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The American Surgeon™

2023, Vol. 0(0) 1–9
Evaluating the Feasibility of a Novel Firearm © The Author(s) 2023
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Injury Prevention Program for Pre-adolescent sagepub.com/journals-permissions
DOI: 10.1177/00031348231220595
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Children Through Health Care and
Community-Based Partnerships: The Future
Healers Program Pilot Study

Karen Udoh, BS1, Caitlin Wessel, BS1, Rheyana Branch, BA1, Jessica Mahler, BS1,
Joseph Holland, MSHA1, Briana Coleman, BS1, Satya Alluri, MS1, Symone Jordan, MPH1,
Anam Ahmed, BA1, Baylee Polzin, BA1 , Crystal Dye, BA1, Kiara Smith, BS1,
Alyssa Brown, MD, PhD2 , Zahara Gully, MS3, Susan Sawning, MS1, Craig Ziegler, PhD1,
Matthew Ruther, PhD4 , Christopher 2X5, Christopher Jones, MD1,6, and
Keith Miller, MD1,7 

Abstract
Background: Firearm violence is an American public health crisis that negatively impacts children and disproportionately
affects Black youth. Few firearm injury prevention programs have been described in pre-adolescent children. The Future Healers
Program is a novel collaboration constructed via partnership between the medical school, trauma center, academic surgery
department, and local non-profit community organization. Our study sought to evaluate if (1) partnering with community
organizations facilitated recruitment of children with prior exposure to firearm violence and (2) the health care community was
a potential trusted partner appropriate for program delivery.
Methods: Children aged 4-13 were recruited to join the program via news outlets and social media and in partnership with a local non-
profit organization. Of the children and parents participating in the program, 48% (44/92) and 59% (38/64), respectively, completed an
IRB-approved survey study. Pearson’s chi-square, percentages, and 95% confidence intervals evaluated differences between children and
caregivers on sociodemographic characteristics, firearm exposure (FE), firearm violence exposure (FVE), and perception of health care.
Participant’s residence was geocoded in relationship to incidents of firearm injury (2008-2021) in the same region.
Results: Caregivers (95%) and children (84%) reported substantial exposure to firearm violence and resided in areas with
frequent firearm injury incidents. Notably, 82% of caregivers and 66% of children reported having a family member injured by
gunfire. A high percentage of caregivers (79%) and children (91%) self-reported trust in the health care system.
Conclusion: Partnerships between community organizations and health care systems can develop prevention programs that
effectively recruit and engage pre-adolescent children impacted by firearm violence.

Keywords
pediatric trauma, trauma, prevention, firearm violence, adverse childhood experiences

1
University of Louisville School of Medicine, Louisville, KY, USA
2
Department of Surgery, Northwestern University, Chicago, IL, USA
3
Jefferson Community and Technical College, Louisville, KY, USA
4
University of Louisville School of Urban and Public Affairs, Louisville, KY, USA
5
Christopher 2X Game Changers Organization, Louisville, KY, USA
6
Department of Surgery, Division of Transplant, University of Louisville School of Medicine, Louisville, KY, USA
7
Department of Surgery, Division of Trauma and Surgery Critical Care, University of Louisville School of Medicine, Louisville, KY, USA

Corresponding Author:
Keith Miller, Department of Surgery, University of Louisville, 530 S. Jackson St. Louisville, KY 40202, USA.
Email: [email protected]
Data Availability Statement included at the end of the article.
2 The American Surgeon™ 0(0)

Background individuals impacted by violence in our community. Children

and families were invited to participate in the monthly ses-
Firearm injury is the leading cause of death in children and sions incorporating medical education, mentorship, com-
adolescents in the United States (US).1 In 2020, firearms munity support, and wellness interventions. The sessions
constituted 64% of US children/adolescent homicides and occurred at accessible and centralized sites, such as the
79% of all homicides.1 The complex sociological and po- University of Louisville Hospital, the Chestnut Street Family
litical factors entrenched in the alarming rise of US firearm YMCA, and The Galt House Hotel, for the children and
violence have generated calls to develop comprehensive caregivers to attend. We invited program participants (chil-
approaches to this issue and, specifically, firearm injury dren and their caregivers) to complete surveys to evaluate if
prevention programs.1-4 The US Justice Department suggests (1) intentional partnership with community organizations
that firearm injury prevention programs contain several te- resulted in the successful recruitment of children with prior
nets, including research, hospital-based prevention, and exposure to firearm violence, (2) level of FVE in the local
community involvement. Although many of these programs community is as high as local data reports, and (3) if children
have significant community impact, most have focused on and caregivers program participants participating in the
adolescents and young adults rather than pre-adolescents.5 prevention program perceived the health care community as a
Firearm homicide rates are highest in non-Hispanic Black trusted partner in their overall health and well-being.
individuals, regardless of age;1,2 therefore, it is imperative to
have effective prevention programming focused on Black
pre-adolescent youth. Methods
Few studies have examined childhood firearm violence The EQUATOR network guideline was used to ensure proper
exposure (FVE), reporting how children are experiencing reporting of methods, results, and discussion (SDC 1).
indirect and direct firearm violence at an early stage.5,6 Children between the ages of 4-13 were recruited to join the
Exposure to firearm violence is an example of an adverse Future Healers program through advertising, news reports,
childhood experience (ACE) which are defined as stressors social media, and local partner organizations, including the
following traumatic events that can accumulate into toxic Chestnut Street Family YMCA14 and Christopher 2X Game
stress and harm one’s overall health.7 Current literature Changers.15 Many participants had a pre-existing connection
documents the negative long-term consequences of ACEs with Christopher 2X Game Changers, a nonprofit organi-
and general strategies to mitigate their effects.7-9 However, zation that engages victims of firearm violence and promotes
there has been minimal investigation on youth firearm vio- early childhood education to end violence long term. This
lence specifically in relation to ACEs and the potential ef- study was conducted following review and approval by the
ficacy of intervention programs to mitigate trauma impact in Institutional Review Board (IRB) (#22.0243).
younger age groups. Fundamental questions remain un- Children and caregivers registered in the Future Healers
answered on who should deliver these programs and how to program who partook in at least one programming event were
recruit and engage children at risk of firearm injury. eligible to participate in this study. In total at the time of the
In the Louisville, Kentucky (the study region), there is survey, 92 children and 64 parents met these criteria. Staff
substantial morbidity and mortality attributable to firearm members provided IRB-approved survey recruitment letters
violence. A collaborative database reported an overall inci- in person at two Future Healers program events and elec-
dence of 129 firearm injuries per 100,000 individuals in tronically via email. The letter briefly explained the purpose
2021 in the same region, with 664 out of 4266 gunshot in- of the study, the information gained from the study, the risks,
juries occurring in individuals under 18 years of age between and the contact information of the study group. Before
2017 and 2021.10 During the height of the COVID-19 completing the survey, the children and caregivers signed
pandemic, the associated morbidity and mortality in the city IRB-approved assent and informed consent forms. The
increased significantly, with twice as many years of potential children and caregivers completed a paper copy or computer-
life lost to firearm violence as to COVID-19, thereby high- based survey via Qualtrics at Future Healers’ events or
lighting the overwhelming burden of this issue inflicted upon electronically over 3 months (June to August 2022). The
young, Black individuals.11-13 study participants received a $5 gift card following com-
By creating the Future Healers program with a novel pletion of the survey.
multi-partner structure (Figure 1), our study aims to provide
insight relevant to the construction and delivery of a pre-
vention program to youth at risk for firearm injury during the
Primary Outcome Measures
pre-adolescent stage of development. We recruited children The study’s primary outcomes included (1) prior FVE
aged 4 to 13 in the metropolitan region. Successful recruit- amongst participants and (2) the perception of the health care
ment was primarily facilitated through partnership with the community from the child and caregiver. Firearm violence
Christopher 2X Game Changers organization, which had a exposure was assessed through 5 questions: (1) firearm injury
long-standing history of building a network of support to to a friend, (2) firearm injury to a family member, (3) personal
Udoh et al. 3

Figure 1. Partnership structure of Future Healers.

firearm injury, (4) visual witness to firearm shooting, or (5) convention at P < .05. Statistical analysis was completed using
audible witness to firearm shooting on more than a monthly IBM SPSS Statistics for Windows, version 28 (IBM Corp.,
occasion. Additionally, we asked questions related to firearm Armonk, NY, USA). Each participant’s residential address at the
accessibility and safety in the home. We gauged study par- time of survey completion was geocoded and assigned to a
ticipants’ perceptions of health care by evaluating their trust census tract. Firearm injury incidents were similarly geocoded
in the health care system, personal experiences with health from a collaborative firearm injury database, and the total
care providers, and career aspirations. Demographic mea- number of firearm-related injuries was aggregated within each of
sures included age, gender, race and residential address, the region’s 191 census tracts. Maps illustrating the overlay
school/employment status, and event accessibility. The sur- between firearm injuries and participants’ residential addresses
veys were modeled after the Adverse Childhood Experience were created to highlight similarities in their spatial distributions.
(ACE) Questionnaire but were adapted to focus on gun vi- ArcGIS Pro software (v3.0.3ESRI, Redlands, CA, USA) was
olence exposure as an ACE. used for all spatial analyses.

Statistical Analysis Results

We used univariate statistics (frequencies, percentages, means, Of the 92 children and 64 caregivers participating in the program
and standard deviations) to describe the demographic makeup of as of the study date, 44 (48%) and 38 (59%) successfully
the participants and used the Clopper-Pearson exact 95% completed the survey, allowing for a 52.5% response rate.
confidence intervals to get estimates of prevalence of the FVE Survey questions were divided into 3 overarching categories:
and perception of health care questions. Pearson’s chi-square test demographic information, firearm violence exposure, and per-
compared caregivers and children on the FVE and health care ceptions of the health care community.
questions. A power analysis was performed with an estimated
sample proportion of .50 to determine a minimum required
Demographic Characteristics
sample size of n = 70 to produce a 95% confidence interval of
.38 to .62. All statistical tests comparing caregiver and children’s Demographic information can be found in Table 1. Male (41%)
responses were two-tailed, and the significance level was set by and female (59%) children participated in the survey, with an
4 The American Surgeon™ 0(0)

average age of 8.8 years (SD = 3.3). Three-fourths of the Table 1. Sociodemographic Characteristics of Caregiver and
children attended public school. Caregivers were predominantly Children Participants.
female (84%), and the average age of all caregivers at program Children Baseline Characteristics Children (n = 44)
events was 39 years (SD = 9.3). Regardless of age and gender,
97% of all participants identified as non-Hispanic Black/African Gender, % (n)
American. Most of the participants (96%) lived in the metro- Female 59 (26)
politan area, with the remaining residing in close proximity. Male 41 (18)
Overall, 36% of participants lived in the Downtown/West area, Race, % (n)
24% in South area, and 36% in East areas. Black/African American 95 (42)
Asian 3 (1)
No response 3 (1)
Firearm Violence Exposure and Accessibility and Age, mean (SD) 8.8 (3.3)
Safety in the Home Type of school % (n)
Public 75 (33)
While caregivers and children were asked similar questions, Private 5 (2)
different wording was used to accommodate the respective Homeschool 2 (1)
participants. Questions and results are demonstrated in Unknown 7 (3)
Figures 2 and 3. Caregivers reported hearing gunshots in their No response 11 (5)
neighborhood more frequently than children (66% vs 50%, Primary transportation to events, % (n)
respectively, P = .154) and witnessing firearm violence in Personal vehicle 97 (37)
person at significantly higher rates (caregivers 65%; children Public transportation 3 (1)
21%, P = .001). Regardless of the frequency of hearing or Siblings in program, % (n)
seeing gunshots, nearly all survey participants stated that the Yes 50 (21)
current presence of guns in their neighborhood had them No 50 (21)
concerned for their children’s safety or, if they were a child, Children in program, mean (SD) 1.42 (0.72)
their own safety (caregivers: 92%; children: 95%, P = .661). Caregivers Baseline Characteristics Caregivers (n = 38)
Although 13% of caregivers and 2% (P = .091) of children
were personally injured by a firearm, many adult survey Gender, % (n)
respondents had a friend (84%) or family member (82%) Female 84 (32)
directly affected by firearm violence. For children, 30% had a Male 16 (6)
friend directly injured and 66% had a family member injured Race, % (n)
Black/African American 94 (36)
as a result of firearm violence. Overall, 95% of caregivers and
Asian 3 (1)
84% of children (P = .166) had experienced at least one of the
No response 3 (1)
5 FVE questions assessed in this study.
Age, mean (SD) 39 (9.3)
Caregivers and children were equally likely to report that
Employment status (n)
firearms were stored in their home (50% vs 50%, respec- Full-time 26 (68)
tively) with 90% of adults and 70% of children reporting that Part-time 3 (8)
guns were safely secured in a gun lock; however, only 2% of Free-lance 1 (3)
children reported that they could access that firearm. Unemployed 8 (21)
Primary transportation to events, % (n)
Personal vehicle 97 (37)
Participant Residence in Relation to Reported Firearm Public transportation 3 (1)
Injury Incidents Children in family, mean (SD) 2.71 (1.84)
Children in program, mean (SD) 1.42 (0.72)
Figure 4 demonstrates the participants’ residence locations in
relation to firearm injury incidents as determined by a col-
laborative database.10 Although the children participating in
the program were from many areas of the city, most were 5 gunshot injury incidents that occurred within the past
proximate to recent gun violence incidents. The median 3 years within a half-mile of the participating kids. The home
distance from the residence of a child to the nearest gunshot of one child was within 400 meters of 51 gunshot incidents
incident that occurred in the past year was 470 meters and the that occurred in the past 3 years.
median distance to the nearest gunshot incident that occurred
in the past 3 years was 280 meters. More than 60% of the
Perception of the Health Care System
children lived within 400 meters of a gunshot incident that
occurred in the past year. These nearby instances of gun The results in Table 2 demonstrate that most caregivers (79%)
violence were not exceptional cases. There was a median of and children (91%) trusted the health care system. When asked if
Udoh et al. 5

Figure 2. Firearm exposure in caregivers and children participants.

Figure 3. Firearm violence exposure in caregivers and children participants.

they had a negative experience when visiting the doctor’s office negative experience compared to caregivers detailing interac-
or hospital, 37% of caregivers and 17% of children reported tions in which they were not listened to by their provider. Most
“yes.” There was an apparent difference in how children and children (60%) believed they could become health care pro-
caregivers interpreted this question. The children tended to viders such as physicians or nurses, and 53% of children listed a
describe instances where they received certain treatments that medical/STEM profession when asked what they wanted to be
may elicit a negative response, such as “receiving a shot,” as a when they grew up.
6 The American Surgeon™ 0(0)

Discussion credible to the population that is being served are essential.

Through partnerships with community groups such as Chris-
The rise of community firearm violence in the US has topher 2X Game Changers, the Future Healers program ap-
drastically impacted and shortened the lives of our youth, propriately engaged children most at risk of firearm violence, as
especially those from marginalized populations. The FVE in shown through our results. A large majority of the caregivers
our study was defined as a participant affirming that they have (96%) and children (86%) had been exposed to firearm violence.
experienced an injury to a friend or family member, personal Half of the children in our study had heard gunshots fired in the
injury, or audible/visual witness to gunfire on more than a past month and a third had a similarly aged peer injured by
monthly occasion. This study found that caregivers and gunfire. Again, this is a sobering number given that the children
children in the Future Healers program reported a high were all under the age of 13. This exposure is significantly
percentage of total FVE, with a third of the children having a higher than a previous study that reported 36% of children aged
peer injured by gunfire. Although the majority of our study 5-12 in Boston, Philadelphia, and rural Tennessee had experi-
group had a positive perception of the health care system, enced indirect firearm violence in their lifetime.5 Our study’s
there were several reports of negative interactions with health higher percentage of FVE is consistent with our objective to
care providers as well, thereby reaffirming the importance of recruit and engage children at increased risk for gun violence.
partnerships with credible community partners. As has been demonstrated in multiple American cities, there
For health care entities to recruit and engage children at are significant geospatial disparities in our community relevant
highest risk of injury, community partners that are trusted and to the incidence of firearm injury.16,17 As demonstrated in

Figure 4. Firearm injury vs participants’ residences in metro area.

Table 2. Participant Trust in the Health Care Community.

Count/Total (Affirmative) Proportion (95% CI)

Caregivers
If you are hurt or sick, do you trust the health care system to take care of you? 30/38 0.79 (0.63, 0.90)
Have you ever had a bad experience when seeing a doctor? 14/38 0.37 (0.22, 0.54)
Children
When you’re sick, do you trust doctors to take good care of you? 39/43 0.91 (0.78, 0.97)
Have you ever had a bad experience at the doctor’s office or hospital? 7/42 0.17 (0.07, 0.31)
Udoh et al. 7

Figure 2, children and caregiver program participants resided in already involved in the Future Healers program, results
neighborhoods within the study region with a high incidence of are not necessarily generalizable to the community as a
firearm injury. Their communities were regularly subjected to whole with regard to firearm violence exposure and
gunfire and injury, and these areas have experienced a long- perceptions of health care institutions. Results from
standing history of targeted disinvestment highlighted by his- children and caregivers were not combined among
torical policies and structural racism.16-19 One clear objective of families, which could also limit the generalizability of the
the Future Healers program is to combat historical targeted results. The perception of the children and caregivers
disinvestment in these communities with investment in the individually was the primary focus of the study, but the
youngest members of these communities and their families. results of children’s surveys could have been influenced
Additionally, our results indicate that health care entities, by the presence of the parents. Most participants were
including medical schools/students and trauma centers, can recruited from our partnered local community organiza-
serve as trusted partners in the implementation and delivery of tions, allowing for efficient targeting through working
prevention programming. Children who were screened by their with organizations with known relationships with this set
physicians early for gun-safety interventions had significantly population. However, recruitment efforts may not have
higher rates of handgun removal or safe storage when compared reached impacted individuals not affiliated with com-
to those with no counseling from physicians.9,20 The children munity organizers. Further investigations are needed to
surveyed in our study had an overwhelmingly positive per- assess the effectiveness and perception of firearm vio-
ception of health care providers. Although there was a decrease lence prevention programs on children and their care-
in the caregivers’ perceptions compared to the children, almost givers. Longitudinal evaluation will allow further
80% had a positive perception of health care providers. The information to demonstrate if early intervention equates
frequent interactions between families and health care workers to lasting changes in a child’s adult years. Additionally, it
in Future Healers may have influenced the positive response. will be necessary to evaluate potential factors associated
However, some caregivers documented negative encounters at with program adherence, attendance, and engagement by
doctor visits or hospital stays that were often due to the health participants and their caregivers. Future studies are also
care providers’ dismissiveness of their medical concerns. Sys- needed to assess the impact on medical students’ personal
temic racism and discriminatory practices continue to impact the and professional identity formation as leaders of Future
overall care of Black patients and their communities.21-23 De- Healers programming and evaluation.
spite these promising results, we must continue to rebuild trust in
these communities that have been ignored and mistreated for
too long.
Most children (60%) in our study believed they could
Conclusion
become health care providers such as physicians or nurses, The significant incidence of childhood firearm violence expo-
and 53% of children listed a medical/STEM profession when sure necessitates innovative interventions tailored for this
asked what they wanted to be when they grew up. The Future marginalized population. In this study, within the context of a
Healers program is intended to immerse the children in an novel pre-adolescent violent injury prevention program (Future
environment with medical students and providers with whom Healers), we demonstrated that partnership with local com-
they may better relate. These unique experiences would munity organizations successfully facilitated the recruitment of
otherwise not have been available to these participants out- young children with significant exposure to firearm violence.
side the program. The Future Healers program is an attempt We found that children and their caregivers had a positive
to provide a fresh perspective in this realm by building re- overall perception of the health care community, thereby sug-
lationships, cultivating mentorship, and intertwining medi- gesting that health care entities can serve as a trusted partner with
cine with wellness for youth. community organizations to deliver injury prevention pro-
The authors acknowledge the limitations of this study. The gramming during this critical period of development.
response rate of 52% was low, given the 3-month timeframe
given to participants in the program. Various forms of
communication, such as email, text messaging, and in-person Author’s Note
distribution, helped to garner responses. However, low par- A version of this work was presented in oral format at the Kentucky
ticipation may stem from a fundamental distrust of the American College of Surgeons Chapter Conference.
research community and participation in such studies due to
past discriminatory acts that severely damaged the Black
community.24 Author Contributions
The objective of this study was to ascertain if the All authors have made substantial contributions to (a) conception and
program was successfully recruiting children and fami- design, or acquisition of data, or analysis and interpretation of data; and/
lies that had experienced firearm violence. Given that the or (b) drafting the article or revising it critically for import intellectual
results of the survey were representative of individuals content; and/or (c) final approval of the version to be published.
8 The American Surgeon™ 0(0)

Declaration of Conflicting Interests review and meta-analysis. Lancet Public Health. 2017;2:
e356-e366.
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article. 8. Holman DM, Ports KA, Buchanan ND. The association
between adverse childhood experiences and risk of cancer in
adulthood: a systematic review of the literature. Pediatrics.
Funding
2016;138:S81-S91.
The author(s) received no financial support for the research, au- 9. Brown DW, Anda RF, Tiemeier H, Felitti VJ, Edwards VJ,
thorship, and/or publication of this article. Croft JB, Giles WH. Adverse childhood experiences and the
risk of premature mortality. Am J Prev Med. 2009;37(5):
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This manuscript is original and neither published, accepted, or 10. Miller KR, Egger ME, Pike A, et al. The limitations of hospital
submitted for publication elsewhere. and law enforcement databases in characterizing the epide-
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ORCID iDs 92(1):82-87. doi:10.1097/TA.0000000000003367
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Baylee Polzin  https://orcid.org/0009-0004-5146-8970
and an old epidemic: the impact of COVID-19 and gun
Alyssa Brown  https://orcid.org/0000-0003-4422-3356
violence as measured by years of potential life lost in a US
Matthew Ruther  https://orcid.org/0000-0002-1375-2792
city. Surgery. 2022;172(5):1555-1562. doi:10.1016/j.surg.
Keith Miller  https://orcid.org/0000-0003-0105-2454
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Data Availability Statement
Pediatric surgery consortium. The COVID-19 pandemic and
Data statement: the research data is confidential. associated rise in pediatric firearm injuries: a multi-institutional
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