).

Participants were asked questions regarding their exposure to community firearm violence, firearm attitudes and behaviors, basic demographics, and social determinants of health, such as housing instability, substance usage, and mental health status. All participants who successfully completed each survey received $60 in cash or in VISA gift card form. Study activities were approved by the Tulane University Institutional Review Board.

2.3. Measures

Firearm carrying. Firearm carriage was assessed through a non-validated, single item asking about frequency of carrying a firearm outside of the home. Initially, participants were asked about frequency in the past 30 days (n = 9); however, because of initial low frequency in acknowledging any firearm carriage in the past month, the item was changed to assess firearm carriage in the past year (n = 39) shortly after study commencement. For past 30-day carriage, responses included: “never”, “1 day”, “2–3 days”, “4–5 days”, and “6 or more days”. Responses changed when the question was altered, and included: “never”, “once”, “twice”, “3–5 times”, “6–10 times”, “11–20 times”, and “more than 20 times”. Given the firearm carriage item was modified early in data collection to expand the recall period, this measure was not administered uniformly across all participants at baseline.

Gun beliefs. Gun beliefs were assessed through a modified three-item version of the Gun Beliefs and Behavior Scale (GBBS) (Wamser-Nanney et al., 2020). Two of the three selected items were from the safety subscale and the remaining item was from the gun presence subscale. Questions included: “I am less likely to be victimized if I carried/when I carry a gun”, “Many of the people I know carry a gun”, and “I feel the need to carry a gun to protect myself”. The GBBS utilizes a seven-point Likert scale ranging from “Strongly Disagree” (zero) to “Strongly Agree” (six). A mean score was calculated for individual items ranging from zero to six, with higher scores reflecting more endorsement of firearm-related beliefs and perceived normative gun presence.

Exposure to community firearm violence. Exposure to community firearm violence was measured in two different ways. During the first year of data collection (n = 9), exposure was measured using a single binary item: “In the last six months, have you heard of, witnessed, or experienced gunshots in your neighborhood?” from the Exposure to Violence Questionnaire (Orue & Calvete, 2010; Quiroga et al., 2017). Response options included “no,” “yes,” and “refuse to answer”. One year into the study, this item was replaced with a non-validated, three-item measure designed to capture distinct dimensions and frequency of firearm-related exposure, resulting in variation in the baseline sample size across items. Participants (n = 39) were asked the following: (1) “In the last twelve months, have you seen someone get shot?” (yes/no); (2) “In the last twelve months, have you seen a gun pulled on someone?” (yes/no); and (3) “In the last twelve months, how often have you seen somebody carry a gun (excluding police or security)?”, with the response options ranging from “never” to “more than once a week.” This expanded measurement approach was intended to better capture variability in both the type and intensity of community firearm exposure.

Prior direct violence victimization. Previous direct violence victimization was measured using a non-validated, single item and was introduced to the evaluation study one year into data collection. Participants (n = 39) were asked “Before the recent event, were you ever previously been shot or stabbed?”, with the response options of “yes” or “no”. This item was introduced to capture individual experiences of violence.

Perceived neighborhood safety. Perceived neighborhood safety was measured using two different, non-validated items over the course of the study. During the first year of the evaluation study, participants (n = 9) were asked a single binary question “Do you feel safe in your neighborhood?”, with the response items “yes” and “no”. One year into the study, participants (n = 39) were asked “How often do you feel safe in your neighborhood?”. The response items were “none of the time”, “some of the time”, “most of the time”, and “all of the time”. The revised measure was implemented to provide more nuance than was reflected in a binary response. By updating the perceived safety item, the team was not able to harmonize data across the full sample.

Post-traumatic stress disorder (PTSD). PTSD was measured using the PCL-5 (Blevins et al., 2015). This is a 20-item measure that assesses the 20 DSM-5 symptoms associated with PTSD, including repeated, disturbing and unwanted memories of stressful experiences, a loss of interest in activities that you used to enjoy, having difficulty concentrating, and having trouble falling or staying asleep. Although the PCL-5 has primarily been validated among adults, it was retained for minor participants due to its widespread use in trauma research. Furthermore, emerging evidence supports its use among adolescents, with Ghazali and Chen (2018) demonstrating good internal consistency, test–retest reliability, and concurrent validity among adolescents. These items are measured on a five-point Likert scale ranging from “Not at all” (zero) to “Extremely” (five). Items are summed up to create a composite score ranging from 0 to 80, with higher scores indicating more severe PTSD symptoms. A binary variable was created based on the clinical cut off for high risk of PTSD, with those who had scores 31 or higher coded as high risk for PTSD (National Center for PTSD, 2016). The PCL-5 has demonstrated strong psychometric properties across trauma-exposed populations, including strong internal consistency and convergent validity (Blevins et al., 2015). Internal consistency within the current sample was high (Cronbach’s alpha = 0.90).

Substance use. The Screening to Brief Intervention (S2BI) tool was used to measure substance use (Levy et al., 2014). It is a screening tool that asks about frequency of use to categorize substance use by adolescent patients. Although the S2BI was originally developed for adolescent populations, it was retained for the current study because recent research has demonstrated the successful identification and classification of substance use disorders among emerging adults of up to age 24, supporting it potential utility across the current sample in this study (Huynh et al., 2023). Questions include “In the past year, how many times have you used alcohol”, “In the past year, how many times have you used marijuana?”, “In the past year, how many times have you used prescription drugs that were not prescribed to you?,” and “In the past year, how many times have you used illegal drugs?”. Response options included “Never” (one), “Once or twice” (one), “Monthly” (two), “Weekly or more” (three), and “Daily” (four).

Sociodemographic. Several factors were included to measure sociodemographic variables, such as age, educational attainment, employment status, household income, gender, and race/ethnicity. Age was calculated based on the date of survey completion and the participant’s date of birth. Educational attainment was categorized as “No formal education”, “Grade 1–11”, “Completed high school or GED”, “Some college or technical school”, “Completed 4-year college or university”, or “Completed a graduate degree”. Employment was categorized as “Working full time (35 h or more per week)”, “Working part time (less than 35 h per week)”, “Have a job, but currently on leave”, “Unemployed or laid off and looking for work”, “Unemployed or laid off and not looking for work”, “In school or training only”, “On public assistance”, “Supplemental security income”, and “Other”. Household income was categorized in $10,000 increments, ranging from “Less than $10,000” to “$90,000 or more”. Minors were asked a different question to assess household income. They were asked “How much money does your family have?”. Response options included “not enough to get by”, “just enough to get by”, “we only have to worry about money for fun or extras”, and “we never have to worry about money”.

2.4. Analysis

Descriptive univariate analyses included frequency distributions, means and standard deviations to examine sociodemographic characteristics, exposure to community firearm violence, firearm behaviors and beliefs, substance use, PTSD, and gun carrying amongst participants. Baseline comparisons between intervention and TAU participants were conducted using independent samples t-tests for continuous variables and chi-square tests for categorical variables. Data management and analysis were completed in SAS version 9.4.

3. Results

Sociodemographic characteristics and key social determinants assessed are presented in

Table 1. Sample sociodemographic characteristics and social determinants.

	Total n = 48 Mean (SD)/n (%)	Intervention n = 22 Mean (SD)/n (%)	Treatment at Usual n = 26 Mean (SD)/n (%)	p-Value a
Age (Range: 17–24)	21.65 (2.1)	20.80 (2.0)	22.37 (2.0)	0.01
Gender				0.46
Male	41 (85.4%)	19 (86.4%)	22 (84.6%)
Female	6 (12.5%)	2 (9.1%)	4 (15.4%)
Other	1 (2.1%)	1 (4.6%)	-
Race				0.52
White	5 (10.6%)	3 (14.3%)	2 (7.7%)
Black	41 (87.2%)	18 (85.7%)	23 (88.5%)
Multi-racial	1 (2.1%)	-	1 (3.9%)
Hispanic				0.45
Hispanic	3 (6.3%)	2 (9.1%)	1 (3.9%)
Non-Hispanic	45 (93.8%)	20 (90.9%)	25 (96.2%)
Education				0.72
No formal education	1 (2.1%)	-	1 (3.9%)
Some grade school	21 (43.8%)	9 (40.9)	12 (46.2%)
Completed high school or GED	21 (43.8%)	10 (45.5%)	11 (42.3%)
Some college or technical school	5 (10.4%)	3 (13.6%)	2 (7.7%)
Completed 4-year college	-	-	-
Completed a graduate degree	-	-	-
Employment				0.16
Full time	13 (27.1%)	5 (22.7%)	8 (30.8%)
Part time	1 (2.1%)	1 (4.6%)	-
On leave	5 (10.4%)	3 (13.6%)	2 (7.7%)
Unemployed/Laid off and looking for work	16 (33.3%)	6 (27.3%)	10 (38.5%)
Unemployed/Laid off and not looking for work	5 (10.4%)	2 (9.1%)	3 (11.5%)
In school or training	4 (8.3%)	4 (18.2%)	-
Supplemental security income/disability	3 (6.3%)	-	3 (11.5%)
Other	1 (2.1%)	1 (4.6%)	-
Household income				0.64
Less than $10,000	12 (26.1%)	6 (27.3%)	6 (23.1%)
$10,000–$30,000	14 (30.4%)	6 (27.3%)	8 (30.8%)
$30,000–$70,000	5 (10.9%)	1 (4.6%)	4 (15.4%)
More than $70,000	4 (8.7%)	2 (9.1%)	2 (7.7%)
Housing stability (average number of moves in past 2 years)	1.74 (1.9)	1.80 (1.8)	1.69 (2.0)	0.13
Substance use
Alcohol	n = 44	n = 19	n = 25	0.62
Never	12 (27.3%)	6 (31.6%)	6 (24.0%)
Once or twice	16 (36.4%)	8 (42.1%)	8 (32.0%)
Monthly	10 (22.7%)	4 (21.1%)	6 (24.0%)
Weekly or more	4 (9.1%)	1 (5.3%)	3 (12.0%)
Daily	2 (4.6%)	-	2 (8.0%)
Marijuana	n = 44	n = 19	n = 25	0.60
Never	9 (20.5%)	3 (15.8%)	6 (24.0%)
Once or twice	3 (6.8%)	1 (5.3%)	2 (8.0%)
Monthly	4 (9.1%)	3 (15.8%)	1 (4.0%)
Weekly or more	4 (9.1%)	1 (5.3%)	3 (12.0%)
Daily	24 (54.6%)	11 (57.9%)	13 (52.0%)
Prescription drugs	n = 45	n = 20	n = 25	0.46
Never	40 (88.9%)	19 (95.0%)	21 (84.0%)
Once or twice	1 (2.2%)	-	1 (4.0%)
Monthly	2 (4.4%)	-	2 (8.0%)
Weekly or more	-	-	-
Daily	2 (4.4%)	1 (5.0%)	1 (4.0%)
Illegal substances	n = 45	n = 20	n = 25	0.43
Never	43 (95.6%)	20 (100%)	23 (92.0%)
Once or twice	1 (2.2%)	-	1 (4.0%)
Monthly	-	-	-
Weekly or more	-	-	-
Daily	1 (2.2%)	-	1 (4.0%)
Post-traumatic stress disorder (PTSD)				0.45
High symptom severity	18 (37.5%)	7 (31.8%)	11 (42.3%)
Low symptom severity	30 (62.5%)	15 (68.2%)	15 (57.7%)

Note. ^a p-values derived from independent samples t-tests for continuous variables and chi-square tests for categorical variables.

. The mean age of participants was 21.65 years old (SD: 2.14; range: 17–24), and intervention participants were significantly younger than TAU participants (M = 20.80 versus 22.37 years, p = 0.01). All participants enrolled as a result of experiencing a gunshot wound. The majority of participants identified as male (85.4%) and Black (87.2%). A small portion identified as Hispanic/Latinx (6.3%). In terms of highest level of educational attainment, nearly half reported some grade school education (43.8%) and a similar proportion had completed high school or a GED (43.8%). Only 10.4% reported some college or technical education, and none reported completing a four-year or graduate degree. Employment status varied, with over one-third of participants reported being unemployed and actively seeking work (33.3%) and approximately one-quarter (27.1%) reported full-time employment. Only 8.3% reported being in school or vocational training. More than half (56.5%) of participants reported an annual household income below $30,000. Housing instability was also prevalent, with participants reporting an average of 1.74 residential moves in the past two years (SD: 1.91). Substance use was common amongst participants, particularly daily marijuana use (54.6%). Alcohol use varied, with more than one-third of participants (36.4%) reporting use once or twice monthly. Prescription drug misuse and illegal substances were relatively uncommon. Over one-third of participants screened positive for high PTSD symptom severity (37.5%). Aside from age, no statistically significant differences were observed between intervention and TAU participants across sociodemographic characteristics or social determinants of health (all p > 0.05).

Exposure to community firearm violence and perceived neighborhood safety are reported in

Table 2. Exposure to community firearm violence.

	Total Mean (SD)/n (%)	Intervention Mean (SD)/n (%)	Treatment at Usual Mean (SD)/n (%)	p-Value a
Community Firearm Violence Exposure
Hearing, witnessing or experiencing gunshots in neighborhood—last 6 months b	n = 9	n = 5	n = 4	0.76
Yes	5 (55.6%)	2 (40%)	2 (50%)
No	4 (44.4%)	3 (60%)	2 (50%)
Had seen someone get shot—last 12 months c	n = 39	n = 17	n = 22	0.20
Yes	16 (59.0%)	5 (29.41%)	11 (50%)
No	23 (41.0%)	12 (70.59%)	11 (50%)
Had seen a gun pulled on someone—last 12 months c	n = 39	n = 17	n = 22	0.36
Yes	13 (33.3%)	7 (41.2%)	6 (27.3%)
No	26 (66.7%)	10 (58.8%)	16 (72.7%)
Had seen somebody carry a gun—last 12 months c	n = 39	n = 17	n = 22	0.71
Never	5 (12.8%)	3 (17.7%)	2 (9.1%)
Less than once a month	4 (10.3%)	2 (11.8%)	2 (9.1%)
Monthly	7 (18.0%)	3 (17.7%)	4 (18.2%)
Once a week	2 (5.1%)	-	2 (9.1%)
More than once a week	21 (54.0%)	9 (52.9%)	12 (54.6%)
Previous direct firearm or stabbing victimization c	n = 39	n = 17	n = 22	0.39
Yes	12 (30.8%)	4 (23.5%)	8 (36.4%)
No	27 (69.2%)	13 (76.5%)	14 (63.6%)
Perceived neighborhood safety a	n = 9	n = 5	n = 4	0.14
Yes	7 (77.8%)	4 (80%)	3 (75%)
No	2 (22.2%)	1 (20%)	1 (25%)
Perceived frequency of neighborhood safety b	n = 39	n = 17	n = 22	0.31
None of the time	5 (12.8%)	4 (23.5%)	1 (4.6%)
Some of the time	11 (28.2%)	4 (23.5%)	7 (31.8%)
Most of the time	7 (18.0%)	2 (11.8%)	5 (22.7%)
All of the time	16 (41.0%)	7 (41.2%)	9 (40.9%)

Note. ^a p-values derived from independent samples t-tests for continuous variables and chi-square tests for categorical variables; ^b indicates survey item(s) were only asked for the first year of data collection; ^c indicates survey item(s) were introduced one year into data collection.

. Among participants who responded to the item (n = 39), nearly one-third reported prior direct firearm victimization (30.8%). Of the sample who answered the initial community firearm violence exposure question (n = 9), just over half (55.6%) endorsed hearing, experiencing, or witnessing gunshots in their neighborhood, including hearing of or witnessing a murder in the past six months. For those that responded to the updated survey items on exposure (n = 39), more than half (59.0%) reported having seen someone get shot in the past 12 months, and 33.3% reported witnessing a gun being pulled on someone during the same period. Over half (53.9%) of participants reported seeing someone carry a gun (excluding police or security) more than once per week in the past 12 months. Of the respondents who responded to the initial item on perceived neighborhood safety (n = 9), 77.8% reported feeling safe. The remainder of the sample (n = 39) were asked how frequently they felt safe in their neighborhood, with 59.0% reported feeling safe most or all of the time, 28.2% reported feeling safe only some of the time, while a minority (12.2%) reported never feeling safe. No statistical differences were observed between intervention and TAU participants in measures of community firearm violence exposure, prior victimization, or perceived neighborhood safety (all p > 0.05).

Participants endorsed neutral-to-moderate firearm-related beliefs, as demonstrated by the mean scores for statements reflecting perceived need for firearms for protection (mean = 3.77, SD = 2.18) and perceptions that most people known to the participant carry a gun (mean = 3.60, SD = 2.04;

Table 3. Firearm beliefs and behaviors.

	Total Mean (SD)/n (%)	Intervention Mean (SD)/n (%)	Treatment at Usual Mean (SD)/n (%)	p-Value a
Firearm beliefs and behaviors (range: 0–6)	N n = 48	n = 22	n = 26
Less likely to be victimized if/when I carry	2.67 (2.18)	2.55 (2.20)	2.77 (2.20)	0.23
Need a gun to protect myself	3.77 (2.18)	3.68 (2.21)	3.85 (2.19)	0.79
Most people known carry a gun	3.60 (2.04)	3.64 (2.08)	3.58 (2.04)	0.84
Frequency of gun carrying in last 30 days b	n = 9	n = 5	n = 4	0.86
Never	7 (77.78%)	4 (80%)	3 (75%)
1 day	-	-	-
2–3 days	-	-	-
4–5 days	-	-	-
6 or more days	2 (22.22%)	1 (20%)	1 (25%)
Frequency of gun carrying in last 12 months c	n = 39	n = 17	n = 22	0.23
Never	20 (51.28)	8 (47.06%)	12 (54.55%)
Once	1 (2.56%)	1 (5.88%)
Twice	2 (5.13%)	1 (5.88)	1 (4.55%)
3–5 times	4 (10.26%)	-	4 (18.18%)
6–10 times	-	-	-
11–20 times	-	-	-
More than 20 times	12 (30.77%)	7 (41.18%)	5 (22.73%)

Note. ^a p-values derived from independent samples t-tests for continuous variables and chi-square tests for categorical variables; ^b indicates survey item(s) were only asked for the first year of data collection; ^c indicates survey item(s) were introduced one year into data collection.

). However, participants also reported mild disagreement of the belief that carrying a firearm reduces risk of victimization (mean = 2.67, SD = 2.18). Regarding firearm carriage, initial participants (n = 9) were asked about the past 30 days, and the majority reported no carriage (77.8%), while 22.2% reported carrying a firearm six or more days. After shifting measurement of carriage over the past 12 months (n = 39), over half of participants reported never carrying a gun outside of the home (51.3%). However, nearly one-third reported carrying a firearm more than 20 times during that period (30.8%), while 10.26% reported carrying 3–5 times, 5.13% reported carrying twice, and nearly 3% reported once. Firearm-related beliefs and firearm carriage patterns did not significantly differ from intervention and TAU participants (all p > 0.05).

4. Discussion

This study provides an exploratory descriptive analysis of the social determinants of health, community firearm violence exposure, perceived neighborhood safety, firearm-related beliefs, and gun carriage among youth and young adults enrolled in an evaluation study of a youth-focused HVIP. By situating firearm beliefs and behaviors within broader social, structural, and psychosocial contexts, these findings extend prior work that has often examined firearm exposure or carriage in isolation. Further, our results contribute to a growing body of literature emphasizing multilevel risk environments for youth firearm involvement and reinjury (Carter et al., 2021; R. Cunningham et al., 2009; Richardson et al., 2016). This study highlights how firearm-related beliefs and behaviors may co-occur alongside housing instability, unemployment, substance use, trauma symptoms, and pervasive community violence exposure—underscoring the importance of integrated, trauma-informed intervention approaches.

Participants experienced substantial socioeconomic disadvantages, including low educational attainment, high unemployment, low income, housing instability, and elevated substance use and PTSD symptom severity. These findings align with the prior research demonstrating that violently injured youth frequently face overlapping structural vulnerabilities that increase their risk of recurrent injury and ongoing firearm involvement (Buggs et al., 2022; Cooper et al., 2006; Juillard et al., 2016). Further, exposure to community firearm violence was common, with many participants reporting witnessing shootings, seeing firearms carried regularly, or experiencing direct victimization. Such patterns mirror broader evidence showing that firearm violence is highly concentrated in structurally marginalized neighborhoods and that repeated exposure is associated with adverse mental health outcomes and behavioral adaptations (Abba-Aji et al., 2024; Leibbrand et al., 2020; Fowler et al., 2017; Semenza & Kravitz-Wirtz, 2025).

Gun carriage was prevalent for a significant subset of participants, with higher endorsement observed after the introduction of the revised measure. While just over 20% of participants reported gun carriage when assessed over the prior 30 days, nearly half of participants reported carrying when asked about the past year and approximately one-third reported carrying a firearm more than 20 times. This pattern suggests that shorter assessment windows may underestimate firearm exposure in this population. Further, this finding is consistent with prior studies demonstrating that youth exposed to violence may adopt firearm carriage as a perceived protective strategy (Carter et al., 2013; Rowhani-Rahbar et al., 2015; Spano & Bolland, 2013). Participants also endorsed neutral-to-moderate firearm-related beliefs, including moderate endorsement that firearms are needed for protection and perceptions that peers commonly carry guns, compared to somewhat disagreeing and remaining neutral to the idea that firearm carriage would reduce victimization. These results support ecological models suggesting that firearm carriage is shaped by both environmental threat and social norms (Semenza & Kravitz-Wirtz, 2025). These findings further align with a smaller subsample of social learning frameworks, which posit that youth firearm behaviors are shaped by social network norms and attitudes (Carter et al., 2013; R. M. Cunningham et al., 2015). Importantly, while over half of participants reported never carrying a firearm, the variability in the reported frequency of firearm carriage highlights heterogeneity within this population and suggests a need to tailor the intervention strategies that target firearm carriage behavior, given that experiencing a traumatic event may shift youths’ perceptions.

An important finding of this study is that nearly one-third of participants reported prior violent victimization, reinforcing the characterization of firearm violence as a recurrent cycle rather than a singular event. This pattern of repeat injury aligns with the prior literature demonstrating that individuals who experience violent injury face a substantially elevated risk of subsequent victimization (Mueller et al., 2023). Recurrent exposure compounds both physical and psychological harm and often occurs within the same structural and social environments that contribute to the original injury. For youth, repeated victimization may further normalize violence, intensify perceived threats and the lack of perceived safety, and reinforce firearm carriage as a protective strategy. These findings underscore the critical role of HVIPs as secondary prevention interventions, uniquely positioned to disrupt cycles of violence at a moment of heightened vulnerability and receptivity to change.

Perceptions of neighborhood safety were mixed, with many participants reporting feeling safe most or all of the time, despite widespread exposure to firearm violence. This apparent disconnect may reflect the normalization of violence, and perpetuate the idea that firearms are necessary to provide protection (Carter et al., 2013; R. M. Cunningham et al., 2015). This is consistent with research where youth cite “protection” as the number one reason for why they carry a firearm (Buschmann et al., 2017; Oliphant et al., 2019). Our sample further substantiated these claims with their firearm beliefs, most notably their agreement with the statement “Need a gun to protect myself”. Prior work has similarly shown that youth living in chronically violent communities may report subjective safety even when objective risk remains elevated (Foster et al., 2014). These findings emphasize the importance of interpreting perceived safety cautiously and in conjunction with exposure and behavioral measures. In this sample, firearm-related beliefs coexisted with both perceived safety and high levels of community violence exposure, suggesting that perceived safety alone may not adequately capture motivations for firearm carriage.

Collectively, these findings underscore the importance of critically examining how constructs such as safety, firearm exposure, and firearm beliefs are operationalized, particularly within intervention settings. Current research indicates that youth cite protection as the biggest motivator for firearm carriage, and this need for protection may vary based on external factors such as geographical location, location density, and if it is a familiar or unknown location. In addition to physical factors, there may be further context-specific factors, such as neighborhood conditions, recent victimization, or fear of retaliation. These considerations support our decision to alter the firearm carriage questions to expand the time frame from 30 days to 12 months. The timing and framing of assessment may meaningfully shape responses, especially when youth are enrolled following acute injury or crisis. Baseline measures may capture survival-oriented beliefs, whereas follow-up assessments may reflect evolving perspectives as individuals engage with services and stabilize (Becker et al., 2004; R. Cunningham et al., 2009). These considerations have direct implications for intervention design and evaluation, highlighting the need for longitudinal, developmentally informed measurement strategies.

From an intervention development perspective, our results suggest that HVIPs serving violently injured youth may benefit from explicitly addressing firearm-related beliefs alongside structural needs such as housing stability, employment, trauma symptoms, and substance use. Prior HVIP research indicates that programs integrating case management, trauma-informed care, and social service linkage are associated with reductions in reinjury and arrests (Jay et al., 2026; Juillard et al., 2016; Purtle et al., 2013). Our findings extend this work by highlighting firearm beliefs and carriage as potentially modifiable targets that may complement existing HVIP frameworks. Given the observed variability in firearm behaviors, individualized and context-sensitive approaches may be particularly important for this population.

This study is not without limitations. First, the study utilized self-reported data, which is subject to bias. In addition, several primary constructs were assessed using single items that had not been formally validated. Although these measures were designed to enhance developmental and contextual relevance for the target population, the lack of formal validation limits the extent to which these findings can be directly compared to those from studies using standardized instruments. Furthermore, the inclusion of minor participants meant that the team would need to slightly alter items asked between the samples (minor versus adult) to ensure that all participants could answer the questions to the best of their ability. Second, the small sample size limits generalizability. Third, analyses were primarily descriptive and exploratory, with limited inferential testing due to the small sample size, preventing examination of causal relationships. A longitudinal evaluation of the current HVIPs and others are needed to ensure that programs are sufficiently tailored for their target population capable of engaging youth earlier in the life course to support prevention and reduce reinjury risk. Finally, the measurement of perceived safety, firearm beliefs, and firearm carriage behaviors changed approximately one year into the study, complicating direct comparisons across participants as not all participants were administered the same measures. However, this measurement change may also represent a strength for future work, as the change in measures ultimately offered more nuance and granularity, resulting in a more complete picture compared to the previously used items. Larger longitudinal, cohort studies with consistent measures are needed to clarify temporal relationships between social determinants, firearm exposure, beliefs, and carriage, and to inform development of targeted, developmentally appropriate violence prevention strategies.

5. Conclusions

These findings highlight the heterogeneity of firearm behaviors among violently injured youth and underscore the importance of moving beyond a one-size-fits-all approach with HVIPs. Rather, programs need to be developmentally informed to ensure their age appropriateness, as well as flexible in terms of providing referrals and services to meet participants where they are. From a research perspective, these results reinforce the need for longitudinal evaluation using measures that capture more nuance and better demonstrate the way in which firearm beliefs, perceptions of safety, and firearm carriage may evolve over time and in response to intervention. This supports the notion that perhaps firearm beliefs are a more important evaluation outcome, compared to firearm-related behaviors. Taken together, these findings call for developmentally tailored, trauma-informed HVIPs that are rigorously evaluated over time and implemented through strong cross-sector collaboration to effectively disrupt the evolving pathways linking firearm beliefs, perceived safety, and carriage among violently injured youth.