An informed approach to the development of primary care pediatric firearm safety messages

Background Firearm ownership is prevalent in the US and many children spend time in areas where firearms are not stored safely. The AAP recommends firearm safety counseling at pediatric well-visits. Methods We developed and tested six contextual messages to promote safe firearm storage based on: absence of harm, collective appeal to understanding child behavior, pediatrician’s authority, evidence-based, fear appeal, and general safety considerations. One hundred four parents who keep firearms at home were recruited from Amazon Mechanical Turk Prime and viewed video messages and reported behavioral intentions and emotional reactions following each message. Results All six contextual messages were perceived as important and believable and increased parents’ intentions to follow safety advice provided, but also elicited negative emotions. The authority message elicited more negative emotions and resulted in lower intentions to follow safe storage advice. Conclusions Including firearm messages with other child safety advice merits further evaluation. Authority messages should be avoided.

Perceptions of firearm-related harm among US adults living in firearm-owning households: a nationally representative study

Decision-making on having firearms at home may be contingent on perceptions of the likelihood of their negative and positive outcomes. Using data from a nationally representative survey (n=4030) conducted during 30 July 2019 to 11 August 2019, we described how US adults living in firearm-owning households perceived the relative likelihood of firearm-related harm by injury intent (‘accidentally harm self or someone else with a gun’, ‘injure self on purpose with a gun’ and ‘injure someone else on purpose with a gun’) for groups at risk of compromised decision-making (children; adolescents and individuals with mental health issues, substance use disorders or cognitive impairment). We found that US adults living in firearm-owning households believe that unintentional firearm injuries are more likely than intentional self-inflicted or assault-related firearm injuries, despite evidence to the contrary. Prior evidence indicates that communicating risk in relative terms can motivate behaviour change; therefore, findings from this study might helpfully inform health communications around firearm safety.

Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care

Background Insights from behavioral economics, or how individuals’ decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., “Nudge”) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers? Methods The Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians’ use of an evidence-based firearm safety practice, S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receive S.A.F.E. Firearm materials, including training and cable locks. Half of the practices (k = 16) will be randomized to receive Nudge; the other half (k = 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to the S.A.F.E Firearm program. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning. Discussion The ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care. Trial registration ClinicalTrials.gov, NCT04844021. Registered 14 April 2021.

Attitudes and perceived barriers to firearm safety anticipatory guidance by pediatricians: a statewide perspective

Background Firearms are the second leading cause of injury-related death in American children. Safe storage of firearms is associated with a significantly decreased odds of firearm-related death, however more than half of US firearm owners store at least one firearm unlocked or accessible to a minor. While guidance by primary care providers has been shown to improve storage practices, firearm safety counseling occurs infrequently in the primary care setting. The primary objective of this study was to describe pediatricians’ perceived barriers to providing firearm safety education to families in the pediatric primary care setting. Secondary objectives included identifying pediatric provider attitudes and current practices around firearm counseling. Methods This was a cross-sectional survey of pediatric primary care providers in Ohio. Participants were recruited from the Ohio AAP email list over a 3-month period. Only pediatric primary care providers in Ohio were included; subspecialists, residents and non-practicing physicians were excluded. Participants completed an anonymous online survey detailing practice patterns around and barriers to providing firearm safety counseling. Three follow-up emails were sent to pediatricians that failed to initially respond. Response frequencies were calculated using Microsoft Excel. Results Two hundred eighty-nine pediatricians completed the survey and 149 met inclusion criteria for analysis. One hundred seven (72%) respondents agreed that it is the responsibility of the pediatric primary care provider to discuss safe storage. Counseling, however, occurred infrequently with 119 (80%) of respondents performing firearm safety education at fewer than half of well child visits. The most commonly cited barriers to providing counseling were lack of time during office visits, lack of education and few resources to provide to families. A majority, 82 of pediatric providers (55%), agreed they would counsel more if given additional training, with 110 (74%) conveying they would distribute firearm safety devices to families if these were available in their practice. Conclusion Ohio pediatricians agree that it is the responsibility of the primary care provider to discuss firearm safety. However, counseling occurs infrequently in the primary care setting due to a lack of time, provider education and available resources. Improving access to resources for primary care pediatricians will be critical in helping educate families in order to protect their children through improved storage practices.

Rural youth’s exposure to firearm violence and their attitudes regarding firearm safety measures

Background In the wake of an epidemic in firearm-related deaths and injuries, youth have become leading voices of concern. This study’s objective was to investigate rural youth’s personal experiences with firearm-related violence, and their attitudes towards firearms and gun violence prevention strategies. Methods Attendees of the 2019 Iowa FFA Leadership Conference were surveyed about personal experiences with firearm-associated deaths and injuries, and their attitudes regarding firearm-related issues. Descriptive (frequencies), bivariate (chi square, Fisher’s exact test) and multivariable logistic regression analyses were performed utilizing Stata 15.1 (StataCorp, College Station, Texas). Results Responses from 1382 FFA members 13–18 years of age were analyzed. About 5% had personally seen someone threatened with a firearm. Over one-third (36%) stated they knew someone who had been killed or injured by gunfire. Of these, over two-thirds knew of someone who had died or was injured unintentionally and 30% knew of someone killed or injured intentionally (e.g. suicide). Nearly all agreed or strongly agreed that the right to use firearms for hunting and shooting sports should be legal (94%), that a firearm safety course should be required to get a hunting license (89%), and that there should be a required background check before purchasing a firearm (89%). Over three-fifths (61%) agreed or strongly agreed that there should be laws requiring safe storage of firearms in homes. Although still high, lesser support for firearm safety policies was seen among males, older youth, participants living on farms or in the country, and youth who hunted, had firearms in their homes, and/or were in homes with unsafe firearm storage. Conclusions The majority of youth in this study supported firearm safety measures including required training, background checks, and safe firearm storage in homes. These findings are consistent with the national youth-led call for firearm safety. Additionally, over one-third of respondents personally knew someone who was killed or injured by a firearm and 5% had seen someone or been personally threatened with firearm violence. Our study did not investigate the effects of firearm violence on participants’ mental health and wellbeing, but future studies addressing this question seem highly justified.

Documentation of Firearm Safety Screening During Emergency Department Visits for Assault-Related Injury

Assault-injured youth have an increased risk of future violence. Identifying firearm access among youth in the emergency department (ED) creates an opportunity for interventions aimed at reducing future violent events. We performed this study to determine the extent to which children with assault-related injuries are screened for access to firearms in the ED. We performed a retrospective chart review of all medical records from adolescent ED visits to an academic, tertiary care pediatric hospital in Washington DC with ICD-10 codes related to assault in a 3-month period. We found that among 252 assault-related encounters, none had any documentation of firearm access in the provider note, social work note, or psychiatry consultant note. Therefore, we concluded that firearm access screening is rarely documented in ED visits among patients who present for an assault, highlighting an important missed opportunity for firearm access screening among this high-risk group.