PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1125-1132

Attitudes of New York City High School Students Regarding Firearm Violence

Doron J. Kahn, BA, Marwan M. Kazimi, BS, and Michael N. Mulvihill, DrPH

From the Department of Family Medicine and Community Health, Albert Einstein College of Medicine, Bronx, New York.

	ABSTRACT

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Objectives.  To assess prevalence of gun possession, attitudes regarding gun possession and gun violence, knowledge and influences of gun violence, and the potential role of physicians in gun violence prevention education among adolescents.

Methods.  An anonymous questionnaire was distributed to 9th through 12th grade high school students at 3 public high schools in New York City.

Results.  Three hundred forty-two surveys were distributed and returned. The prevalence of guns in the homes was 19.6%. Of respondents, 43.2% thought it was okay for anyone to have guns, and 57.3% had been injured or have had a relative injured by a gun. Although 11.6% of adolescents had felt the need to talk to an adult about guns, only 3.0% listed their physicians as one of these adults. However, if asked by their physician, 63.8% would discuss the issue with them. Only 5.7% of adolescents have had a physician speak to them about guns.

Conclusions.  The adolescent population surveyed is frequently exposed to gun violence. Although physicians rarely counsel adolescents regarding gun violence and firearm safety, many adolescents would be receptive to this mode of intervention.adolescence, attitude, firearm ownership, firearm violence, physician role.

Firearm deaths remain a scourge on this country's youth despite advances in numerous areas of health care and social welfare. The United States has the highest youth homicide and suicide rates among the 36 wealthiest nations in the world, as well as one of the highest homicide rates worldwide.¹ In the United States, homicide and suicide are the second and third leading causes of death among all adolescents, and homicide is the leading cause of death among black youth.² Firearm-associated morbidity also continues to exact a grave toll among children and adolescents in the United States. It is estimated that for every fatal assault with a firearm, there are twice as many nonfatal firearm assaults that receive treatment in emergency rooms.³ Accurate statistics on the number, specific injury cause, and degree of disability resulting from the use of firearms among children and adolescents remain difficult to obtain because no surveillance system has been established to document these conditions, despite their high prevalence.

Analysis of the nature of the firearm problem among American youth has called into question the role of physicians.⁴ The medical profession in general, and pediatrics and family medicine specifically, provide preventive medical, psychosocial, and emotional care to their patients. Several organizations have advocated the routine incorporation of youth violence screening, education, research, and clinical services in the pediatric health care setting, because all pediatricians are likely to encounter youths at risk for firearm-related injuries.^5-10 In 1994, 1 out of 5 pediatricians treated a patient <20 years old for a firearm-related injury.¹¹

Although there is abundant literature on risks and causes of violence, especially gun violence, only recently have published data become available on gun violence prevention protocols.¹² Less data exists on the use and effectiveness of treatment strategies. Studies indicate that few pediatricians and family practitioners follow the advice of firearm prevention protocols,^13,14 although most gun owners say they would follow the recommendations of their children's pediatricians regarding safe gun storage, and many would even consider removing guns from their home.^15-17 It is reasonable to assume that if all patients were educated regarding the safest ways to store firearms and some of them followed through with this advice, many unintentional firearm-related injuries could be prevented.

Published surveys on gun violence mostly address the opinions of parents, as they are more often responsible for the presence of guns in their homes. Those who have addressed adolescents did not assess factors that influence their opinions about firearm violence.^18,19 Other surveys, such as the Annual Youth Risk Behavior Surveillance, which gather data on health risk factors that contribute to youth morbidity and mortality (eg, smoking, carrying a weapon), also do not assess opinions regarding firearm violence and physician involvement in firearm violence prevention.²⁰ The primary objective of this survey was to assess physicians' role in gun violence prevention among adolescents. To this end, we surveyed high school students regarding the prevalence of guns in their homes, attitudes toward gun ownership and gun violence, and influences shaping their opinions of gun violence. We also surveyed student knowledge regarding gun violence to assess their awareness of the severity of the issue and how this might affect their opinions regarding gun violence education.

	METHODS

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This study was conducted by a questionnaire (see survey)that was distributed to 9th through 12th graders at 3 public high schools in New York City: 1 in the Bronx and 2 in Manhattan. The schools in this study were chosen because all 3 are large, inner-city high schools in different areas of the city, the student populations of which were easily accessible by our contact person. The students surveyed came from socioeconomic backgrounds typical of both working and welfare recipient residents of New York City. The questionnaires were given to classroom teachers at the 3 schools during a 1-week period, along with an instruction sheet for the teachers that explained the study and gave explicit instructions on how to distribute the survey to the students (available from the corresponding author). The instructions stressed the anonymous nature of the survey. Both complete and partially complete surveys were placed in an envelope and returned to the school contact person, a special education supervisor who coordinated the distribution and collection of the questionnaires.

The questionnaire consisted of 31 questions assessing basic demographic data (age, grade, sex, and race), attitudes toward gun ownership, knowledge of facts related to gun violence, prevalence of gun violence, factors influencing student perception of gun violence, and opinions on the extent of physician involvement in gun violence prevention education. None of the questions were knowingly taken from, or modeled on, previous surveys. Question format included yes/no, Likert scale, and "check all that apply." For analysis, questions that asked the respondent to check all those that apply were scored by a system that grouped responses according to theme. All data analyses were performed using ² statistics to assess statistical significance.

	RESULTS

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Characteristics of Study Population

Of the 342 questionnaires distributed to students, 273 (79.8%) were returned complete. The remainder of the questionnaires was almost fully complete. Only 4 of the 31 survey questions were left unanswered by >11 respondents (69 for question 24, 28 for question 20, 25 for question 27, and 17 for question 11). No questionnaires were discarded because of missing data, and all available data were used for each question. Patient demographics are presented in Table 1. Of the respondents, 191 (56.7%) were female, and 146 (43.3%) were male. Because most of the students were Hispanic, ethnicity was not analyzed as a separate subgroup. Students from all 4 grades were represented.

Student Knowledge of Factual Data

Overall, 95 (27.9%) students correctly identified the 2 most common causes of death among adolescents in this country as motor vehicle accidents and homicide, and another 182 (53.5%) students knew that murder was among the top 2. Males answered correctly more often than females (51/144 or 35.4% vs 43/191 or 22.5%, P < .03). The remainder of the students' responses to factual questions is presented in Table 2.

High School Student Attitudes Toward Gun Ownership

Of respondents, 146 (43.2%) thought it was okay for anyone to own a gun, and 27 (8.0%) thought it was okay for children/adolescents to have guns. There were no differences across grades with regard to these questions; however, more males than females thought it was okay for anyone to own a gun (76/144 or 52.8% vs 66/189 or 34.9%, P < .001) and for children/adolescents to have guns (18/144 or 12.5% vs 8/189 or 4.2%, P < .005).

Gun Prevalence Data

The overall number of students who knew of any member of their household, including themselves, having a gun was 66 (19.6%). The number of households reported to have ever had a gun was 137 (41.0%). Gender differences, as well as differences based on responses to other questions, are presented in Table 3. Guns were more likely to be found in the homes of students who support the right to bear arms and who have had personal experiences with gun violence. When subgroup analysis was performed on data from households reported to have ever had a gun, results were entirely parallel to those in the table.

Responses to questions regarding students' personal experiences with gun violence are presented in Table 4. Of respondents, 35.1% indicated that they had thought of getting a gun at one time, with males reporting this more frequently than females. No differences were noted by grade. The thought of getting a gun was associated with increased frequency of hearing shots in the neighborhood (P < .001), but not with increased frequency of fearing getting shot (data not shown). Of respondents, 57.3% answered that a gun had injured either them or a relative at some time. Of those who have lived in a household with a gun, 101/127 (79.5%) answered that either they or a relative had been injured by a gun, compared with 75/180 (41.7%) of those who have not lived in a household with a gun (P < .001).

Gun Violence Influences

Of respondents, 258 (76.6%) listed multiple sources of exposure to excessive violence in their everyday lives. The police (33.0%), movies (25.3%), and music lyrics (13.2%) were mentioned most frequently as single greatest factors influencing students with respect to guns. Television shows (3.3%) ranked below video games (7.7%), friends (7.3%), and news (4.0%).

Discussion and Intervention With Gun Violence From a Student Point of View

Of adolescents surveyed, 39 (11.6%) said they have felt the need to talk to an adult about guns at least once. More 9th and 10th graders answered affirmatively than 11th and 12th graders (22/130 or 16.9% vs 17/199 or 8.5%, P < .03), and more males answered affirmatively than females (23/142 or 16.2% vs 15/188, or 8.0%, P < .03). Differences based on responses to other questions are shown in Table 5. Respondents who had seen a gun in school, had been threatened with a gun, had seen another person threatened with a gun, or feared getting shot were more likely to want to discuss guns with adults than those who had been exposed to gun violence less frequently. Knowing of a gun in their household and hearing gunshots in their neighborhood were also associated with wanting to discuss guns with adults; however, these data were not significant.

Data on whom students said they would talk to about guns and who has spoken to them about guns are presented in Table 6. At the time of the survey, students were willing to discuss the issue of guns with relatives, friends, and authority figures much more readily than with their physicians. Respondents reported that their physicians have rarely brought up the issue of guns with them.

However, 213 (63.8%) adolescents said that if their physicians asked about guns in general, they would be willing to talk to them about the issue. Not surprisingly, this number dropped to 174 (52.6%) when asked if they would answer honestly about guns in their homes. Data based on responses to other questions are presented in Table 7. Respondents who have thought of getting a gun or have used a gun to threaten someone else were less willing to discuss the issue of guns with their physicians. Having a gun in their household, having seen a gun in school, having been threatened with a gun, having seen another person threatened with a gun or injured by a gun, hearing gunshots in the neighborhood, and fearing getting shot did not affect willingness to discuss guns with physicians.

When asked what their physician's role should be with regard to discussing guns with them, 179 (54.1%) respondents said that it was not their physician's role to ask about guns, 104 (31.4%) said it was up to their physician whether or not to ask about guns, 39 (11.8%) said it was as much their physician's responsibility as others to ask about guns, and only 9 (2.7%) said that it was their physician's responsibility more than others to discuss guns with them.

	DISCUSSION

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This survey of high school students in New York City revealed several trends among the sample population regarding experiences with and attitudes toward gun violence. Based on a generalized reading of their responses, the high school students were diverse in their thinking, as well as their socioeconomic backgrounds. Although the gender and race distributions of the students are not representative of New York City averages,²¹ being weighted more toward female gender and the Hispanic population, it does provide a reasonable snapshot of adolescent opinions and concerns regarding guns and violence. Of students surveyed, 19.6% responded that they or someone in their household possessed a gun, whereas 41% responded that at some point, past or present, a member of their household had a gun. Although the figure in our study for gun prevalence is at the lower end of estimated national averages, these figures are consistent with reports from other urban areas, which tend to maintain gun possession rates lower than those of rural areas.^22,23 One recent survey of family practice patients in different areas of residence found that an estimated 16% of those who live in a city keep a gun in the home, whereas 51% of those who live in rural areas have a gun in the house.²⁴ Two other surveys of urban high school youth report similar availability of handguns.^18,19 Although the student population sample was not an ideal demographic match for New York City, the rates of gun ownership and the diversity of experience with firearms and violence were favorable for drawing conclusions from the data.

Regarding students' factual knowledge, the fact that less than half (38%-47%) knew the numbers of guns, loaded guns, and deaths caused by guns indicates the need for greater gun violence education.

An overwhelming majority of the students surveyed believed, correctly, that guns are more likely to be found in homes with children than in homes without children. The fact that students were aware of the presence of firearms in homes with children might imply either that they are highly attuned to their own environments or that the recent high profile episodes of gun-related violence in schools around the country have raised their suspicion of the easy accessibility of guns. Concerning, however, is the fact that only half of the students knew that guns kept in the home are more likely to harm someone known to the owner than in self defense. This supports data obtained from a recent telephone survey of adults which found that only 40% of adults believed that keeping a gun in the home makes the home less safe, and the remainder stated that it depends (23%) or that the home would be more safe (29%) with a gun in the home.²⁵ In reality, guns kept in the home are 43 times more likely to be used to kill someone known to the family than to be used to kill in self defense.²⁶ With an estimated 65% of firearm injuries occurring in homes,¹² the likelihood of a child experiencing either direct injury or indirect emotional trauma in these cases of gun violence is evidently quite high. The ramifications are already present in this study population, where nearly 60% of respondents indicated that either they or a relative had been injured by a gun, and more than one quarter answered that they feared being injured by a firearm either daily or often.

Another disturbing trend associated with the presence of guns in households with children is the effect it has on opinions about firearms. Those who answered yes when asked whether it was okay for children and adolescents to own guns were much more likely to come from homes with guns. These findings bear grave implications for the future behavior and attitudes of children exposed to guns in homes. Just as exposure to depictions of violence on television are associated with the subsequent development of violent behavior, the extension of this social learning model, whereby children learn through watching, imitating, and assimilating information about the functioning of adult society,²⁷ predicts that children exposed to firearms and firearm violence in the home will more likely develop complacent attitudes toward firearms as adults.

Although much has been written on the influence of violence in media (specifically movies, television shows, music videos, and music lyrics) on children and its association with aggressive behavior, fear, and desensitization,²⁸ little has been published regarding alternative influences, such as the Internet²⁹ and law enforcement officials. The decade-long increase in police presence and recent violent events in New York City involving police officers have clearly influenced the students surveyed in this study. Although the majority of students cited several sources as influencing them with regard to guns, among them movies, video games, and music lyrics, the single most common influence chosen was the police. In addition, this question provoked the majority of unsolicited remarks written on the questionnaires, containing mostly antipolice sentiment. It is likely that future work will have to consider the influence of police officers as role models who, at the same time, are licensed to carry and use firearms at their discretion. Their portrayal by the media and their personal interaction with adolescent civilians must be improved before New York City police officers will be able to effectively act as agents devoted to firearm safety and the prevention of youth violence, whether or not their portrayal is deserved.

This study uncovered a number of other important issues related to firearm violence. There was a small but significant number of adolescents, especially males, who thought it was appropriate for adolescents to possess guns. With data supporting the ease of obtaining guns illegally in our country,²¹ there is little to stop these children from obtaining firearms if desired. There were also a significant number of adolescents who felt the need to speak with adults about gun violence, once again more among males than females and more among the younger adolescents surveyed. This need increased as the adolescent was exposed to gun violence, whether personal or witnessed, and either in school or in their neighborhood. Those who wanted to talk to an adult about guns, however, seemed hesitant to bring up the issue with their physician. This is consistent with previously published data that shows that only 4% of gun owners named their physician as a source of information on injury prevention.¹⁹ Very few adolescents in our study had any recollection of their physician ever discussing the issue with them. This is supported by the literature, in which 1 study found that only 3% of the respondents received gun counseling from their physicians.¹²

Approximately two thirds of the students reported that they would confide in their physicians and would be receptive to gun safety education. This data are supported by studies that show that most questionnaire respondents would find counseling regarding gun safety helpful, and many would follow physician advice to remove guns from the home¹⁶ or keep guns unloaded and locked.¹⁵

Although just over half of adolescents felt that it was not their physician's role to discuss the issue of guns with them, a large number did feel that the physicians should play a part in gun violence counseling. If directly asked by their physician about guns in general or guns in the home, the majority of teens would be willing to talk about the issue, and even a third of those with guns in their homes said they would confide in their physicians. Also, half of those who have considered obtaining a firearm and half of those who have used a firearm in a threatening manner said that if asked, they would discuss the issue with their physician. Thus, physicians should not hesitate to bring up guns with their patients, as it seems that many adolescents are receptive to discussions about the issue.

There are several limitations to this study. This concentrated, inner-city school population may not represent all communities and, therefore, generalizations from the findings should be made cautiously. Also, it is possible that many of the adolescents we polled were unaware of the presence of firearms in their homes. However, this would only serve to underreport the already large number of students that said they knew of firearms kept in their homes and the larger number of students who knew that there had been a firearm in their home at some time. The questionnaires were distributed in a classroom setting so students may have been reluctant to answer truthfully for fear of a lack of anonymity, although the anonymous nature of the questionnaire was stressed both by the teacher distributing the questionnaire and on the top of each questionnaire. Once again, this would probably only serve to underreport the extent of the problem of gun-related violence among adolescents. On the other hand, a similar prosocial influence may have caused the students to overreport a willingness to discuss the issue of firearms with their physicians. Also, 20% of surveys were returned incomplete by 1 or more questions, perhaps again because of the fear of lack of anonymity. Finally, we did not assess the frequency in which the students surveyed visit the physician. It is possible that many of these students rarely come into contact with a physician and, therefore, have not had the opportunity to be counseled regarding firearm violence and safety. However, every student must have come into contact with a physician at least once to obtain school health clearance.

	CONCLUSION

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The reported prevalence of guns in the homes of adolescents studied in New York City was ~20% at present and ~40% in the present or past. The likelihood of owning a gun increased with the belief that it was appropriate to own a gun, having been injured by a gun, or having had a relative injured by a gun. Alarmingly, ~60% of adolescents said that a gun had injured either them or a relative. Although adolescents were not seeking advice from physicians regarding gun violence, more than half were willing to discuss the issue with physicians and would even be honest with them regarding guns in their homes. The more violence an adolescent was exposed to, the more likely they were to want to discuss this issue with an adult. Exposures to violence came in many forms, but those listed most often by adolescents as the most influential factor exposing them to excessive gun violence were the police, movies, and music lyrics. Finally, more adolescents were willing to discuss gun violence and firearm safety with physicians than actually had.

Firearm violence among our nation's youth has reached an alarming level and may soon take over as the number one cause of death among children and adolescents.³⁰ Many fatalities and injuries may be prevented through improved education and safety practices. Ideally, this education will come from the parents and other relatives at home, teachers in school, religious figures, and police. However, because some of these sources of helpful information may be uneducated as to proper firearm safety practices, physicians must use their influence and contact with children, adolescents, and parents in the community to engage in discussions about firearm violence, safe storage of firearms, and removal of firearms from the home. Ideally, physicians will strive to prevent firearms from entering any home, especially those with children. Although some studies have shown only small benefits of physician intervention in gun violence prevention education,¹⁵ most agree that counseling by physicians regarding gun ownership and gun storage is beneficial.^4,10

	ACKNOWLEDGMENTS

We thank Amy Mulvihill for generously taking the time to distribute and collect the student surveys; Dr William Burton for his help in analyzing the data; Devora Kahn and Gladys Valdivieso for their ideas and support throughout the project; Dr Catherine Weber and Dr Philip Ozuah for commenting on the manuscript; the schoolteachers of the 3 high schools who took the time to administer our survey; and the students who participated in the survey.

	FOOTNOTES

Received for publication Sep 11, 2000; accepted Nov 29, 2000.

Reprint requests to (M.N.M.) Department of Family Medicine and Community Health, Albert Einstein College of Medicine, 906 Belfer, 1300 Morris Park Ave, Bronx, NY 10461. E-mail: mulvihil{at}aecom.yu.edu

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