Firearm Exposure, Health Risk Behaviors, and Health Outcomes in Rural Youth: An Integrative Review

Firearm violence was the leading cause of death among children and adolescents in the United States in 2024, with suicide and firearm-related injuries in rural youth representing a particular concern. This integrative review aims to investigate rural youth exposure to firearms, including trends in handgun carrying, usage, and exposure to firearm violence. Additional evidence is reviewed for associated health outcomes such as adverse mental health symptoms and substance use. A search of databases including EBSCOhost, Web of Science, and Google Scholar was conducted to identify relevant manuscripts. Eligible studies were required to include a rural youth population in relation to handgun carrying, adverse mental health symptoms, or suicide. Nineteen (n = 19) studies were included that varied in population size (n = 25,454,460), study design, measures, and location within the United States. There are three main themes present in the findings: (a) rural youth exposed to firearms and firearm violence are more likely to report adverse mental health symptoms than non-exposed youth; (b) handgun carrying is rising among rural youth, with concerning outcomes and associations such as peer violence, victimization, and risky behavior; and (c) suicide rates in rural youth double that of their urban counterparts. In all three domains, there is little robust evidence on health outcomes involving rural youth that limits the ability to inform harm prevention initiatives, highlighting the critical need for further research. The unique intersection of rural youth, firearms and firearm violence exposure, and health risk behaviors and outcomes in rural communities is alarming yet understudied.