Research Proposal: Examining the Relationship between Gun Violence Exposure and Stress

and Hypertension in Low-Income Women

Carley Robinson

1) Specific Aims
Gun violence in the United States eclipses all other industrialized nations (World Bank 2012)

and demands a new approach. Despite the implications to public health, this new pandemic has

yet to be contained by legislative action in the same way as similar issues, such as drug

addiction. However, just as drug addiction leaves the most vulnerable communities at risk, so

too does exposure to gun violence, which continues the proliferation of increased health issues

and high mortality rates in these populations. Investigating gun violence from a public health

perspective can give new insights into addressing the issue. Currently, the CDC does not have

access to any funding for research or programs that specifically address gun violence in the

United States (Frankel 2017). This lack of focus and gap in research leaves many questions on

the table. Therefore, separate action needs to take place in order to explore this unique health

concern and fully understand both the impact and the solution.

To further this investigation, this study will target low-income women, an at-risk, vulnerable,

population in the United States, in order to clearly define the risk factors associated with

exposure to gun violence in this group, and how that exposure impacts health, specifically

stress and hypertension. The tools used will involve surveys as well as in-depth interviews to

better gauge all facets of this issue. Once the details of how this specific population experiences

this exposure, and its subsequent influence on health, are clearly mapped, this study will seek

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to develop specific intervention strategies and recommendations to help alleviate these

impacts.

Aim 1: To clearly define the risk factors associated with exposure to gun violence in a

population of low-income women.

Aim 2: To understand how exposure to gun violence impacts levels of stress and hypertension

in this population.

Aim 3: To propose possible intervention strategies that address the risk factors associated with

exposure to gun violence.

Examining this exposure in a socio-economic context will help lay the groundwork for

addressing this issue in a vulnerable population, which can be built upon for other

communities. Because gun violence is complex and poorly researched, the use of surveys, as

well as in-depth interviews, will allow this study to add as much detail as possible to the

scientific conversation surrounding this exposure. Both tools provide the participants the

opportunity to fully articulate their experience across a range of feedback platforms. The

surveys will be issued to individuals that meet the study population criteria. These surveys will

afford basic data on exposure, health outcomes, demographic information, family history, and

other pertinent data collection points that can then be easily tracked, reported and analyzed.

The in-depth interviews will deepen the understanding of this data, adding additional insight

that cannot be captured by data points alone.

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2) Significance

Mass shootings and urban violence have a particularly magnified effect on the health of low-

income neighborhoods; with those that are food insecure, unemployed, and possess lower-

levels of education experiencing gun violence at a higher rate than more affluent communities

(Santilli 2017). These kind of weapon related violent events (WRVE) peak for those in the 16-18

age range (Russell 2016) and exposure to violence has resonating impacts on health outcomes

for the duration of adulthood (Greenfield 2009).

Previous research has found a correlation between socio-economic standing and the odds of

experiencing violence, stating that as one’s economic status decreases, the odds ratio of

experiencing violence increases (Winnersjo 2012). Additionally, women are especially

vulnerable to violence, and violence against women has a trickle down impact on the long-term

health of children and families (Bhattacharya 2014). By addressing the timely issue of gun

violence as it relates to, and impacts, those at the intersection of this gender and economic

pattern, the study results can lay the ground work for improving the health of communities as a

whole.

Violence also has a definitive impact on health care systems, with an increasing need for

providers to be able to identify, treat, and prevent aspects of violence-related health issues

(Knapp 2011). Therefore, this study will also seek to articulate strategies for addressing gun

violence in low-income populations as a framework for healthcare providers and future

interventions. In this regard, the response from the in-depth interview piece of the study design

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will allow for feedback solicitation directly from the impacted population; thus generating

valuable ideas for effective interventions.

3) Innovation
There is little, if any, research examining gun violence in this low-income. In fact, most studies

that stratify gun violence exposure by gender focus mostly on African American males; outlining

the various aspects of what is referred to as ‘street life’ and how this erodes physiological

factors (Harden 2014). In addition, the research pertaining to violence exposure in women is

primarily concerned with domestic violence or intimate partner violence; noting the clear

physical injuries women suffer and how best healthcare systems can prevent these types of

injuries (Colomnini 2017). Even in this realm, most violence-based research targeting female

populations is from the international stage. Other nations, like Turkey and India, are keeping a

close eye on these trends and researchers abroad are proposing interesting strategies to

tackling this brand of violence (Wolf 2014).

To be sure, domestic and intimate partner violence is a mounting concern for all women across

the world. However, in the United States, where gun violence continues to grow in incidence

and prevalence, it is increasingly important to scrutinize how gun violence permeates our

culture.

Additionally, the concerns pertaining to gun violence demand a novel approach. Addressing gun

violence as a health exposure, with measurable impacts on health outcomes, can provide a new

understanding about the unique blend of factors that allow this exposure to propagate. In the

same way that tobacco use, car safety, workplace safety, fluoridation of drinking water, and the

control of infectious disease have all benefited from the rigorous work of public health in the
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20th century (CDC 2013) so too can the issue of gun violence benefit from a public health

approach.

The public health method can lead to stronger surveillance, control, and enhanced outcomes

surrounding this issue. The public health model (see figure below) can also inform other aspects

of the debate, including public policy, increased life expectancy for at-risk populations,

information credibility, enhanced community partnerships and better law enforcement

strategies.

(Ranney 2013)

This study will seek to begin that conversation by investigating the most vulnerable

communities, building outward on that knowledge to develop proposed interventions that

might be translatable to other populations as well.

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Public health is credited with adding 25 years to the life expectancy of people in the United

States in this century (CDC 2013). Adding a reduction of gun violence to the list of public health

achievements takes imagination and a true revolution of thought. However, if realized, it could

be possible to augment this life expectancy number for all citizens.

4) Approach

Capturing the incidence and health impact of gun violence can be very difficult. Often, in the

communities that are affected the most, the very nature of the violence itself can lead to an

unwillingness to talk about openly. In addition, it has been shown that the impact of exposure

to violence can be interpreted differently by participants based on gender (Jackson 2017).

Therefore, a two-prong approach will help get the most out of the available data.

This study will be a cross-sectional analysis using both survey methods and in-depth interviews

aimed at low-income women in Duval County, Florida. This will allow researchers to collect

categorical and continuous data that can easily be examined using statistical software. The in-

depth interviews will expand on this data and help give a clearer picture of how the study

population internalizes and understands gun violence and the corresponding health impacts.

This will also give significant feedback on ways in which the participants feel this exposure can

be mitigated. The interviews will take place after the surveys, as analysis of the survey data can

inform the formation of the interview questions by providing insight into the areas of interest

that the participants should elaborate on.

The population being studied is low-income women, as this population is the intersection risk

for violence exposure on both the gender and income continuums as shown in the previous

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section. Participants will be randomly selected based on municipal income data for Duval

County, Florida. The outcomes of interest are changes in levels of stress and hypertension.

The hypothesis of this study is that exposure to violence will have a relationship between both

stress levels and hypertension in low-income women. By examining an incredibly

disenfranchised section of the population, there are quite a few confounding factors that

attribute to poor health outcomes. These include pre-existing health issues, family medical

history, access to health care, living conditions, etc. Therefore, by focusing on these two health

outcomes in particular, the study can control for confounding factors as much as possible, by

limiting the scope of the health conditions of interest and including the aforementioned

confounders into the statistical analysis.

Primary data will be collected from the human subjects in the study. This will be done by

researchers overseeing the completion of surveys and in-depth interviews. Survey questions

will address demographic, health, economic, and family history data. In-depth interviews will

consists of open-ended questions designed to prompt participants to elaborate on their survey

responses, while also giving them the ability to convey details to researchers that may not have

been captured in a survey structure.

In order to keep this data confidential, personal data will be housed in a separate, secure

electronic file, while the data that is analyzed will contain only a person’s randomly assigned ID

number.

A regression analysis will compare the relationship between exposure to gun violence and the

health outcomes of stress and hypertension, where p=0.05. This analysis will also control for

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other possible confounding variables, such as family history of violence, employment status,

health insurance coverage, and any other known health conditions, and will only apply to that

information that was collected and recorded via the survey method. The in-depth interview

information will be summarized separately and add insight to any relationship found within the

data.

The data and the interview results will be synthesized to create suggested intervention models

for reducing gun violence and/or addressing the corresponding health issues, in this population.

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