Research Activities

(funded by the Silver Family Faculty Innovation and Excellence Award, 2022-2024)

Extreme Risk Protection Order (ERPO) laws have received increasing attention as effective tools to prevent firearm suicide and homicide, including mass shootings. However, their utilization is not well described. Oregon’s ERPO law allows family or household members or a law enforcement officer to petition a civil court for an order to temporarily restrict a person’s access to firearms or other weapons if the court determines that the person is at imminent risk of causing harm to themselves or other. For this project, we analyzed ERPO use in Oregon for the 5-year period after implementation of the law, 2018-2022, to determine the frequency of ERPO use, petitioner characteristics (e.g., family/household member, law enforcement), the reasons for petitioning (e.g., risk of assault, self-harm, mass violence), and the rate of petition approval/denial. Our findings suggest that Oregon’s ERPO law is being used as intended to try to prevent self-harm, assault, and mass violence by firearm, but that there are opportunities to increase its effectiveness by expanding petitioner eligibility, improving documentation of the weapons surrender process, increasing public awareness about the law, offering training for those involved in implementation of the law, ensuring petitioners and respondents in need receive effective healthcare or social services, and providing assistance for the public in petitioning effectively.

(funded by the Silver Family Faculty Innovation and Excellence Award, 2022-2024)

This project collects and analyzes data from emergency department records of patients presenting to the OHSU and Legacy Emanuel Trauma Centers with firearm injury from 2010 to the present. The research team utilizes administrative data from the electronic health record (EHR) as well as manual electronic health record (EHR) review to understand characteristics surrounding incidents leading up to, and resulting from, firearm injury.

Data collection is based on standardized processes used in the National Violent Death Reporting System (NVDRS), which tracks information related to fatal firearm injury. There is no comparable system for nonfatal injuries. This project aims to fill the void of information surrounding these nonfatal firearm injuries by compiling and reviewing records from both Level 1 trauma centers in Portland. Researchers use documentation in the EHR to distinguish between unintentional, assault, self-harm, legal intervention and undetermined intent, and meet weekly to discuss cases. All injury cases are reviewed by at least two independent coders. The overarching goal is to understand how and why firearm injuries are occurring locally, and inform tailored prevention strategies.

(funded by the Friends of Doernbecher Foundation, the Doernbecher Tom Sargent Safety Center through the Injury Free Coalition for Kids, 2013-2014)

The Doernbecher Tom Sargent Safety Center at OHSU promotes secure firearm storage in households with children by providing education and offering firearm storage devices to the public at low-cost. However, there is limited knowledge about parents’ and caregivers’ firearm storage practices and preference for storage devices, including their willingness to pay for such devices. In collaboration with the Doernbecher Tom Sargent Safety Center, Dr. Carlson and her team conducted an in-person survey, between April 2018 and November 2019, of 294 parents/caregivers, aged ≥18, with both children and firearms in the home. Surveys asked about reasons for firearm ownership, storage practices, preferences among five storage-device options, and prices participants were willing to pay for devices. Many participants (73%) reported owning firearms for personal protection, and few (29%) stored them unloaded and locked, with ammunition stored separately. Over half (55%) of the survey participants owned cable locks, but only 36% of owners reported regularly using them. Rapid-access devices (electronic and biometric lockboxes) were less-commonly owned (26%), but more likely to be regularly used (73%). Most participants (78%) preferred rapid-access devices, and many were willing to pay at least retail cost for them. These findings can help inform injury prevention program development and implementation and suggest that rapid-access devices may be the most preferable firearm storage devices for distribution by injury prevention programs. 

(funded by the Oregon Criminal Justice Commission, 2022-2024)

The Gun Violence Review Commission (GVRC) for Multnomah County, a collaboration with the Multnomah County District Attorney’s office, includes representatives from 30 organizations and government agencies engaged in finding preventative solutions to gun violence. Launched in December 2023, Commission Members meet monthly to discuss details of two closed gun violence cases, provide information from their organizational records or personal experiences about the individuals involved, and reflect on the circumstances of and antecedents to the incidents. Case reviews offer a holistic window into the lives of the individuals involved in gun violence incidents, which when examined across multiple cases, reveals patterns and opportunities to intervene and prevent future violence. Commission Members develop recommendations for violence prevention, which are then implemented by a Leadership Committee composed of community changemakers. Similar review commissions are found across the United States, most notably in Wisconsin (Milwaukie Homicide Review Commission), and are an effective public health approach to violence prevention.

(funded by the OHSU-PSU School of Public Health Catalyst Award, and the OHSU Trunkey Center Research and Innovation Award, 2022 – 2024)

This project uses a participatory approach to evaluate Healing Hurt People-Portland (HHP), a Hospital-Linked Violence Intervention Program (HVIP) operating at OHSU’s and Legacy Emanuel’s Level 1 Trauma Centers and managed by the Portland Opportunities Industrialization Center. HHP’s Intensive Case Managers meet patients of color who are survivors of violent, penetrating injuries at their hospital bedside ideally within four hours of injury, which is also known as the “golden moment” because individuals are most likely to make life changing decisions during that time. Case Managers, who themselves have lived experience of violent injury, seek to address and diffuse victims’ anger, prevent retaliation, and provide up to 18 months of wraparound support – in the form of housing, mental health care to process trauma, and job placement – to encourage a life without violence.

Our research team works closely with HHP and the OHSU Trauma Program to evaluate the implementation and effectiveness of HHP at OHSU. We have developed a plan for long-term evaluation and are currently executing the first phase: a Photovoice pilot project with HHP’s Intensive Case Managers. Case Managers will take photos of aspects of their everyday lived experience to illuminate their perspectives on conducting violence prevention work. Case Managers will then engage in a series of discussions about the photos with the research team and choose the most impactful photos, which will be displayed in a curated photo exhibit open to the public, decision-makers, and community leaders. In future phases of our research, these qualitative data will be combined with quantitative data to build a richer understanding of HHP successes, barriers, and outcomes, ultimately supporting a full-scale implementation-effectiveness study of HVIPs across Oregon.

(funded by the National Institute of Mental Health, 2016-2018)

• War Veterans have a significantly increased risk of fatal and nonfatal traumatic injury in the years immediately following combat deployments. Intentional self-harm injuries (e.g., suicide) are well- documented sources of Veterans’ fatal injuries, particularly among those who served in the military post-9/11. Firearms are the most commonly used mechanism in Veterans’ suicide deaths, and are involved in up to 60% more Veteran suicides than non-Veteran suicides. Little is known about Veterans’ nonfatal firearm injuries or their unintentional firearm injuries, even though these comprise the majority (81%) of all firearm-related injury events. We linked Veterans Affairs (VA) administrative data to four Oregon state public health databases to analyze the rates, risk factors, and circumstances of firearm injury among post-9/11 Veterans in Oregon.

There were 104 firearm-related events between 2007 and 2016 among Oregon post-9/11 Veterans. Of these, 45 (43%) were fatal and 59 (57%) were nonfatal. Most fatal firearm injuries were self-inflicted (suicide; 87%) and about half of nonfatal firearm injuries were unintentional (54%). A quarter (25%) of nonfatal firearm injuries were caused by assault. Compared to non-veterans in Oregon, Veterans had an overall higher rate of firearm events (21 events versus 18 events per 10,000 population). Additionally, we found that, among Veterans, a larger proportion of nonfatal firearm injuries were unintentional (54%) compared to non-Veterans (35%), whereas a larger proportion of nonfatal injuries were caused by assault in non-Veterans (43%) compared to Veterans (25%). A similar difference was seen in fatal firearm injuries. The proportion of fatal firearm injuries caused by assault among non-Veterans was higher compared to Veterans (14% versus 7%).

(funded by the Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center – Portland, 2019-2024)

This multi-faceted project: a) describes the scope of firearm-related injuries and deaths among Veterans receiving VA healthcare; b) examines health records of injured Veterans to describe the circumstances of and healthcare treatment for firearm injuries; c) conducts an analysis comparing VA healthcare costs among Veterans with and without firearm injuries; d) interviews VA providers and rural-residing Veterans who own firearms and receive VA healthcare to understand their experiences and elicit their recommendations for ways VA can help prevent firearm injuries; and e) synthesizes quantitative and qualitative results to build a comprehensive, culturally competent firearm injury prevention toolkit of strategies tailored to VA facilities and rural-residing Veterans, their caregivers, clinicians, and communities.

Key Findings To Date:

The Veterans Firearm Injury Dashboard displays rates of firearm-related injuries and deaths among Veterans receiving VA healthcare from 2010-2021, organized by rurality of residence, county, and state.

We used a retrospective cohort design to analyze associations between nonfatal firearm injuries and subsequent suicide among all Veterans who used VA healthcare, nationally, between 2010 and 2019. Key results showed that the odds of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries were more than doubled. Among Veterans with nonfatal firearm injuries, those with depression or substance use disorder diagnoses had twice the odds of subsequent suicide than those without these diagnoses (https://doi.org/10.1111/acem.14711).

Our review of national VA health records indicated significant differences in firearm injury intent by rurality: unintentional injuries were more frequent among rural-residing Veterans and assault/homicide injuries were more frequent among urban-residing Veterans. Injuries from handguns were most common regardless of rurality of residence, although injuries from rifles were four times more common among rural-residing Veterans. Few injured Veterans had documentation of firearm safety-related interventions in their health records, reflecting a missed opportunity for prevention.

Identification and development of firearm injury prevention strategies was informed by literature reviews and our project’s qualitative interviews with rural Veterans who own firearms and receive VA healthcare and VA providers at four rural-serving VAs in Louisiana, Wyoming, and Oregon. An overarching goal of these public health strategies is to normalize conversations about firearms and safety within VA healthcare environments. Beginning in 2023, partners at VA Alexandria (Louisiana) implemented pilot strategies with our team’s support. Our formative evaluation data indicated pilot strategies were acceptable to Veterans and VA clinicians. Pilot site implementation and evaluation findings are summarized here. In 2024 we are expanding pilot implementation and evaluation in partnership with VA Sheridan (Wyoming).

When asked about universal and dementia-specific firearm safety discussions, older Veterans and VA clinicians unanimously endorsed firearm safety discussions for older patients experiencing cognitive decline or dementia, a high-risk population. In general, most Veterans accepted the idea of universal firearm safety discussions at the VA and said raising the topic would not stop them from engaging with VA care (https://doi.org/10.1080/07317115.2023.2254292).

(funded by the Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center – Portland, 2020-2024)

In partnership with OHSU’s Oregon Clinical and Translational Research Institute’s (OCTRI) Health Experiences Research Network, this project used Database of Individual Patient Experiences (DIPEx) qualitative methods to conduct video- and/or audio-recorded interviews with Veterans who experienced a firearm injury. Veterans told their stories in their own words, describing their lifetime experiences with firearms, the context in which their firearm injury occurred, and the physical, social, and emotional impacts of their injuries. They offered comments to other firearm owners and to healthcare providers treating people with firearm injuries. Participants’ stories are organized into an online public-facing resource for members of the public (www.healthexperiencesusa.org). A subsequent project explores whether viewing interview content supports healthcare providers’ comfort and competence to discuss firearm injury prevention with patients.