We examined whether firearm mortality rates among children varied across US counties along a rural-urban continuum.


US vital statistics data were accessed for all pediatric (age: 0–19 years) firearm deaths from 1999 through 2006. Deaths were analyzed according to a modified rural-urban continuum code (based on population size and proximity to metropolitan areas) assigned to each county (3141 counties).


In the 8-year study period, there were 23649 pediatric firearm deaths (15190 homicides, 7082 suicides, and 1377 unintentional deaths). Pediatric nonfirearm mortality rates were significantly higher in the most-rural counties (adjusted rate ratio: 1.36 [95% confidence interval [CI]: 1.13–1.64]), compared with the most-urban counties. The most-rural counties demonstrated virtually identical pediatric firearm mortality rates (adjusted rate ratio: 0.91 [95% CI: 0.63–1.32]), compared with the most-urban counties. The most-rural counties had higher rates of pediatric firearm suicide (adjusted rate ratio: 2.01 [95% CI: 1.43–2.83]) and unintentional firearm death (adjusted rate ratio: 2.19 [95% CI: 1.27–3.77]), compared with the most-urban counties. Pediatric firearm homicides rates were significantly higher in the most-urban counties (adjusted rate ratio: 3.69 [95% CI: 2.00–6.80]), compared with the most-rural counties.


Children in the most-rural US counties had firearm mortality rates that were statistically indistinguishable from those for children in the most-urban counties. This finding reflects a greater homicide rate in urban counties counterbalanced by greater suicide and unintentional firearm death rates in rural counties. Nonfirearm mortality rates were significantly greater outside the most-urban US counties.

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